Aug 02 2010
One of the recurring themes of this blog, not surprisingly given its name, is the proper role of science in medicine. As Dr. Novella has made clear from the very beginning, we advocate science-based medicine (SBM), which is what evidence-based medicine (EBM) should be. SBM tries to overcome the shortcomings of EBM by taking into account all the evidence, both scientific and clinical, in deciding what therapies work, what therapies don’t work, and why. To recap, a major part of our thesis is that EBM, although a step forward over prior dogma-based medical models, ultimately falls short of making medicine as effective as it can be. As currently practiced, EBM appears to worship clinical trial evidence above all else and nearly completely ignores basic science considerations, relegating them to the lowest form of evidence, lower than even small case series. This blind spot has directly contributed to the infiltration of quackery into academic medicine and so-called EBM because in the cases of ridiculously improbable modalities like homeopathy and reiki, deficiencies in how clinical trials are conducted and analyzed can make it appear that these modalities might actually have efficacy.
Given this thesis, if there’s one aspect of medical education that I consider to be paramount, at least when it comes to understanding how to analyze and apply all the evidence, both basic science and clinical, it’s a firm grounding in the scientific method. Unfortunately, in medical school there is very little, if any, concentration on the scientific method. In fact, one thing that shocked me when I first entered what is one of the best medical schools in the U.S., the University of Michigan, was just how “practical” the science taught to us as students was. It was very much a “just the facts, ma’am,” sort of presentation, with little, if any, emphasis on how those scientific facts were discovered. Indeed, before I entered medical school, I had taken graduate level biochemistry courses for a whole year. This was some truly hard core stuff. Unfortunately, I couldn’t get out of taking medical school biochemistry my first year, but taking the course was illuminating. The contrast was marked in that in medical school there was very little in the way of mechanistic detail, but there was a whole lot of memorization. The same was true in nearly all the other classes we took in the first two years. True, for anatomy it’s pretty hard not to have to engage in a lot of rote memorization, but the same shouldn’t necessarily be true of physiology and pharmacology, for example. It was, though.
Over time, I came to realize that there was no easy answer to correcting this problem, because medical school is far more akin to a trade school than a science training school, and the question of how much science and in what form it should be taught are difficult questions that go to the heart of medical education and what it means to be a good physician. Clearly, I believe that, among other things, a good physician must use science-based practice, but how does medical education achieve that? That’s one reason why I’m both appalled and intrigued by a program at the Mt. Sinai School of Medicine for humanities majors to enter medical school without all the hard sciences. It’s a program that was written up in the New York Times last Wednesday in an article entitled Getting Into Med School Without Hard Sciences, and whose results were published in Medical Academia under the title Challenging Traditional Premedical Requirements as Predictors of Success in Medical School: The Mount Sinai School of Medicine Humanities and Medicine Program.
Let’s first take a look at how the NYT described the program:
For generations of pre-med students, three things have been as certain as death and taxes: organic chemistry, physics and the Medical College Admission Test, known by its dread-inducing acronym, the MCAT.
So it came as a total shock to Elizabeth Adler when she discovered, through a singer in her favorite a cappella group at Brown University, that one of the nation’s top medical schools admits a small number of students every year who have skipped all three requirements.
Until then, despite being the daughter of a physician, she said, “I was kind of thinking medical school was not the right track for me.”
Ms. Adler became one of the lucky few in one of the best kept secrets in the cutthroat world of medical school admissions, the Humanities and Medicine Program at the Mount Sinai medical school on the Upper East Side of Manhattan.
The program promises slots to about 35 undergraduates a year if they study humanities or social sciences instead of the traditional pre-medical school curriculum and maintain a 3.5 grade-point average.
