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Darwin, have I failed you?
Darwin, have I failed you?
What is the best way to introduce new medical students to their future careers? What philosophies can we impart that will help them in the years ahead, when the factual minutiae that we teach are long forgotten? Whatever specialty they choose, a transcending issue that they will all have to face is the continuing expansion of the human population. This exponential growth will adversely affect the health and wellbeing of billions of people living in the developing world, and the changing age-structure in the developed world means that the graduates who wish to practise there would do well to take an interest in gerontology. To provide our students ’with some understanding of the global dilemma now facing us, we need to begin at the beginning, and see how Homo sapiens came into being, what selective forces designed us to be the way we are, and why it is we have become such a suicidal success. Although I have been teaching medical students for many years in England, Scotland, and Australia, not until last year had I issued an anonymous questionnaire to the class before my first lecture to gain a clearer understanding of their background knowledge, cultural and religious beliefs, and aspirations. The results surprised me. In a class of just over 150 students, I discovered that 64% had not studied any biology in their final years at school. Perhaps this was why 27% thought that Charles Darwin was wrong in suggesting that species evolved by natural selection, why 27% thought that we could not have evolved from an African ape-like ancestor, and why 21 % believed that Eve was created by God from Adam’s rib. Whilst only 11 % thought that the human species would survive for ever, 54% believed in life after death. No matter, I was supremely confident that some of these views would soon change after an appropriate course of instruction. I was rather more encouraged by their answers to a question about ultimate career destination: 39% wanted to work in developing countries. However, frankly I doubt that we are competent to give them the appropriate training in primary health care, and so we must think again about the structure of our course. A predictable 67% wanted to become specialists and 26% wanted to become general practitioners; only 13% were attracted by the idea of medical research. These attitudes undoubtedly reflect the ethnic, cultural, and religious background of our Australian students. 61 % had been born in Australia, 25% in Asia, and 10% in Europe. As to religion, 24% had none, 18% were Catholic,
17% Anglican, 15% Jewish, 6% Buddhist, 3% Muslim, and 3% Hindu; 26% of the class worshipped at least once a week. 84% had travelled outside Australia. There were equal numbers of women and men in the class.
Department of Physiology, Monash University, Clayton, 3168, Australia (Prof R V Short FAA FRS)
Victoria
528
determine why such a high proportion of the believe in evolution. Non-belief correlated significantly (p 0-05) with a failure to have done biology at school. Perhaps we should change our admission policy? It also correlated highly significantly with religion (p=001), and with frequency of worship. Although most of the students in all religious groups accepted the concept of human evolution, there were differences between religions, with Muslims being the most fundamentalist, followed by Catholics, Anglicans, and Jews. 98% of those with no professed religion were in favour of evolution. Clearly I had to face the challenge and design a course to meet the needs and correct the misconceptions of this polyglot student body. Convinced of the value of a good book, and aware of the reluctance of medical students to read one, I decided to make Jared Diamond’s awardwinning The rise and fall of the third chimpanzee (Vintage, 1991) compulsory reading for the course, with the British Natural History Museum’s Man’s place in evolution (second edition, Cambridge University Press, 1991) as a basic introductory text and Richard Dawkins’ The blind watchmaker (Longmans, 1986) and the new Cambridge encyclopaedia of human evolution (Cambridge University Press, 1992) as additional background reading. I announced in the first lecture that this component of the course would be examined by an essay on the topic "Discuss the origin and destiny of the current races of mankind", for which about an hour’s writing time would be allowed. The course itself consisted of eight one-hour lectures spread over four weeks on the following topics: the origin of species; the monkeys; the apes; the emergence of Homo sapiens; human mating systems; human sexual dimorphisms; the evolution of human reproduction; and the fall of Homo sapiens. The class paid a three-hour visit, in small groups, to Melbourne Zoo to see the extensive collection of monkeys and apes. We showed the students