“Hard science” and medical school

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.

Posted in: Medical Academia, Science and Medicine

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60 thoughts on ““Hard science” and medical school

  1. Mark P says:

    The humanistic part of medicine is very important to being an effective doctor

    If I want to meet someone who is in touch with people, I don’t go to a university Humanities department!

    Getting Humanities trained doctors will not raise the human touch of doctors, as much as the Humanities would like it to be true.

  2. twaza says:


    I think your attack on EBM was not only irrelevant to your main argument, but wrong. You have reified it into something it isn’t, and criticised it for things that may be true of certain people at certain times but are not true of EBM in general.

    EBM isn’t a church with a creed written in stone or a club with defined entrance criteria and explicit rules of behaviour.

    EBM has progressed and developed over the years as we have learned how to take account of evidence in clinical making, and I think that you will find if you look that any differences between SBMers and EBMers have more to do with personalities than the issues you raise.

  3. Marge says:

    It’s a big assumption that science qualification = appreciation of the scientific method. I’ve come to medical school without science qualifications, and I’m a helluva better critical thinker than a large proportion of my peers – I was the one who spoke up in our credulous CAM lectures, not the majority round me who have those science qualifications.

    You can get good grades in undergrad science through regurgitation rather than understanding, which means a lack of appreciation of the scientific method. You seem to think that critical thinking is not taught in humanities, which in the case of history (my undergrad) is just wrong – not the scientific method, but the importance of having evidence behind a statement is a core skill.

    Secondly, most UK medical students come straight from school with school-level science qualifications – so, with the exception of a handful of mature students in every medical school, no medical students in this country have the level of science education that you seem to think is essential. I’m not sure how to do an appropriate comparison of levels of woo between two countries, but my impression wouldn’t be that the UK has vastly more than the US (I could be wrong). I’ve also never been presented with any evidence that we produce worse doctors than the US, especially as a good number go over to work in the US and pass the USMLE like everyone else.

  4. David Gorski says:


    I haven’t said anything that hasn’t been said on this blog many times, namely that EBM as practiced does in essence worship RCTs almost above all else. More relevant to the distinction between SBM and EBM, EBM does relegate basic science to the very bottom of the evidence heap. As for the “personality” issue, that strikes me as even more of a red herring than you accuse me of.

    In any case, do you have any evidence to back up your statement that EBM is really the same thing as SBM and it’s just the personalities involved that make the difference? For example, has the EBM paradigm recently changed to take into account basic science prior probability? (It’s possible I missed it if it did and used an old link.) Show me, for instance, how EBM takes into account the extreme scientific improbability of the magic that is homeopathy in its evaluation of the evidence regarding homeopathy. I’m perfectly willing to consider the possibility that I’m mistaken. In fact, when SBM first started, I made many of the same arguments you appear to be making (other than the personality argument, which, as I said, is a truly weak and unconvincing argument). I argued with Kimball and Steve in epic e-mail exchanges that they were wrong, that EBM does take science into account, that their criticisms of EBM were off-base or overblown. Over time, they convinced me otherwise. I could be convinced back to my old view with sufficient evidence; so feel free to try.

    In the meantime, as has been stated time and time again over the last two and a half years of this blog’s existence, our view is that SBM is in essence EBM as it should be practiced, EBM that actually takes into account all the evidence and not in practice only clinical trial evidence. As for relevance to medical school education, the relevance is that the lack of basic science and firm grounding in the scientific method risks making the current situation with quackademic medicine even worse than it is. You can disagree, but do please tell us how EBM doesn’t have a problem with considerations of prior probability when it comes to CAM.

  5. doublehelix20 says:

    Do most major medical schools also educate PhD students? I’m curious as to whether professors who also teach graduate students might be more inclined to teach medical students similarly, i.e., underlying mechanisms, or if there’s any difference in medical education at schools with grad training programs than those without. I mean, I suspect not, but my own anecdote is kinda mixed. We could always pick out the profs (clustered in immunology, mostly) who had lectures meant for medical students (lots of memorization, very little explanation of what was going ON). But we also had a couple MDs that lectured LIKE PhDs…

  6. I was just discussing something similar about understanding science with my wife yesterday. She is a Pharmacist and a student asked her what the difference between Wafarin, Plavix, and aspirin was and why you’d prescribe one over the other. She explained the difference to her and the student was amazed that she could “memorize” so many things. My wife said said something to her like, “yeah, I don’t know where that came from.”