I first became aware of this program four years ago, when the NYT ran a story about how art appreciation was being taught as part of the curriculum at Mt. Sinai. At the time, I was puzzled why such courses were being offered in medical school when there is so little time and so much to teach. Don’t get me wrong. I wish I had taken more humanities and arts classes during my undergraduate years. My not having done so is one of the great regrets of my life, truly a missed opportunity. However, in medical school, unless one is going into medical illustration, my thought at the time was that such a program was all very well and good, but medical school is not a liberal arts school; it is, as I have pointed out, more or less a specialized school, an advanced program of education designed to inculcate into students the basic knowledge and skills that all physicians should have.
But who knows? I might be wrong.
Humanities versus basic science in a cage match for pre-med
Let’s look at the study itself. Basically, it’s pretty thin gruel whose only findings the authors, Dr. David Muller and Dr. Nathan Kase (the latter of whom is the founder of Mount Sinai’s Humanities in Medicine Program), extrapolate far beyond what is justified. It amazes me, in fact, that Academic Medicine would allow so much data-free speculation and pontification in the discussion section of this study. Let’s put it this way. There are really only three findings in this study regarding the Humanities in Medicine (HuMed) students. Basically, Muller and Kase looked at the outcomes of HuMed students from 2004 to 2009 and compared them to the outcomes of medical students on the “traditional” track and found that:
- There was a trend among HuMed students toward residencies in primary care and psychiatry and away from surgical subspecialties and anesthesiology.
- There were no statistically significant differences between the groups in clerkship honors other than psychiatry (HuMed students outperformed their peers, P < .0001) or in commencement distinctions or honors. Although HuMed students were significantly more likely to secure a scholarly-year mentored project (P = .001), there was no difference in graduating with distinction in research (P = .281).
- HuMed students were more likely to have lower United States Medical Licensing Examination Step 1 scores (221 ± 20 versus 227 ± 19, P = .0039) and to take a nonscholarly leave of absence (P = .0001).
The wag in me can’t resist wondering whether the way HuMed students apparently excelled in psychology says anything about the scientific basis of psychiatry, but that’s just the nasty, reductionistic cancer researcher in me. The most important point of this study is that, for the most part, the HuMed students don’t appear to do significantly differently than students in the traditional medical education track other than a tendency towards more “touchy-feely” specialties. This result doesn’t actually surprise me much, given that it is the mission of medical schools to teach the common knowledge and skills that all doctors require. One would expect that, if the medical school curriculum is constructed to provide adequate “catch up” instruction to students whose background in the basic sciences is somewhat … lacking, then most students, particularly students who are highly motivated, as medical students tend to be, should be able to keep up. And HuMed students do get a bit of a catch up course in the form of a “summer boot camp,” described thusly by the NYT:
The students apply in their sophomore or junior years in college and agree to major in humanities or social science, rather than the hard sciences. If they are admitted, they are required to take only basic biology and chemistry, at a level many students accomplish through Advanced Placement courses in high school.
They forgo organic chemistry, physics and calculus — though they get abbreviated organic chemistry and physics courses during a summer boot camp run by Mount Sinai. They are exempt from the MCAT. Instead, they are admitted into the program based on their high school SAT scores, two personal essays, their high school and early college grades and interviews.
I must admit that I’m a bit disturbed by some of this, and here’s why. The reason we know that, for example, homeopathy is incredibly — nay, monumentally — implausible is based primarily on basic science, specifically very basic physics and chemistry. It is chemistry and Avogadro’s number that tell us that a 30C homeopathic dilution almost certainly has not a single molecule of original remedy left. It is basic physics and chemistry that tell us that water doesn’t have “memory,” at least not the way that homeopaths tell us. It is basic chemistry that tells us that, even if water did have “memory,” there’s no known mechanism by which such “memory” could be transmitted to cells for therapeutic effect. In other words, I worry that science-based medicine is in danger if future generations of physicians eschew the hard sciences and elect to “get by” on the bare minimum that they can get by with. Worse, the attitude that seems to be underlying the entire HuMed program is that science is an obstacle to becoming a physician.
Science: An “obstacle” rather than a prerequisite?
