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Medical education, irrelevancy and the humanities
Medical
Hypotheses
6: 509-515,
1880
MEDICAL
EDUCATION,
IRRELEVANCY
AND THE HUMANITIES
Plinio Prioreschi, of Medicine
Department
of Pharmacology,
Creighton
University,
School
ABSTRACT: The author reviews the criticism aimed at medical education and suggests that its shortcomings could be corrected by modifying the curriculum so that irrelevant material is eliminated and replaced in part with the humanities. Ke.y Words:
Medical
education,
medical
curriculum
INTRODUCTION: It is generally accepted that medical education is, at present, in a period of change. At the turn of the century dissatisfaction with the status quo resulted in the implementation of the Flexner report and it would appear that toward the end of this century, again under the stimulus of dissatisfaction with the present state, medical education may have to climb another step on its evolutionary ladder, Much has been written on this sub. ject. This paper is not presented as a set of wholly original ideas but rather as a synthesis of opinions and proposals submitted or discussed by many (including the author) on various occasions.
SHORTCOMINGS: -___ The main weaknesses of the present system are perceived to be: scarcity of primary-care physicians with consequent difficulties on the part of the public to obtain routine medical care; extreme specialization and, as a result, arousal of feelings that physicians are more interested in disease than in people: high cost; lack of relevance of much of the required knowledge; graduate's knowledge limited to biomedical sciences and inadequacy of the mechanisms of medical student selection. The scarcity of primary-care physicians and specialization are, of course, two facets of the same problem. Medical students obtain their clinical training mostly in University hospitals and are taught by faculty
509
members who are specialists or subspecialists and who have, by necessity, little interest in primary care. This, of course, tends to encourage enrollment in the residency programs of the medical specialities. The scarcity of general practitioners can also be traced to another cause that is often ignored: the general practitioner is often considered, by his specialist colleagues, a second-class physician. Particularly among the clinical faculty in University hospitals, "primary-care physician", "GP", or "family physician" are sometimes euphemisms for borderline incompetence and intellectual shortcomings. The recent creation of departments of Family Practice in many medical schools does not seem to have eliminated the problem. Given this situation it is hardly surprising that speciality residencies are preferred. The high cost of medical education and the lack of relevance of a great part of the medical curriculum are also two aspects of the same problem. Obviously by teaching medical students irrelevant material money and time are wasted. In the Basic Sciences, for example, we insist on teaching the mysteries of the anatomy of the inguinal canal to the future psychiatrist and the complexities of cardiac contraction to the future dermatologist, not to mention the subtleties of the pharmacology of antipsychotic drugs to the future ophthalmologist. As for the Clinical Sciences we do not fare better: we insist that the future ENT specialist be trained to diagnose pelvic inflammatory disease, the future neurologist be trained to deliver babies and so on. Medical students' knowledge tends to be strictly limited to biological sciences. The ignorance of the so-called Liberal Arts sometimes reaches incredible depths. Even if in this discussion we mercifully disregard, as a -let's hope- transitory phenomenon, the fairly common case of medical students unable to write a comprehensible page of correct prose, we can easily observe that their knowledge of Literature, History, Philosophy, etc. is usually negligible (this, of course, is not the fault of the medical schools but we are here concerned with the shortcomings of the final product and not with the assignment of blame). Given this state of affairs it is not surprising that in general medical students, and therefore physicians, will be more interested in diseases than in people: diseases and their treatment are the only things that they know. If fact what Huxley said in 1876: II
. . . There is no position so ignoble as that of the so-called "liberally-educated oractitioner" who may be able to read Galen in the original; who knows all the plants from the cedar of Lebanon to the hysop upon the wall; but who finds himself with the issues of life and death in his hands, ignorant, blundering and bewildered because of his ignorance of the essential and fundamental truths upon which practice must be based . . . ’ nowadays could be changed to: " . There is no position so ignoble as that of the "techn;cally-educated practitioner" who may be able to take care of sick bodies; who may be familiar with the latest statistics of the most rare diseases; but who finds himself, with issues involving human and ethical 510
values in his hands, ignorant, blundering and bewildered because of his ignorance of his own language, of history, of literature, or art, in other words of the essential and fundamental elements of intellectual progress upon which the technical education of a physician must be based . . . ’
In view of the large number of applicants to medical schools it has been necessary to establish certain. mechanisms of selection with final judgement usually passed by an Admissions Conrnittee. The selection is generally based on the student's grades (MCAT, QPA, etc.) and, for those who have consistently obtained high marks, the system is satisfactory. However, problems arise in the large grey area of median marks where the final judgement is based on interviews, discussion of hobbies, family histories, gut feelings, mood of a given member of the Admissions Corranittee, nepotism, etc. Admissions committees usually give preference to a student with a strong scientific curriculum. This tends to have the unfortunate results of encouraging further neglect of the humanities. The students correctly perceive that their chances of selection are enhanced to the extent that they concentrate their energies on courses in biology, physics, chemistry and mathematics and the achievement of the highest possible marks in as many of these courses as possible. The obvious result is that they effectively foreclose their opportunity to prepare themselves in the arts and humanities at the only time in the school curriculum when that would be possible.