    I chastised her when she told me that story. She needed to give herself and her education more credit. I told her that she remembered that information not because she “memorized” it, but because she really understood the bodily systems the drugs are acting on and how they act on them. (In more technical terms she really knows her pharmacology)

  7. phren0logy says:

    What I noticed in medical school is that information is presented at such a rapid pace, there is very little time to examine that information critically.

    The main problem is that it encourages taking information at face value, leaving students vulnerable to uncritical acceptance of both implausible therapies and pharmaceutical industry marketing.

    Lastly, I see a strong core of key players moving psychiatry toward increased scientific rigor. I’m hopeful that the explosion in neuroscience research will continue to bear fruit along these lines.

  8. Xplodyncow says:

    May I (pretty please) have some clarification on SBM? Dr. Gorski writes, “SBM tries to overcome the shortcomings of EBM,” including its “blind spot.” What blind spots does SBM have (if any)?

    And now to play devil’s advocate (mwahahahaha!): It seems logical that a solid foundation in the hard sciences is necessary to practice medicine. But is there a correlation between how well physicians did in their required science classes and how effective they are as physicians? What if well-designed studies showed that the hard sciences have no effect on how well physicians practiced medicine — should med school requirements then be changed?

  9. Kylara says:

    I agree with Marge; I don’t have a degree in science, but that doesn’t stop me from UNDERSTANDING science, and most particularly understanding “woo” and bad science. (I teach undergrad philosophy; I end up spending enormous amounts of time in that class explaining why evolution is true and is not a belief-optional situation — AFTER my students have had biology AND DID NOT LEARN IT IN THAT CLASS.)

    In fact, I have known several science majors and engineers with the heavy science background who refuse to “believe in” evolution (including some in medicine!), who refuse to “believe in” climate change, and who continually appall me by applying the word “belief” to scientific theories, as if they were religious dogmas one could take or leave.

    Critical thinking and the history of science were both taught extensively in my humanities curriculum, which I think frequently gave me a better understanding of the scientific method than my peers who were frantically cramming and regurgitating science itself without caring what it meant. (In fact, I was employed in a chemistry lab, getting the job above several science and pre-med students, because I was curious, careful, and interested in the work. I knew a lot about the topic because I was interested in chemistry, and I showed an ability and willingness to learn. Most of science students who interviewed, my boss said, didn’t really care what the lab did and didn’t know anything about it because it wasn’t covered in the official coursework. The good students had research assistantships already and didn’t want this job; the middling students just crammed-and-barfed their way through and wanted to pad a resume. Chemistry itself wasn’t interesting to them.)

    In fact, that is why I didn’t study science, despite my fascination with the the biological sciences in particular — I learned in high school that it was a struggle for me to learn science the way that we teach it, cramming and regurgitating along a specified, often disjointed path that’s frequently totally disconnected from “real life.” Here, memorize all the parts of the cell and what they do. Now label them. Good, you understand cells. But what I needed to do to learn science was have the freedom to explore the ideas, read the history, try some things. High school biology made cells downright boring until my squash started wilting and I was reading college botany textbooks to figure out wtf was wrong with them — and look at that, it as cellular! Suddenly the cell components and processes were interesting and relevant and I remember them all now. I struggled to keep up in science classes in high school and the early years of college because I kept trying to LEARN what we were being taught, and that was not the point of science classes — the point was to regurgitate it all on tests, not understand it.

    I don’t think the fault is in me, or my ability to understand science. I think the fault is in a narrow model of student learning that insists ALL students will learn topic X in exactly 16 weeks, regardless of how long topic X may require and regardless of individual student learning differences.

    And now that I’m on the topic of science education that drives students away from the sciences, this is a big topic in K-12 education. Because the cutting edge of biology is in microbiology, for example, we have high school students study microbiology — in a disconnected way where they don’t really know what these processes mean or do (even if they memorize it) and don’t really understand why it’s important. It’s becoming difficult to even FIND scientists who are what we might call “naturalists,” who understand animals and plants at a “macro” level. A good biology curriculum for K-12 students starts macro with things that are observable and begins to teaching them about their world, working into more complex things and eventually into the micro levels of the world. But because our colleges emphasize research and cutting-edge science, not teaching, and our teacher training and subject matter training don’t match up at all on any topic, we have more and more students who are taught random, disconnected science and ask, bored, how this relates to the “real world.” Which is probably why I’m sitting in a philosophy classroom explaining evolution and WHY IT MATTERS over and over and over.