David Attenborough’s film on primates from the Life on Earth series and we displayed fibreglass casts of the skulls of Australopithecus boisei, Homo habilis, and Homo erectus prepared by the National Museums of Kenya, and actual skulls of Gorilla gorilla and Homo sapiens. Students were provided, in advance, with a brief written summary of each lecture, and given handouts of all overheads shown during the lectures. At the end of the course I issued a questionnaire, inviting comments and criticisms of the lectures, the zoo visit, the film, and the assigned reading. All components of the course were rated highly by the vast majority of the class. The open essay examination was a big disappointment. Although there were a few outstanding responses, notably by the Asian students, one of whom achieved an unprecedented 100%, 6-5% of the class did not achieve the 50% pass mark. I was amazed how many could not even spell Homo sapiens correctly. No student presented any counter-evolutionary arguments in any of
I tried class did
to
not
=
the essays. Few showed any
sign of having read around the
subject. Secure in the knowledge that the course had at least been appreciated by the class, I decided as a parting shot to surprise them all by reissuing the original questionnaire several weeks after the examination to see how many attitudes I had managed to influence. To my utter dismay, there were no statistically significant changes in any of the answers to any of the questions. I was shattered. I believe in the truth of evolution and still regard it as the most exciting fundamental concept that underpins the whole of biological thinking, so why had I failed in my efforts to teach the concept to my students? Is the scientific evidence on the origins of mankind now so overwhelming that failure to
believe is no longer acceptable, or are we dealing with fundamental concepts of life and death that are emotional and irrational and hence beyond the reach of scientific logic? At best, perhaps I have sown a few seeds of truth that will take time to germinate. At worst, maybe I should retire from teaching. Of course, Charles Darwin himself dropped out of Medicine at Edinburgh because he saw the danger of remembering and believing in everything his professor taught him, since that would merely have turned him into a carbon copy of a man he despised.... I thank Ms Pheona Selby of the Higher Education Advisory and Research Unit at Monash University for analysing the responses to the
questionnaires.
BOOKSHELF well
The renin-angiotensin system Vals 1 and 2.-Edited
bylan S Robertson and M Gary Nicholls. London: Gower. 1993. Pp 1000+. L150.ISBN 1-563755505. There were some people twenty years ago who were of the opinion that renin and angiotensin were not particularly noteworthy substances. The interests of renin enthusiasts seemed academic rather than practical. The observation that hypertensive patients tended to have lower plasma renin and angiotensin II than normotensives, and the inverse correlation between renin and blood pressure in the general population, meant that those who had an epidemiological bias on their thinking felt that there were more important : topics to worry about. Well they were wrong. The advent of the angiotensin-converting enzyme (ACE) inhibitors has had a : dramatic effect on the practice of medicine not only in hypertension but also in diabetes, cardiology, and rheumatology. We now know that there is a circulating renin-angiotensin system, and there are also probably many
important non-circulating
or
local renin systems that are relevant to the function of almost all tissues. So here
we
: have it: The renin- :
angiotensin system with 100 chapters (it is
difficult
to calculate the : This must be the pages). definitive book on the reninangiotensin system with important chapters by an international galaxy of stars. Volume 1 is largely concerned with the biochemistry and physiology of the renin-angiotensin system, the important topic of standardisation of renin measurement, and the role of renin in kidney, brain, ovary, and testis as well as the peripheral arteriole. In volume 2, much of this more
number of
the favourable side-effect that wretched cough), make ACE inhibitors a group that richly deserve to be used as first-line as
profile (except
therapy. The problem with enormous texts theory is put into practice with: on the such as this is that they rapidly become place comprehensive chapters of ACE inhibitors in the treatment of obsolete. This is a particular hazard heart failure, diabetic nephropathy, for these two volumes because the imminent arrival of the angiotensinand, of course, hypertension. There is undoubtedly a niche for receptor antagonists such as losartan volumes such as will large comprehensive radically change our view of these. Even acknowledged authorities the system renin-angiotensin on hypertension cannot be totally au and the benefits of blocking it. fait with all that is going on in research Robertson and Nicholls will have into the renin-angiotensin system. to be thinking about their second Clinicians will find the cellular and edition straight away. molecular chapters interesting and it is Gareth Beevers to be hoped that the basic scientists Department of Medicine, Dudley Road Hospital,