GOALS OF A NEW CURRICULUM: As a first step toward the elimination of these shortcomings we should define our goals, which are now rather fuzzy. What kind of physicians do we want and what kind of knowledge do we want these physicians to possess? It would appear logical that the medical needs of society could be best served by primary-care physicians supported by a sufficient number of specialists. The curriculum of the primary-care physician (in this discussion we will call him Doctor in General Medicine or G.M.D.) must be such that besides the obvious degree of competence in general practice he should also have the capacity to deal with the patient as a human being and by his expertise and knowledge earn the respect of his colleagues who are specialists. We have already established that to be able to understand and cope with the problems of a patient as a human being and not as a receptable of diseases the physician must have an education that goes beyond the mere knowledge of diseases and their treatment. To accomplish this goal the curriculum of the Doctor in General Medicine (G.M.D.) must include the humanities, the forgotten disciplines capable of adding to the technical capabilities of the physician the wisdom of a well-educated human being. Serious and extended courses in Latin (and possibly Greek), Literature, History and Philosophy should be considered essential. Sociology and Economics should also be included. A fundamental change in the philosophy of
medical education will take place when medical educators realize that, to the primary-care physician, a course on the Aeneid may be more profitable than another course in physicochemistry. It is obvious however that the knowledge of Virgil will not automatically transform medical students into enlightened sages no more than the knowledge of Microbiology will transform them into Pasteurs. The humanities do not teach wisdom, they familiarize the student with man's age-long effort to acquire it; they are not the solution of the problem, only a necessary step toward its solution. When can the time be found to teach the humanities in an already crowded curriculum? The answer is: in what are now the pre-medical years (as discussed below) and in medical school when the teaching of irrelevant material is eliminated.
It is evident that the G.M.D. does not need to spend almost two years Six to eight months of Anatomy, Physiology, studying the Basic Sciences. Biochemistry and Microbiology will be probably sufficient. Anybody familiar with the practice of general medicine knows that most of the Basic Sciences as taught in medical schools today are irrelevant. Unfortunately it is common experience that clinicians when asked, almost invariably state that a profound knowledge of the Basic Sciences is essential in their pracOne is that sometimes the tice. There are two reasons for this response. usefulness of the Basic Sciences in the practice of medicine is confused with their usefulness in medical research and the other is that the insistence on the importance of such Sciences makes the clinician feel that he, by necessity, knows them well and therefore his knowledge is not limited to his clinical practice but extends to more esoteric fields. Any doubt on this point could easily be dissipated if all the clinicians of an average medical school were asked to take a serious comprehensive examination on, let us say, biochemistry. If we agree that the Basic Sciences have a limited value in the practice of medicine (especially general medicine), in view of the fact that the G.M.D.s are not trained to do research, it is logical to conclude that in their curriculum, six to eight months of Basic Sciences would be sufficient. In the present four year curriculum this represents a saving of almost a year. The goal of the curriculum of the G.M.D. would be therefore to produce a physician with a very good humanistic education and who is a specialist in general medicine. The curriculum for the specialities would, by necessity, be different. It is among the specialists that the future investigators would be. Therefore their study of the Basic Sciences would be more intensive than it is now, together with intensive clinical training in their field of speciality. The total training period could however be shortened because of the elimination of irrelevant teaching (the psychiatrist would not spend much time The teaching of the in obstetrics, the dermatologist in urology, etc.). humanities for the specialists would be limited to what are now the premedical years (see below).
512
According to this plan, training of the G.M.D. and of the specialists in most disciplines would be completed at the end of what is now the fourth year of medical school, and therefore the present day residency programs would be eliminated with consequent great shortening of the total curricuPossibly a one or two year residency could be maintained for certain lum. specialities. The final degree for specialists would be Doctor in Ophthalmology (Opht.D.), Doctor in Gastroenterology (G.E.D.), Doctor in Neurology (Neuro.D.), etc. and obviously each specialist would have a license to prac tice only in his field.
A MODEST
PROPOSAL:
It is evident from the previous capable of solving the many problems a radical departure from the present
discussion that any new curriculum outlined, would by necessity involve one.