  10. Kylara says:

    I meant to say, grad school also emphasizes specialization, and what K-12 students DON’T need is specialization; they need someone with a broad, interconnected understanding who can introduce them to science and help them draw connections. We don’t reward that at the college or graduate level, and finding science teachers is hard enough. Finding ones who are trained appropriately and have the correct skillset to teach K-12 students is becoming impossible. It’s just luck, really, if they happen to be good at teaching K-12 science because we certainly don’t train teachers for that. And that leads us to students who enjoy the sciences but abandon them as “too hard” because they’re taught poorly, and students who go into the sciences and are content to cram-and-regurgitate and take information at face value in the race to memorize everything necessary.

    I also did not mean to write quite such a novel or quite such a tangent.

  11. marcus welby says:

    Kylara: ….and why, as comedian Lewis Black observes, the majority of the population thinks THE FLINTSTONES is a documentary.

  12. DTR says:

    Not a tangent at all, an excellent addition to an excellent article.

    As a graduate student at a military technical/engineering school, I am amazed that there are so many “skeptics” of global warming and evolution enrolled here. One fellow student even referred to a publication from the Oregon Institute of Science and Medicine as “hard, factual data.” A presentation by a faculty member on The Origin of Species produced such an acrimonious atmosphere that students had to be reminded to speak respectfully to faculty (not something you usually have to remind military officers).

    My point is basically the same as Kylara’s – one’s undergraduate degree (mine was in economics), is less important than the ability to think critically and to see through pseudoscientific garbage, which is the core of the scientific method. I’m not saying that a science education is unnecessary, just that teaching critical thinking needs to be the core of both a humanities-based and science-based education.

  13. David Gorski says:


    I agree that more emphasis on basic science than what is required now won’t guarantee more critical thinking. I do think, however, that the converse is likely to be true: Less basic science is likely to make it less likely that physicians in training will imbibe deeply of the scientific method to the point that they can recognize most bad science and pseudoscience when they see it, be it from CAM practitioners or pharmaceutical and device manufacturers. In other words, less intense training in basic science is arguably likely to make the situation worse.

    Personally, what I’d like to see is training that combines training in critical thinking (which can be done through the humanities, such as philosophy and logic) with a detailed study of the scientific method.

    I’m also not particularly surprised about the talk on evolution. There are, unfortunately, also many physicians who deny evolution. One prominent example is Dr. Michael Egnor, a creationist neurosurgeon about whom Steve Novella has blogged on NeuroLogica and I’ve blogged as my super secret alter ego. Dr. Egnor, who seems to be a capable and respected neurosurgeon, is capable of laying down some astounding idiocy about evolution on a regular basis over at the propaganda outlet of the Discovery Institute. He’s also an anthropogenic global warming denialist and regularly argues for mind-brain dualism using language the rivals Deepak Chopra in its inanity. In fact, he’s arguably quite anti-science in that he has written some astounding attacks on scientists in general, most recently after the “Climategate” fiasco.

    One reason I’ve seen postulated why engineers and physicians tend to be prone to this sort of pseudoscience is that they are not scientists per se, but rather apply science to practical problems. Consequently, in the normal course of their education, it’s quite possible for them to complete their educations and become highly competent in their fields without much exposure to or experience applying the scientific method. I’m not sure I entirely agree (after all, there are “pure scientists” who also fall for pseudoscience), but I see the point. Most engineers and physicians are not scientists, although their professions are supposed to be science-based.

  14. superdave says:

    I can tell you that even in the engineering disciplines student feel as though that math and science portions are just the rough classes you have to “get through” in order to graduate. I think that there is a real problem developing in the undergraduate curriculum where students just think of classes as nothing more than benchmarks. There was a recent new york times editorial about plagiarism which implied that liberal arts majors are having the same problem.

    We need to teach students early and often why the topics they are studying are important. This should start in the first grade and continue really I thin for the rest of life.

  15. superdave says:

    I really liked your post. I DID have a pretty intensive science background as an undergrad and I felt that I learned just as much about the scientific method from this blog than I did in 2 years of undergraduate work. I don’t think my education really taught me anything about how science is done until I joined a research lab. That experience taught me a hell of a lot more about how science works than any class.