From my perspective, science and medicine should go hand in hand. Science informs what is good medicine, and physicians should have a sufficient grounding in the scientific method to be able to recognize what is and is not good scientific and clinical evidence for a therapy. EBM only goes part of the way to reaching that goal. SBM, properly applied, is what EBM could and should be were it not for its devaluation of basic science. Now that devaluation appears to be evident in medical education. Witness some of the quotes from the NYT story and Muller and Kase’s article. For example, from the NYT:
“You have to have the proper amount of moral courage to say ‘O.K., we’re going to skip over a lot of the huge barriers to a lot of our students,’ ” said Dr. David Battinelli, senior associate dean for education at Hofstra University School of Medicine.
And, from Muller and Kase’s study:
The HuMed program at Mount Sinai was designed to determine the extent to which the MCAT and traditional premed courses in organic chemistry, physics, and calculus are necessary for successful completion of a medical school curriculum. It was also designed to encourage students interested in the humanistic elements of medicine to seriously consider pursuing a medical career. Many of these students are initially reluctant to pursue medicine because they are uncertain about their interest in science, they are concerned about their ability to meet the high scholastic expectations of admissions committees, or they are unwilling to divert the time and effort required to meet standard medical school admission requirements.
And, from Dr. Kase himself, as quoted in the NYT:
“There’s no question,” Dr. Kase said. “The default pathway is: Well, how did they do on the MCAT? How did they do on organic chemistry? What was their grade-point average?”
“That excludes a lot of kids,” said Dr. Kase, who founded the Mount Sinai program in 1987 when he was dean of the medical school, and who is now dean emeritus and a professor of obstetrics and gynecology. “But it also diminishes; it makes science into an obstacle rather than something that is an insight into the biology of human disease.”
While it’s a fair question to ask just how much basic science is necessary as a prerequisite for medical school in order to produce the best physicians possible, is anyone else disturbed at how, for example, Dr. Battinelli characterizes the basic sciences as “barriers” to medical students, rather than reasonable prerequisites that try to ensure a knowledge base necessary to succeed in medical school? Or how Muller and Kase seem to dismiss science as relatively unimportant in medicine to the point that they seriously argue that, just because some students are discouraged from a medical career because they fear the science medical schools should decrease the amount of science required of premeds? Or how Kase seems to think of basic science as more of an “obstacle” than anything else? Or how Muller and Kase seem want to bend over backwards to admit students who apparently can’t be bothered to “divert the time and effort required to meet standard medical school admissions requirements”? If such students are not sufficiently interested in medicine to do what it takes when what it takes is not an unreasonable expectation, I worry about their commitment to medicine. I really do. After all, as physicians, we deal with people’s lives and health.
In fact, I would counter that pretty much every prerequisite and requirement to be admitted to medical school and then complete its curriculum are “barriers” and “obstacles” — yes, even any new set of prerequisites that Muller and Kase might come up with to replace the currently existing paradigm. They’re supposed to be barriers! That’s what maintaining standards is all about: excluding those who can’t make the cut and making sure that the educational curriculum gives those who do make the cut the knowledge and skill base to be at least competent physicians, preferably excellent physicians. What should be argued is what is the proper nature and difficulty of these barriers, not whether there should be such barriers. Should there be more basic science? Are we demanding too much basic science? Is it enough to have a humanities degree and “fill in” later the science? Certainly this study doesn’t answer any of these questions. Even Dr. Batinelli points out that the more important question is how graduates of Mt. Sinai’s HuMed program do 5 and 10 years down the road, after they’ve completed their residency training and entered practice. What I do not like to see are students who voice attitudes like one of the featured students in the NYT article:
Among the current crop is Ms. Adler, 21, a senior at Brown studying global political economy and majoring in development studies.
Ms. Adler said she was inspired by her freshman study abroad in Africa. “I didn’t want to waste a class on physics, or waste a class on orgo,” she said. “The social determinants of health are so much more pervasive than the immediate biology of it.”