will want to know more about the Birmingham BT8 7QH, UK clinical their of significance discoveries. There is still an understandable reluctance on the part of physicians, Management of cancer-related in the to embrace ACE UK, especially pain inhibitors with enthusiasm. In the Edited by Ehud Arbit. Mount Kisco, New early days with captopril, there were a York: Futura. 1993. Pp 534.$90. disturbing number of problems ISBN 0-879935529. largely because, like so many new drugs, it was initially given in excesEvery day more than 3 million people sive doses. Nihilistic and sometimes suffer from unrelieved cancer pain, clinical atavistic pharmacologists still although established and effective methods of relief exist. The WHO preach unwarranted caution and have failed to endorse this major therapeustates that one of the reasons for tic advance. unsatisfactory management of cancer In the treatment of mild to moderate pain is the lack of systematic it is that we education. In this respect, every probable hypertension, will never have the final incontroveradditional book on this topic is valuable to increase our knowledge. tible proof that ACE inhibitors are better than thiazides. This is partly : Management of cancer-related pain is can afford to look. because edited by a neurosurgeon, Ehud Arbit, The British Hypertension Society is from New York. The editor’s specialty mount such a and has focused the contents and the study attempting to one must wish them well with their recommendations towards surgery fund raising. In the meantime, the and a surgical approach. 25 of the 41 beneficial effects of ACE inhibitors in authors are surgeons or from operative the treatment of diabetic nephropathy disciplines, and 19 of the 31 chapters and left ventricular hypertrophy, as are written by surgeons.
nobody
529
What is the best way to introduce new medical students to their future careers? What philosophies can we impart that will help them in the years ahead, when the factual minutiae that we teach are long forgotten? Whatever specialty they choose, a transcending issue that they will all have to face is the continuing expansion of the human population. This exponential growth will adversely affect the health and wellbeing of billions of people living in the developing world, and the changing age-structure in the developed world means that the graduates who wish to practise there would do well to take an interest in gerontology. To provide our students ’with some understanding of the global dilemma now facing us, we need to begin at the beginning, and see how Homo sapiens came into being, what selective forces designed us to be the way we are, and why it is we have become such a suicidal success. Although I have been teaching medical students for many years in England, Scotland, and Australia, not until last year had I issued an anonymous questionnaire to the class before my first lecture to gain a clearer understanding of their background knowledge, cultural and religious beliefs, and aspirations. The results surprised me. In a class of just over 150 students, I discovered that 64% had not studied any biology in their final years at school. Perhaps this was why 27% thought that Charles Darwin was wrong in suggesting that species evolved by natural selection, why 27% thought that we could not have evolved from an African ape-like ancestor, and why 21 % believed that Eve was created by God from Adam’s rib. Whilst only 11 % thought that the human species would survive for ever, 54% believed in life after death. No matter, I was supremely confident that some of these views would soon change after an appropriate course of instruction. I was rather more encouraged by their answers to a question about ultimate career destination: 39% wanted to work in developing countries. However, frankly I doubt that we are competent to give them the appropriate training in primary health care, and so we must think again about the structure of our course. A predictable 67% wanted to become specialists and 26% wanted to become general practitioners; only 13% were attracted by the idea of medical research. These attitudes undoubtedly reflect the ethnic, cultural, and religious background of our Australian students. 61 % had been born in Australia, 25% in Asia, and 10% in Europe. As to religion, 24% had none, 18% were Catholic,
17% Anglican, 15% Jewish, 6% Buddhist, 3% Muslim, and 3% Hindu; 26% of the class worshipped at least once a week. 84% had travelled outside Australia. There were equal numbers of women and men in the class.