    Where the core curriculum comes into play is not in designing or performing experiments, it’s in intelligent hypothesis formulation and the interpretation of data. Here is a trivial but instructive example, Trying to calculate the speed of gravity lead you to very wrong results if you did not know that objects in free fall do not fall with constant velocity. You could throw objects off a building and time their fall, divide the height of the building by that number, and determine an average velocity. The experiment would be ok, but unless you know that x= (at^2)/2 is the correct formula to use and not x=vt, your final results will not be interpreted correctly because you will be missing a key insight into how your experiment actually works.

  16. overshoot says:

    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.

    You could also note that homeopathic dilution (lots of copies of the same information from a few without expending free energy) violates the Second Law of Thermodynamics: the organization of the system is increasing, rather than decreasing.

    Oh, wait — I forgot that the intent of the preparer is essential to separating the “remedy” from the fish feces.

  17. Adam_Y says:

    I agree with Marge; I don’t have a degree in science, but that doesn’t stop me from UNDERSTANDING science, and most particularly understanding “woo” and bad science.

    I doubt it. In a lot of cases understanding a bad science involves a heck of a lot of background in a specific field. Take for example homeopathy. The fact that it violates the laws of mass action and thermodynamics are the least of its problems. It doesn’t take into account acid base theory which says that a glass of pure water is composed of three compounds. It doesn’t take into acount molecular symmetry which dictates how things vibrate.

  18. Adam_Y says:

    I don’t think my education really taught me anything about how science is done until I joined a research lab. That experience taught me a hell of a lot more about how science works than any class.

    Superdave are you an engineer? If so why the hell are you complaining about not receiving an education about how science works when you went to college to get an engineering degree.

  19. Kylara says:

    “I doubt it. ”

    Oh, I see. It’s a special holy field of knowledge which outsiders cannot access the interior knowledge of without undergoing an initiation process limited to a special few identified from on high as worthy.

    If science is too hard to explain to average folks, then I think you shouldn’t wonder at or rage at people’s inability to understand science properly. Nor should you worry about poor science education. Nor should you be concerned about whether humanities majors understand science. It’s just too hard for my poor little humanities brain to comprehend!

    You also rather prove my point about shit science education — “Kids, I’d tell you why homeopathy is a farce, but you just won’t understand it without advanced physics and molecular chemistry, so take my word for it. I know what I’m talking about. Keep in mind in 10 years or so we scientists will be busy complaining about your total inability to understand how science works and your willingness to take the word of authority figures making outlandish claims, and don’t say I didn’t warn you!”

    I completely reject your assertion that science is just “too hard” for regular people to understand, and that attitude is an ENORMOUS part of the problem.

  20. rork says:

    Probability and statistics is lacking, even in the PhD’s.

    It’s largely about how to interpret evidence.
    It is interested in modeling how we learn, and how not to fool yourself.
    It has areas wholly devoted to how to make decisions.
    It helps with the design of experiments too, for researchers.
    Could be important, eh?

    It’s not that new either, but mathy things may be the stuff the people who like squishy subjects, like cellular biology, hate the most. I liked it cause I hated memorizing things.

  21. moderation says:

    I think it is amazing how LITTLE medical school education changed over the years, especially when you consider how much the knowlege base has expanded over the last 40-50 years. For example, just consider pharmacology and the increasae in the number of drugs … it has been an exponential explosion and yet the amount of time devoted has hardly changed. In my opinion, we should be completing the current first year classes of medical school (biochemistry, anatomy, etc.) in undergraduate school to allow more time to be spent in training in the current second year courses (pathology, pharmacology, etc.) and the clinical time of the current 3rd and 4th years.

  22. Harriet Hall says:

    My pre-med major was Spanish language and literature, which allowed me to spend my junior year in Spain and have the mind-broadening and highly educational experience of living in another culture. I got a good, broad liberal education (was even elected to Phi Beta Kappa) that I think helped make me a better doctor. I took all the required pre-med science courses too, but most of what I learned there was irrelevant to practicing science-based medicine. Their only value was teaching me the language of science and the basic concepts that I would need to understand the material taught in med school. I learned most of what I know about the scientific method after I retired from the practice of medicine.