My suggestion to Ms. Adler is that if she doesn’t want to “waste” time on physics or especially organic chemistry, then perhaps she shouldn’t become a physician. Social determinants of health are indeed very important, but in actually treating a patient you still need to understand the biology of disease and the treatment used to combat the disease. I suppose I’ll be labeled “arrogant” for being so blunt in saying that, but I don’t care. As a future patient, I can only hope that Ms. Adler figures out that being a physician is about more than the social determinants of health. In fact, you don’t even need an MD to study the social determinants of health. I work with some very talented epidemiologists and MPHs who do just that. Perhaps Ms. Adler should consider that or a similar career path if that’s what she’s passionate about.
What is the proper role of science in medical education?
Proving once again that everything old is new again, this study and entire discussion remind me that this sort of debate has been going on over 100 years, since before Abraham Flexner published the Flexner Report in 1910. Even now, on the 100th year since the release of that report, it is not a debate that is likely to go away. For one thing, as Muller and Kase point out, there has been opposition to the ideas embodied in the Flexner Report that medical schools require at least two years of college- or university-level basic science education grounded in basic sciences like physics, chemistry, and biology, characterizing as such opposition as falling into three categories, as they describe in their study:
According to Gross and colleagues,9 critics of premed requirements fall into three categories: those who would eliminate all requirements,10 those who advocate for continuously updating the premed science curriculum,5–7 and those who believe that the premed curriculum must broadened to reflect a richer liberal arts education.5,6,8
Personally, my view would probably fall between the last two categories: I believe that the pre-med science curriculum should be continuously updated based on the latest science but see room for a richer liberal arts educations. The two are not necessarily incompatible. However, such a fusion is not what I see happening in Mt. Sinai’s HuMed program. Rather, what I see is a fusion of numbers one and three, meeting halfway, so to speak, between eliminating all requirements and requiring a richer liberal arts education.
In fact, I would go further than that. What bothers me about Muller and Kase’s thesis is, as I have said before, the way that it seems to view science as an obstacle to getting into medical school and becoming a doctor, as opposed to being a necessary prerequisite to being able to put the flood of information taught in medical school into context. The humanistic part of medicine is very important to being an effective, but if those humanistic elements are not also wedded to a firm understanding of the science of clinical practice, we risk producing a generation of physicians who are very good at holding their patients’ hands and offering encouragement to them but not so good at actually treating their medical problems.
In other words, I fear a generation of physicians perfectly suited to “integrate” so-called “complementary and alternative” medicine (CAM) into their practices.
I understand that much of the basic science that we learn in prerequisites for medical school (i.e., the “pre-med” curriculum) is not strictly necessary to be a good physician. However, I would argue that learning the scientific method and, even better, internalizing it as part of one’s being, is critical to being a good physician. Consider, for example, EBM. In EBM, science matters almost not at all. Basic science considerations are in fact relegated to the lowest form of evidence for or against a treatment, even below small case series (i.e., anecdotes). Under normal circumstances, such a ranking of basic science considerations may not seem particularly unreasonable. After all, many are the treatment modalities that seem as though they should work on the basis of science alone but turn out not to work when tested in clinical trials, thus showing us either that our understanding of the science of disease is not as strong as we think or that there are other considerations that we have not taken into account. Either way, it’s not unreasonable in general not to rely on basic science alone — with one exception. That exception, as regular readers of this blog no doubt can guess, is when a treatment proposes a mechanism that is not just implausible based on basic science but so implausible that for all intents and purposes it can be considered impossible because for it to work large swaths of well-established science would have to be not just in error but spectacularly and outrageously wrong.
Think homeopathy. Think reiki. Think “therapeutic touch.”