It is proposed that the present medical school curriculum of four years be changed to eight years. Students would be accepted directly from high school in a number limited only by the capacity of the physical facilities, and in the first four years the number would be reduced to the maximum allowed for the last four years.
In the first two years there would be a special curriculum in humanities with very little science, if any. The curriculum of the third and fourth years would be a mixture of humanities and sciences with emphasis on sciences. Students who are eliminated at the end of the first, second or third years could continue toward a conventional B.A. or B.Sc. At the end of the fourth year the students would be given a B.Sc. in Health Sciences and the option of continuing in Medicine or passing to Dentistry, Pharmacy, etc. Acceptance would be strictly on the basis of merit and limited by the maximum allowed number of students in the various schools. After receiving his B.Sc. in Health Sciences the student accepted in the 5th year would have to choose a "track" that would lead him either to a G.M.D. or to a doctorate in one of the medical specialities.
513
8th year 7th year 6th year 5th year
Pharmacy School to Dental School i to Other Schools t0
B.SC. (Health)
------+
T 4th year 3rd year
to conventional B.A. or B.Sc.
2nd year 1st year
L-
I
T
"unlimited" number of students accepted
Figure 1 - Schematic Outline of the Proposed Structure of a Medical School
514
CONCLUSIONS: The amount of humanities taught in such a curriculum, the possibility of teaching the Basic Sciences in the 3rd or 4th years, the possibility of adding one or two years to the curriculum of certain specialities, are some of the problems that would have to be confronted if this general outline were to be accepted. It is evident that such a curriculum presents advantages and disadvantages. The most obvious among the advantages are: a. b. C.
d.
Great shortening of the total length of medical education because of the elimination of present day residency programs. Elimination of the present inadequacy in the study of the humanities. Elimination of the inadequacy of the existing selection mechanism by substituting a self-selection process based solely on demonstrated achievement. Elimination of difference in status between primary-care physician and specialists.
The most obvious disadvantages are: a. b.
C.
Necessity of a complete restructuring of the curriculum with all the risks and dangers of an untested one. Extreme specialization of all medical graduates (except the G.M.D.s) who would be able to practice only in the field of their speciality. Severe competition among students due to the process of elimination in the first four years.
In view, however, of the present status of medical education it may be worthwhile to consider the possibility that the advantages of a new curriculum could outweigh the disadvantages.
515
Hypotheses
6: 509-515,
1880
MEDICAL
EDUCATION,
IRRELEVANCY
AND THE HUMANITIES
Plinio Prioreschi, of Medicine
Department
of Pharmacology,
Creighton
University,
School
ABSTRACT: The author reviews the criticism aimed at medical education and suggests that its shortcomings could be corrected by modifying the curriculum so that irrelevant material is eliminated and replaced in part with the humanities. Ke.y Words:
Medical
education,
medical
curriculum
INTRODUCTION: It is generally accepted that medical education is, at present, in a period of change. At the turn of the century dissatisfaction with the status quo resulted in the implementation of the Flexner report and it would appear that toward the end of this century, again under the stimulus of dissatisfaction with the present state, medical education may have to climb another step on its evolutionary ladder, Much has been written on this sub. ject. This paper is not presented as a set of wholly original ideas but rather as a synthesis of opinions and proposals submitted or discussed by many (including the author) on various occasions.