    In my opinion, two points argue against the existing pre-med science requirements:
    (1) the current system has produced a lot of MDs who don’t really understand science
    (2) PAs, with a much less rigorous education, can do an excellent job of providing science-based medical care.

    The existing pre-med requirements might be replaced by a course teaching pre-med students what they really need to know about basic science and the scientific method.

  23. Adam_Y on bullshit detection: “In a lot of cases understanding a bad science involves a heck of a lot of background in a specific field. Take for example homeopathy.”

    Homeopathy is an example of how an ordinary person with critical thinking skills and basic high-school math and science could see right through the quackery. I do not need a PhD in chemistry with the accompanying research and literature interpretation skills, or any other measure of “a heck of a lot of background in a specific field,” to know that homeopathy cannot work as proposed.

    In ordinary clinical practice, say when trying to understand what the evidence says about using medication to treat personality disorders, or surgery to treat MS — yes, you may need a heck of a lot of background. Absolutely.

    Question: is this deep background in specific fields (pharmacology, personality disorders, autoimmune disorders, venous anatomy) what pre-med students are expected to bring with them into medical school? If not, what is your issue?

    I’d be interested in seeing more data on the outcomes from this program wrt the practice of SBM. It’s possible that whether medical students come from disciplines that require critical thinking (anything that tests theories with data, whether from the humanities or sciences) vs those that don’t (say, voice performance, or any science program that doesn’t emphasize research skills at the undergraduate level) is more important than whether the particular discipline is classified in the arts, humanities or sciences.

    I understand the fear of welcoming medical students who may use an animist, non-rational strategy for interpreting the world. What’s not clear to me is why it would be assumed that chemists and physicists are the only people who use objective standards and need to justify themselves. If critical thinking skills are what a student most needs to bring with them into medical school, there’s no reason a good humanities program can’t provide them. (See Kylara’s frustration that students study evolution in biology class but that the critical thinking required to understand why it’s important and not optional is what she teaches in her humanities class.)

  24. David Gorski on the scientific basis of psychiatry: “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.”

    A nice post by a psychiatrist about the scientific basis of psychiatric practice:
    “Clinical practice within psychiatry is a very mixed field indeed. Most areas of Secondary Care medicine have diversity in approach but, by and large, the majority of doctors have similar approaches to care. Management of MI, childhood atopy, pre-eclampsia, lateral epicondylitis, angina, COPD or whatever is variable. But not that variable. Maybe one clinician would favour a NSAID over a moderate opiate, but by and large the care pathway is similar. Maybe one medic would do X first then Y, another would do Y then X, but over time most of their patients end up with mostly the same treatment.

    Not so in psychiatry.”

  25. bluedevilRA says:

    Great post and great discussion so far. I will briefly add that I was a history major with bio and chem minors. My critical thinking has mostly developed from free reading (not from my science or humanities courses). I think the bottom line is that you need to have a diverse education and a teacher (whether through class or through books) that emphasizes critical thinking. Carl Sagan advocated that all physicists take courses outside of the “hard” sciences and he personally taught a course in critical thinking at Cornell. As a current med student, I would love to see a critical thinking course added to the curriculum. Perhaps we should add them at the high school and college level too?

  26. At the risk of stirring up a hornet’s nest and in all seriousness, aren’t poor MCAT scores why many people choose to go to osteopathy school instead of medical school?

  27. @ Adam_Yon
    “Superdave are you an engineer? If so why the hell are you complaining about not receiving an education about how science works when you went to college to get an engineering degree?”

    Because if you’ve ever studied engineering in college, you’d know that engineering students don’t really study the basics of how science works. Engineers are not scientists, and they are not trained like scientists. A lot of undergraduate education in general is more about memorizing facts, figures, formulas, and processes rather than fully understanding underlying concepts.

    Not being an MD, I’m going out on a limb a little here, but…If doctors are going to be consumers of medical literature that includes reports on clinical trials and other scientific papers, they need to get a basic understanding of science, the scientific method, statistics, experimental design, and critical thinking from somewhere. Doctors probably couldn’t practice cookbook or Wikipedia medicine and be effective. They need to ability to make judgment calls in diagnosis/treatment, and they should have a good background in the above to call on when making those judgments, especially when something doesn’t fit well within their current knowledge base…here lie dragons!

    Frankly, I think formal education in critical thinking is something that should be required at all education levels from primary education through post grad.