Even leaving aside the question of distinguishing quackery from science, science is important in medicine, as Dr. RW pointed out four years ago:
It’s probably a waste for most of us to memorize the chemical structure of amino acids, but it may be important to know enough about their structure and properties to understand that some are hydrophobic and comprise membrane lipid bilayers while others are hydrophilic and form hydrogen bonds, the basis for the secondary structure of proteins. Memorizing all the steps in the glycolytic sequence and the Krebs cycle won’t make you a better doctor but it could be important to understand how those reactions yield energy, why a molecule of glucose yields only a couple of ATPs in the glycolytic sequence, but an additional 30 some odd in the Krebs cycle, a fact that explains the difference between aerobic and anaerobic metabolism and why folks have to breathe. It’s all about the how and why of health and disease.
Or, as I would put it, physicians need to have a firm grounding in basic science for two reasons. First, as my professors used to reiterate almost ad nauseam, a significant fraction of what we learn in medical school and residency will be obsolete in a decade, and one of the main purposes of medical school is to give us sufficient background knowledge and understanding to be able to keep up with new developments, understand them, and incorporate them into our practices. A strong basic science background makes it easier for physicians to adapt to changes in knowledge leading to changes in recommended therapy and provides the conceptual framework against which to evaluate new scientific and medical findings. As Mark Crislip put it in his usual inimitable sarcastic fashion, if you want job that requires no constant reevaluation of what we do for patients based on new science, perhaps you should be a naturopath or homeopath. Physicians must be constantly learning, from training all the way to retirement, and that learning is much easier if we have a firm background the physiological, biochemical, and anatomical principles involved, even if we quickly forget details like the structures of various amino acids or where Rotter’s nodes are (although as a breast surgeon, I’ll never forget this; that’s why I chose Rotter’s nodes as an example). Second, as I have argued before, a firm grounding in science helps us to recognize pseudoscience when we see it. A poor scientific understanding of one area that leads to credulity towards a pseudoscience is all too often a marker for or harbinger of a tendency to accept other pseudoscience uncritically.
I would agree with Dr. RW that no one knows for sure what the optimal amount of basic science education should be a prerequisite to be admitted to medical school. Similarly, no one knows what the optimal mix between basic science and clinical instruction is to produce the best possible physicians. Certainly I don’t. These are questions for legitimate debate. What worries me is that the role of science in medicine has, ever since I finished medical school, appeared to be continually under siege. The science that is taught in medical school appears to be purely practical in nature. Memorize this. Memorize that. Apply that equation. Don’t think too deeply about it; a superficial knowledge is fine. A survey course in organic chemistry over the summer is just fine. Never mind that one of the key aspects of organic chemistry that most challenged me and made me understand is that you can’t just memorize things. You have to understand reaction mechanisms and how to apply them. You have to be able to use that understanding to design plans to synthesize chemicals. It’s really cool and fun stuff. And I say this even though the lowest grade I ever got in an undergraduate science class was in my second term honors organic chemistry class.
The ideas being pushed by academics like Muller and Kase also strike me as a false dichotomy. Either we require a ridiculous amount of science as prerequisites or we in essence require almost no basic science, supplemented with survey courses that can’t convey the richness of science or emphasize the scientific method at the heart of the sciences that underlie medical knowledge. As Dr. RW also pointed out, it’s perfectly possible to major in the humanities and take sufficient prerequisite science courses to be accepted into medical school. Students have been doing it for generations.
Perhaps what concerns me the most is not so much the deemphasis of science in medicine but rather the deemphasis of the scientific method and the critical thinking that underlies the scientific method. Teaching science to pre-med and medical students isn’t necessarily going to innoculate them against pseudoscientific ideas, such as many of the aspects of CAM that have infiltrated medicine over the last 20 years. A broader approach is needed. Teaching critical thinking skills, a subset of which is the scientific method, would represent a powerful strategy to keep medicine science- and evidence-based. If we could wed a strong understanding of the scientific method with a broader understanding of critical thinking, the latter of which could certainly be taught as part of a humanities curriculum, it would be a powerful weapon against quackademic medicine. Unfortunately, I fear we’re going in exactly the wrong direction, wedding a watered down science curriculum with postmodernist nonsense.
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