SHORTCOMINGS: -___ The main weaknesses of the present system are perceived to be: scarcity of primary-care physicians with consequent difficulties on the part of the public to obtain routine medical care; extreme specialization and, as a result, arousal of feelings that physicians are more interested in disease than in people: high cost; lack of relevance of much of the required knowledge; graduate's knowledge limited to biomedical sciences and inadequacy of the mechanisms of medical student selection. The scarcity of primary-care physicians and specialization are, of course, two facets of the same problem. Medical students obtain their clinical training mostly in University hospitals and are taught by faculty
509
members who are specialists or subspecialists and who have, by necessity, little interest in primary care. This, of course, tends to encourage enrollment in the residency programs of the medical specialities. The scarcity of general practitioners can also be traced to another cause that is often ignored: the general practitioner is often considered, by his specialist colleagues, a second-class physician. Particularly among the clinical faculty in University hospitals, "primary-care physician", "GP", or "family physician" are sometimes euphemisms for borderline incompetence and intellectual shortcomings. The recent creation of departments of Family Practice in many medical schools does not seem to have eliminated the problem. Given this situation it is hardly surprising that speciality residencies are preferred. The high cost of medical education and the lack of relevance of a great part of the medical curriculum are also two aspects of the same problem. Obviously by teaching medical students irrelevant material money and time are wasted. In the Basic Sciences, for example, we insist on teaching the mysteries of the anatomy of the inguinal canal to the future psychiatrist and the complexities of cardiac contraction to the future dermatologist, not to mention the subtleties of the pharmacology of antipsychotic drugs to the future ophthalmologist. As for the Clinical Sciences we do not fare better: we insist that the future ENT specialist be trained to diagnose pelvic inflammatory disease, the future neurologist be trained to deliver babies and so on. Medical students' knowledge tends to be strictly limited to biological sciences. The ignorance of the so-called Liberal Arts sometimes reaches incredible depths. Even if in this discussion we mercifully disregard, as a -let's hope- transitory phenomenon, the fairly common case of medical students unable to write a comprehensible page of correct prose, we can easily observe that their knowledge of Literature, History, Philosophy, etc. is usually negligible (this, of course, is not the fault of the medical schools but we are here concerned with the shortcomings of the final product and not with the assignment of blame). Given this state of affairs it is not surprising that in general medical students, and therefore physicians, will be more interested in diseases than in people: diseases and their treatment are the only things that they know. If fact what Huxley said in 1876: II
. . . There is no position so ignoble as that of the so-called "liberally-educated oractitioner" who may be able to read Galen in the original; who knows all the plants from the cedar of Lebanon to the hysop upon the wall; but who finds himself with the issues of life and death in his hands, ignorant, blundering and bewildered because of his ignorance of the essential and fundamental truths upon which practice must be based . . . ’ nowadays could be changed to: " . There is no position so ignoble as that of the "techn;cally-educated practitioner" who may be able to take care of sick bodies; who may be familiar with the latest statistics of the most rare diseases; but who finds himself, with issues involving human and ethical 510
values in his hands, ignorant, blundering and bewildered because of his ignorance of his own language, of history, of literature, or art, in other words of the essential and fundamental elements of intellectual progress upon which the technical education of a physician must be based . . . ’
In view of the large number of applicants to medical schools it has been necessary to establish certain. mechanisms of selection with final judgement usually passed by an Admissions Conrnittee. The selection is generally based on the student's grades (MCAT, QPA, etc.) and, for those who have consistently obtained high marks, the system is satisfactory. However, problems arise in the large grey area of median marks where the final judgement is based on interviews, discussion of hobbies, family histories, gut feelings, mood of a given member of the Admissions Corranittee, nepotism, etc. Admissions committees usually give preference to a student with a strong scientific curriculum. This tends to have the unfortunate results of encouraging further neglect of the humanities. The students correctly perceive that their chances of selection are enhanced to the extent that they concentrate their energies on courses in biology, physics, chemistry and mathematics and the achievement of the highest possible marks in as many of these courses as possible. The obvious result is that they effectively foreclose their opportunity to prepare themselves in the arts and humanities at the only time in the school curriculum when that would be possible.
GOALS OF A NEW CURRICULUM: As a first step toward the elimination of these shortcomings we should define our goals, which are now rather fuzzy. What kind of physicians do we want and what kind of knowledge do we want these physicians to possess? It would appear logical that the medical needs of society could be best served by primary-care physicians supported by a sufficient number of specialists. The curriculum of the primary-care physician (in this discussion we will call him Doctor in General Medicine or G.M.D.) must be such that besides the obvious degree of competence in general practice he should also have the capacity to deal with the patient as a human being and by his expertise and knowledge earn the respect of his colleagues who are specialists. We have already established that to be able to understand and cope with the problems of a patient as a human being and not as a receptable of diseases the physician must have an education that goes beyond the mere knowledge of diseases and their treatment. To accomplish this goal the curriculum of the Doctor in General Medicine (G.M.D.) must include the humanities, the forgotten disciplines capable of adding to the technical capabilities of the physician the wisdom of a well-educated human being. Serious and extended courses in Latin (and possibly Greek), Literature, History and Philosophy should be considered essential. Sociology and Economics should also be included. A fundamental change in the philosophy of
medical education will take place when medical educators realize that, to the primary-care physician, a course on the Aeneid may be more profitable than another course in physicochemistry. It is obvious however that the knowledge of Virgil will not automatically transform medical students into enlightened sages no more than the knowledge of Microbiology will transform them into Pasteurs. The humanities do not teach wisdom, they familiarize the student with man's age-long effort to acquire it; they are not the solution of the problem, only a necessary step toward its solution. When can the time be found to teach the humanities in an already crowded curriculum? The answer is: in what are now the pre-medical years (as discussed below) and in medical school when the teaching of irrelevant material is eliminated.