  28. qetzal says:

    I completely agree with all the above comments that MDs need a better grasp of critical thinking & the scientific method. However, I don’t agree with Dr. Gorski’s thesis that premeds therefore need hard-core science classes like organic chemistry. Honestly, I can’t imagine even 0.1% of practicing MDs ever using even a tiny fraction of what we learned when I took OChem. Heck, as a career researcher with a PhD in mol bio, I’ve worked very closely with organic chemists, co-authoring multiple scientific papers with them, and I’ve never used more than a tiny fraction of what was taught in OChem!

    As other have argued above, I think it would be much better for pre-meds to take a course that specifically teaches critical thinking & the scientific method, with an emphasis on medical aspects like clinical trial methodology, bias, etc. The whole topic should then be re-taught to 1st year med students.

    I’d happily delete OChem from the pre-med curriculum if it was replaced by something like that.

  29. David Gorski says:

    Well, we could argue about how much organic chemistry is needed, but I point out that organic chemistry is rather necessary to understand basic biochemistry and pharmacology. Do you think biochemistry and pharmacology are similarly unnecessary? Do you not use pharmacology and biochemistry?

  30. bluedevilRA says:

    Karl, in general, MCAT scores are lower at osteopathic schools than MD schools. Of course, there are exceptions. Michigan State and the Texas College of Osteopathic Medicine have decent MCAT scores that are on par with average MD schools (they also have USMLE board scores that are on par with MD schools).

    Dr. G, I agree orgo is needed for biochem and pharm. However, I think the 2 semesters of orgo primarily serve to weed out students. Courses more tailored to pre-meds could be created for chemistry, physics, etc. with critical thinking intergrated into them at the undergrad level. All of my professors joked about how no one wants to become chemists or physicists anymore. Everyone takes those courses simply because they are required to be pre-med.

    I understand the point that Mount Sinai is trying to make. They want out of the box thinkers, people that aren’t just jumping through the pre-med hoops simply because they are told to so. I am all for educational diversity in medical school, but I think they are going about it in the completely wrong way.

  31. Mhops says:

    Dr. Hall’s points are well-taken.

    I think that there is a certain amount of “pre-med” material that does not, necessarily, make providers better critical thinkers and evaluators of information. On the other hand, there is likely quite a bit in the vast liberal arts curriculum that does do that. Finding a common ground/foundation is a good ideal. While I do use Pharmacology and basic sciences, I use but a fraction of what I was taught. We need to find a way to sift through this and maintain the most necessary parts. This definitely should include skills training in the scientific method and critical thinking — even for those who choose the traditional/standard science track.

  32. Mike1 says:

    Hello everyone,

    I enjoy this site a lot, I’ve lurked for a while and this is my first time posting.

    Anyways, I was wondering what you thought about making the pre-requisite courses a bit more focused on medically relevant areas. Take physics for example-might it be a good idea to spend a little less time discussing blocks on a plane in favor of things like electrical properties of cell membranes?

    As far as critical thinking in general is concerned, I’ve think that everyone should have courses in logic and statistics, especially if they’re majoring in science/science related fields.

  33. clodia83 says:

    It seems to me that what students like Ms. Adler want is to be social workers with six figure pay checks and a more prestigious suffix on their business cards. The world needs good social workers, patient advocates/interventionists, health educators, licensed therapists, etc, and they should be paid more than most are.

    But the man or woman writing my prescriptions really ought know how the drugs I’m taking will effect me or interact with other drugs. While memorization is fine in the short term, it seems to me that with thousands of different brand name drugs out there with multiple names often ascribed to each, it would be important for an MD to be able to read and understand a list of ingredients and what they REALLY mean.

    I have a degree in Classical Languages, so I’m usual first in line to defend the Liberal Arts, and I use those skills a fair bit in my non-clinical role in a hospital workplace. But personally, the more my physician knows about the pills I’ll be swallowing, the more sure I can feel as a patient that I am getting the right treatment.

    There is a difference between translating Latin and reading it. I couldn’t learn to truly read Latin until I understood it’s etymology. One can memorize one’s way through pharmacology, but I don’t believe it could be truly mastered without organic chemistry.

  34. I took two semesters of organic chemistry as an undergrad, and it was no big deal. Not sure what people are getting all agitated about. I found it fundamental to my BSc studies in Human Nutrition, and not just because we did analytical chemistry in the food science portion. It was useful background for my biochem courses and I can’t imagine that it would be less useful for someone studying pharmacology or toxicology.