Department of Physiology, Monash University, Clayton, 3168, Australia (Prof R V Short FAA FRS)
Victoria
528
determine why such a high proportion of the believe in evolution. Non-belief correlated significantly (p 0-05) with a failure to have done biology at school. Perhaps we should change our admission policy? It also correlated highly significantly with religion (p=001), and with frequency of worship. Although most of the students in all religious groups accepted the concept of human evolution, there were differences between religions, with Muslims being the most fundamentalist, followed by Catholics, Anglicans, and Jews. 98% of those with no professed religion were in favour of evolution. Clearly I had to face the challenge and design a course to meet the needs and correct the misconceptions of this polyglot student body. Convinced of the value of a good book, and aware of the reluctance of medical students to read one, I decided to make Jared Diamond’s awardwinning The rise and fall of the third chimpanzee (Vintage, 1991) compulsory reading for the course, with the British Natural History Museum’s Man’s place in evolution (second edition, Cambridge University Press, 1991) as a basic introductory text and Richard Dawkins’ The blind watchmaker (Longmans, 1986) and the new Cambridge encyclopaedia of human evolution (Cambridge University Press, 1992) as additional background reading. I announced in the first lecture that this component of the course would be examined by an essay on the topic "Discuss the origin and destiny of the current races of mankind", for which about an hour’s writing time would be allowed. The course itself consisted of eight one-hour lectures spread over four weeks on the following topics: the origin of species; the monkeys; the apes; the emergence of Homo sapiens; human mating systems; human sexual dimorphisms; the evolution of human reproduction; and the fall of Homo sapiens. The class paid a three-hour visit, in small groups, to Melbourne Zoo to see the extensive collection of monkeys and apes. We showed the students David Attenborough’s film on primates from the Life on Earth series and we displayed fibreglass casts of the skulls of Australopithecus boisei, Homo habilis, and Homo erectus prepared by the National Museums of Kenya, and actual skulls of Gorilla gorilla and Homo sapiens. Students were provided, in advance, with a brief written summary of each lecture, and given handouts of all overheads shown during the lectures. At the end of the course I issued a questionnaire, inviting comments and criticisms of the lectures, the zoo visit, the film, and the assigned reading. All components of the course were rated highly by the vast majority of the class. The open essay examination was a big disappointment. Although there were a few outstanding responses, notably by the Asian students, one of whom achieved an unprecedented 100%, 6-5% of the class did not achieve the 50% pass mark. I was amazed how many could not even spell Homo sapiens correctly. No student presented any counter-evolutionary arguments in any of
I tried class did
to
not
=
the essays. Few showed any
sign of having read around the
subject. Secure in the knowledge that the course had at least been appreciated by the class, I decided as a parting shot to surprise them all by reissuing the original questionnaire several weeks after the examination to see how many attitudes I had managed to influence. To my utter dismay, there were no statistically significant changes in any of the answers to any of the questions. I was shattered. I believe in the truth of evolution and still regard it as the most exciting fundamental concept that underpins the whole of biological thinking, so why had I failed in my efforts to teach the concept to my students? Is the scientific evidence on the origins of mankind now so overwhelming that failure to
believe is no longer acceptable, or are we dealing with fundamental concepts of life and death that are emotional and irrational and hence beyond the reach of scientific logic? At best, perhaps I have sown a few seeds of truth that will take time to germinate. At worst, maybe I should retire from teaching. Of course, Charles Darwin himself dropped out of Medicine at Edinburgh because he saw the danger of remembering and believing in everything his professor taught him, since that would merely have turned him into a carbon copy of a man he despised.... I thank Ms Pheona Selby of the Higher Education Advisory and Research Unit at Monash University for analysing the responses to the
questionnaires.