It is evident that the G.M.D. does not need to spend almost two years Six to eight months of Anatomy, Physiology, studying the Basic Sciences. Biochemistry and Microbiology will be probably sufficient. Anybody familiar with the practice of general medicine knows that most of the Basic Sciences as taught in medical schools today are irrelevant. Unfortunately it is common experience that clinicians when asked, almost invariably state that a profound knowledge of the Basic Sciences is essential in their pracOne is that sometimes the tice. There are two reasons for this response. usefulness of the Basic Sciences in the practice of medicine is confused with their usefulness in medical research and the other is that the insistence on the importance of such Sciences makes the clinician feel that he, by necessity, knows them well and therefore his knowledge is not limited to his clinical practice but extends to more esoteric fields. Any doubt on this point could easily be dissipated if all the clinicians of an average medical school were asked to take a serious comprehensive examination on, let us say, biochemistry. If we agree that the Basic Sciences have a limited value in the practice of medicine (especially general medicine), in view of the fact that the G.M.D.s are not trained to do research, it is logical to conclude that in their curriculum, six to eight months of Basic Sciences would be sufficient. In the present four year curriculum this represents a saving of almost a year. The goal of the curriculum of the G.M.D. would be therefore to produce a physician with a very good humanistic education and who is a specialist in general medicine. The curriculum for the specialities would, by necessity, be different. It is among the specialists that the future investigators would be. Therefore their study of the Basic Sciences would be more intensive than it is now, together with intensive clinical training in their field of speciality. The total training period could however be shortened because of the elimination of irrelevant teaching (the psychiatrist would not spend much time The teaching of the in obstetrics, the dermatologist in urology, etc.). humanities for the specialists would be limited to what are now the premedical years (see below).
512
According to this plan, training of the G.M.D. and of the specialists in most disciplines would be completed at the end of what is now the fourth year of medical school, and therefore the present day residency programs would be eliminated with consequent great shortening of the total curricuPossibly a one or two year residency could be maintained for certain lum. specialities. The final degree for specialists would be Doctor in Ophthalmology (Opht.D.), Doctor in Gastroenterology (G.E.D.), Doctor in Neurology (Neuro.D.), etc. and obviously each specialist would have a license to prac tice only in his field.
A MODEST
PROPOSAL:
It is evident from the previous capable of solving the many problems a radical departure from the present
discussion that any new curriculum outlined, would by necessity involve one.
It is proposed that the present medical school curriculum of four years be changed to eight years. Students would be accepted directly from high school in a number limited only by the capacity of the physical facilities, and in the first four years the number would be reduced to the maximum allowed for the last four years.
In the first two years there would be a special curriculum in humanities with very little science, if any. The curriculum of the third and fourth years would be a mixture of humanities and sciences with emphasis on sciences. Students who are eliminated at the end of the first, second or third years could continue toward a conventional B.A. or B.Sc. At the end of the fourth year the students would be given a B.Sc. in Health Sciences and the option of continuing in Medicine or passing to Dentistry, Pharmacy, etc. Acceptance would be strictly on the basis of merit and limited by the maximum allowed number of students in the various schools. After receiving his B.Sc. in Health Sciences the student accepted in the 5th year would have to choose a "track" that would lead him either to a G.M.D. or to a doctorate in one of the medical specialities.
513
8th year 7th year 6th year 5th year
Pharmacy School to Dental School i to Other Schools t0
B.SC. (Health)
------+
T 4th year 3rd year
to conventional B.A. or B.Sc.
2nd year 1st year
L-
I
T
"unlimited" number of students accepted
Figure 1 - Schematic Outline of the Proposed Structure of a Medical School
514
CONCLUSIONS: The amount of humanities taught in such a curriculum, the possibility of teaching the Basic Sciences in the 3rd or 4th years, the possibility of adding one or two years to the curriculum of certain specialities, are some of the problems that would have to be confronted if this general outline were to be accepted. It is evident that such a curriculum presents advantages and disadvantages. The most obvious among the advantages are: a. b. C.
d.
Great shortening of the total length of medical education because of the elimination of present day residency programs. Elimination of the present inadequacy in the study of the humanities. Elimination of the inadequacy of the existing selection mechanism by substituting a self-selection process based solely on demonstrated achievement. Elimination of difference in status between primary-care physician and specialists.
The most obvious disadvantages are: a. b.
C.
Necessity of a complete restructuring of the curriculum with all the risks and dangers of an untested one. Extreme specialization of all medical graduates (except the G.M.D.s) who would be able to practice only in the field of their speciality. Severe competition among students due to the process of elimination in the first four years.
In view, however, of the present status of medical education it may be worthwhile to consider the possibility that the advantages of a new curriculum could outweigh the disadvantages.
515