Whitcomb, Michael E. MD
A recent issue of the Chronicle of Higher Education contains an essay written by Rajan entitled, “Making Medical Education Relevant.”1 In his essay, the author, a professor of immunology and pathology at the University of Connecticut, poses a critical question: Is the content being taught by basic science faculty during the first two years of medical school really relevant to the practice of medicine?
This is not a new question. Not too many years after medical schools adopted Flexner’s recommendations that the study of the natural sciences should be required for entry to medical school and should be integrated into the study of medicine itself, Rappleye, soon to become dean of the College of Physician and Surgeons of Columbia University, published an article in the Journal of Higher Education in which he stated:
In short, in the medical sciences, there has been great overcrowding; the students have been obliged to memorize too many details too early, often before they have become oriented in the work; the different departments frequently have been isolated and their courses have had little regard to the work of other departments carrying instruction simultaneously or subsequently.2
Now, unfortunately for me, and I suspect for other students studying medicine in the 1960s, Rappleye’s concerns about how the biomedical sciences were being taught did not seem to have had much influence on basic science faculty. I remember all too well sitting in lecture halls for hours upon end during the first two years of medical school listening to professors present fact after fact that seemed to have little relevance to what I thought I would need to know once I got to the wards. But since I had not experienced the practice of clinical medicine on the wards, I took it on faith that I needed to master the content being presented. After all, why would the faculty make me learn the material if it wasn’t going to help me practice good medicine? But to be frank, once I got to the wards I saw little reason for all of the time I had spent, both in college and as a medical student, learning many of those facts. Fortunately, things did begin to change somewhat after I graduated in the mid 1960s, albeit quite slowly.
For example, in a 1983 report of the Conference on Teaching the New Biology, sponsored by the Josiah Macy, Jr. Foundation, the conference participants stated:
We recommend that the basic science component of medical education be changed from its current focus on the acquisition of large amounts of overly detailed information. Instead, students should be required to master the more general concepts of the arts and sciences relevant to the practice of medicine and the process through which this conceptual material is used to solve medical problems.3
And in 1992, the Commission on Medical Education: The Sciences of Medical Practice, sponsored by The Robert Wood Johnson Foundation (RWJ), reiterated that theme.4 In an attempt to make the teaching of basic science content more relevant to clinical practice, the commission went on to recommend that medical schools should ensure that the sciences of medical practice be integrated throughout the entire course of study. Recognizing the difficulty of accomplishing that goal if the responsibility for the teaching of the material remained embedded in individual basic science departments, the commission called for the establishment within schools of an authority responsible for the oversight and management of the entire medical education program. In response, many medical schools did begin to implement changes in their curricula in accord with the commission’s recommendations.
In 2001, the Association of American Medical Colleges issued a report prepared by an expert panel on basic science education convened under the auspices of the association’s Medical School Objectives Project.5 In that report, the panel set forth recommendations for the learning objectives that should guide the teaching of biomedical sciences in the medical school curriculum. The panel acknowledged that medical schools had adopted a number of the recommendations made by the RWJ commission, but called specific attention to the fact that schools had not done enough to integrate content drawn from the biomedical sciences into the third and fourth years of the curriculum. And perhaps as a way of explaining why that had not occurred, the panel noted that the National Caucus of Basic Biomedical Science Chairs had opposed the commission’s recommendations that management and oversight of the curriculum should be centralized. Indeed, the caucus viewed that recommendation and others made by the RWJ commission as threats to the education of future physicians. Fortunately, medical schools have continued to make changes in the ways the biomedical sciences are being taught to make the content more relevant.6,7
Now, while the teaching of basic science content in the medical school curriculum is naturally of interest to some of the readers of Academic Medicine, I wonder why the editors of the Chronicle deemed the essay by Rajan to be of interest to its readers. I speculate that it has to do with the issues he raised in the essay’s last few paragraphs. His message there is that medical students really are not being educated properly to provide high-quality care. Rajan notes that in his experience doctors didn’t seem to relate to patients properly. And he reports that students at his school believe that they are often exposed to faculty physicians who do not practice evidence-based medicine. He suggests that these shortcomings may relate to the fact that professors who have little “understanding of what it means to be a physician” present too much of the content of the curriculum.
Maybe the editors of the Chronicle, as individuals who may have been patients in the past, were attracted to the essay because of their own experiences with physicians. Perhaps those experiences led them to believe that it is more important that medical educators spend time teaching medical students how to provide high-quality care than to concentrate on teaching a litany of facts that have little to do with how their students, when they become physicians, will practice medicine. In this regard, I am reminded of the observation made by Henry Pritchett in his introduction to the Flexner Report:
The interests of the general public have been so generally lost sight of in this matter that the public has in large measure forgot that it has any interests to protect. And yet in no other way does education more closely touch the individual than in the quality of the medical training which the institutions of the country provide.8
The editors of the Chronicle have provided a useful service to their readers by making them aware of how doctors are being educated. Henry Pritchett would have smiled.
Michael E. Whitcomb, MD
1 Rajan TV. Chron High Educ. 2006;52:20.
2 Rappleye WC. J High Educ. 1930;1:154–59.
3 Friedman CP, Purcell E, De Bliek R (eds). The New Biology and Medical Education: Merging the Biological, Information, and Cognitive Sciences. New York: Josiah Macy, Jr. Foundation, 1983.
4 Marston RQ, Jones RM. Commission on Medical Education: The Sciences of Medical Practice. Medical Education in Transition. Princeton, NJ: The Robert Wood Johnson Foundation, 1992.
5 Medical School Objectives Project Report IV. Contemporary Issues in Medicine: Basic Science and Clinical Research. Washington, DC: Association of American Medical Colleges, 2001.
6 Smith HC. A course director’s perspectives on problem-based learning curricula in biochemistry. Acad Med. 2002;77:1189–98.
7 Clough RW, Shea SL, Hamilton WR, et al. Weaving basic science and social sciences into a case-based, clinically oriented medical curriculum: one school’s approach. Acad Med. 2004;79:1073–83.
8 Flexner A. Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4. Boston: Updyke, 1910.