BOOKSHELF well
The renin-angiotensin system Vals 1 and 2.-Edited
bylan S Robertson and M Gary Nicholls. London: Gower. 1993. Pp 1000+. L150.ISBN 1-563755505. There were some people twenty years ago who were of the opinion that renin and angiotensin were not particularly noteworthy substances. The interests of renin enthusiasts seemed academic rather than practical. The observation that hypertensive patients tended to have lower plasma renin and angiotensin II than normotensives, and the inverse correlation between renin and blood pressure in the general population, meant that those who had an epidemiological bias on their thinking felt that there were more important : topics to worry about. Well they were wrong. The advent of the angiotensin-converting enzyme (ACE) inhibitors has had a : dramatic effect on the practice of medicine not only in hypertension but also in diabetes, cardiology, and rheumatology. We now know that there is a circulating renin-angiotensin system, and there are also probably many
important non-circulating
or
local renin systems that are relevant to the function of almost all tissues. So here
we
: have it: The renin- :
angiotensin system with 100 chapters (it is
difficult
to calculate the : This must be the pages). definitive book on the reninangiotensin system with important chapters by an international galaxy of stars. Volume 1 is largely concerned with the biochemistry and physiology of the renin-angiotensin system, the important topic of standardisation of renin measurement, and the role of renin in kidney, brain, ovary, and testis as well as the peripheral arteriole. In volume 2, much of this more
number of
the favourable side-effect that wretched cough), make ACE inhibitors a group that richly deserve to be used as first-line as
profile (except
therapy. The problem with enormous texts theory is put into practice with: on the such as this is that they rapidly become place comprehensive chapters of ACE inhibitors in the treatment of obsolete. This is a particular hazard heart failure, diabetic nephropathy, for these two volumes because the imminent arrival of the angiotensinand, of course, hypertension. There is undoubtedly a niche for receptor antagonists such as losartan volumes such as will large comprehensive radically change our view of these. Even acknowledged authorities the system renin-angiotensin on hypertension cannot be totally au and the benefits of blocking it. fait with all that is going on in research Robertson and Nicholls will have into the renin-angiotensin system. to be thinking about their second Clinicians will find the cellular and edition straight away. molecular chapters interesting and it is Gareth Beevers to be hoped that the basic scientists Department of Medicine, Dudley Road Hospital,
will want to know more about the Birmingham BT8 7QH, UK clinical their of significance discoveries. There is still an understandable reluctance on the part of physicians, Management of cancer-related in the to embrace ACE UK, especially pain inhibitors with enthusiasm. In the Edited by Ehud Arbit. Mount Kisco, New early days with captopril, there were a York: Futura. 1993. Pp 534.$90. disturbing number of problems ISBN 0-879935529. largely because, like so many new drugs, it was initially given in excesEvery day more than 3 million people sive doses. Nihilistic and sometimes suffer from unrelieved cancer pain, clinical atavistic pharmacologists still although established and effective methods of relief exist. The WHO preach unwarranted caution and have failed to endorse this major therapeustates that one of the reasons for tic advance. unsatisfactory management of cancer In the treatment of mild to moderate pain is the lack of systematic it is that we education. In this respect, every probable hypertension, will never have the final incontroveradditional book on this topic is valuable to increase our knowledge. tible proof that ACE inhibitors are better than thiazides. This is partly : Management of cancer-related pain is can afford to look. because edited by a neurosurgeon, Ehud Arbit, The British Hypertension Society is from New York. The editor’s specialty mount such a and has focused the contents and the study attempting to one must wish them well with their recommendations towards surgery fund raising. In the meantime, the and a surgical approach. 25 of the 41 beneficial effects of ACE inhibitors in authors are surgeons or from operative the treatment of diabetic nephropathy disciplines, and 19 of the 31 chapters and left ventricular hypertrophy, as are written by surgeons.
nobody
529