Jul 04 2009
This month I will begin my third year of medical school, after a three-year break for laboratory research. Living alternately in the worlds of med school and grad school has prompted me to reflect on differences between these training programs.
[Obvious disclaimer: I have studied at a single institution, and only for five years.]
I am enrolled in a dual-degree MD/PhD program. About 120 US medical schools have such programs, and the National Institutes of Health funds a third of them (MSTP). The schedule of such programs is generally: 2 years of medical school (culminating in USMLE Step 1), 3+ years of graduate school (culminating in dissertation and PhD), and then the last 2 years of medical school (which I begin this month). The most popular residency choices for MD/PhD graduates are internal medicine, pediatrics, and pathology (match data). Other residencies that attract these graduates include dermatology, neurology, ophthamology, and radiology (survey data). The hopes of those funding the MD/PhD training programs and of those accepting the graduates is that these individuals will become physician-scientists, bridging the divide between lab bench and patient bedside with insights from both.
[Note that the majority of physician-scientists do not receive dual degrees but rather are MD physicians who began conducting research after residency. Degrees are imperfect signals of scientific acumen, as SBM readers surely know.]
One tricky bit during MD/PhD training (and presumably also during the career of a physician-scientist) is transitioning between lab and clinic. One of the feared jumps is what I am facing right now: after years of focus on my thesis project, I will begin clerkships with third-year med students fresh from their USMLE board exam. Of course I forget much of the detailed knowledge about drugs and diseases that I accumulated for the board exam, which I took in 2006. My clinical skills, rudimentary as they ever were, are undoubtedly quite rusty. Just to top it off, all my friends who shared first and second year with me are now residents, so I know few of my new classmates!
As I transition back to med school, I am reflecting on my grad school experiences and how they will support my further training. The details of my research project will not likely lead to any breakthrough cures, but by participating in the endeavor of science I am beginning to truly appreciate the painstaking process by which scientific knowledge is generated. My experiences in the lab have taught me the risk of relying on a transitory positive finding before it is replicated. From designing my own experiments, basic they may have been, I can recognize how challenging it must be to properly study a complex intervention in human subjects by asking focused questions and adhering to rigorous methodology. In graduate school, students are trained to ask not just “what do you know?” but more importantly “how do you know it?”
On the other hand, first and second year of medical school are largely concerned with teaching the basic facts and models that undergird modern medicine. Courses such as the biochemistry and physiology are often referred to as “science” courses, but in general these courses teach the results of science without dwelling much on the process of science. This focus on facts is understandable; physicians cannot function without knowing the languages of genetics, anatomy, pharmacology, and the like. But I wonder if an adverse effect of these years of rapid fact accumulation is an overly trusting attitude towards authorities. Most of the curriculum in years 1 and 2 of med school represents the consensus that forms the knowledge base of medicine. It can be learned not just from textbooks and lectures but from review books and even Wikipedia at times. A lecturing professor is not challenged; rather, her words are dutifully transcribed and memorized for the test. And safely so! Lectures rarely focus on controversy or uncertainty. Therefore, the first half of medical school imparts a great amount of requisite knowledge, but it does not do much to encourage scientific skepticism.
[CAM tie-in: Some training programs for alternative practitioners describe similar "science classes" to those taught in medical school. Even assuming high quality, such classes (in medical school, naturopathy school, whatever) are more about teaching dogma than critical thinking. Physiology dogma is more useful than homeopathy dogma, to be sure, but such coursework is nothing like the training of a scientist.]
The good news is that third year looks designed to begin fostering independent learning and critical thinking in a clinical setting. My new med school classmates and I were advised, “Don’t complain that ‘no one is teaching me.’ The physicians’ top priority is the patient, not you. Take charge of your own learning.” Of course there are still a lot of new facts to learn (and in my case, old facts to remember), so I’ve already bought a ponderous textbook for my first clerkship. But the book-learning is supplemented with apprentice-style participation in care for patients. Ultimately, it seems to me, the challenge of medicine is the thoughtful application of population data to the care of the individual, and I expect that third year will begin my training in this art.
I recognize that we neither need nor can afford to train all medical students to be physician-scientists. I also recognize that the pre-clinical years of undergraduate medical education have little room for learning goals beyond mastery of basic facts. But I wonder, particularly as I read SBM reports of sloppy thinking and bad science permeating medicine and academia, if a shift of focus from “what we know” to “how we know” might be in order. In the age of smart phones and handheld computers, instant recall of obscure facts by human brains may be slightly less important than it once was. Web-savvy patients come to the doctor with facts and myths and worries. The physician of the future surely cannot know everything but must be able to evaluate anything.
I am halfway through Snake Oil Science by R. Barker Bausell (reviewed by Dr. Hall). The lessons of this terrific book are what I wish I had found more of in med school so far.
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