    One thing I’ve noticed is that after I’ve taken a course I take for granted what I’ve learned. I’m a very poor judge of the benefit I took from a class. As a mundane example, I learned that dairy products are low in iron, that meat products are high in highly-available iron, and that plant products have variable iron content of variable availability (but always lower than meat). I don’t expect non students of human nutrition to be familiar with the fine points of the debate over whether breast-fed infants need iron supplementation after six months, but I assume everyone knows that cheese is not a source of iron. Which of course they don’t. Unless I’m reminded that I had to go to college to learn it (whatever “it” is), I’ll tend to assume it’s common knowledge.

    Which is a roundabout way of saying that you may have learned more in your organic chemistry courses than you realize. After having suffered through boring, confusing, unintuitive OrgChem, you got to the good stuff — which you were, perhaps, able to absorb relatively quickly and easily thanks to your OrgChem background. (Then of course poor old OrgChem suffers even more piteously by comparison.)


  35. jmm says:

    In this article, you seem to equate good training in science with the current requirements of organic chemistry, calculus and physics. It’s hard to think of less relevant science courses. They are keeping the requirements of general biology and general chemistry, the relevant ones. General chemistry is quite sufficient to see why homeopathy is silly, organic chemistry adds nothing. One can do just fine in a biochemistry class without taking an o-chem prereq first. I certainly did.

    What astonishes me it there is no med school requirement for probability and statistics (so that students know what a prior probability IS, to begin with), and often no requirement for genetics (even if many premeds take it). “Science” does not equal “reductionism”. Clinical trials are a core part of the scientific method. Their methodology can be learned very well in a psychology, animal behavior, or ecology class. I am all for a total revision of the requirements to ask for RELEVANT sciences, something the MCAT does not currently do. At my institution, the O-Chem requirement means that students postpone taking biology and genetics and likely forgo more advanced biology courses, and the calculus requirement displaces statistics.

    As for critical thinking via the scientific method, as somebody who teaches science to premeds, I see every day that the system is broken. Students are more likely to learn critical thinking in a philosophy class than in a science class. I am doing my best to fix this locally, but there is a system-wide problem.

  36. superdave says:


    there are two reasons.
    1) I am in a very research oriented area of engineering and many engineers in other areas do research too. That’s what the R stands for in R & D.

    2) Required for my major were two semesters of bio, one advanced biology elective, 4 semesters of physics, 4 semesters of physics lab, 2 semesters of chemistry, one semester of chem lab and one semester of physiology.

    I would like to think that all of those courses would have done a better job of teaching how science actually proceeds.

  37. Adam_Y says:

    Homeopathy is an example of how an ordinary person with critical thinking skills and basic high-school math and science could see right through the quackery. I do not need a PhD in chemistry with the accompanying research and literature interpretation skills, or any other measure of “a heck of a lot of background in a specific field,” to know that homeopathy cannot work as proposed.

    Fine then tell me why the vibrational aspect of homeopathy is wrong from a chemistry perspective if you know its so readily obvious that it doesn’t work.

    Oh, I see. It’s a special holy field of knowledge which outsiders cannot access the interior knowledge of without undergoing an initiation process limited to a special few identified from on high as worthy.

    Actually, everything I listed there was either basic high school chemistry or something you learn with a degree in chemistry. The point is that critical thinking skills are utterly useless without the basic science background to utilize it. And also get over yourself. The mentality that every single subject and area of science can be distilled down to a simplistic easy to understand piece of information is why a lot of pseudoskeptics exisist in the first place.

    Because if you’ve ever studied engineering in college, you’d know that engineering students don’t really study the basics of how science works. Engineers are not scientists, and they are not trained like scientists. A lot of undergraduate education in general is more about memorizing facts, figures, formulas, and processes rather than fully understanding underlying concepts.

    Yeah I know that they aren’t supposed to be trained like scientists. Scientists in general don’t face open ended problems which would mean you are getting a crappy education as an engineer if you learn about the scientific method.

    Well, we could argue about how much organic chemistry is needed, but I point out that organic chemistry is rather necessary to understand basic biochemistry and pharmacology.

    Actually, the ACS meeting in Boston has a chemistry skeptics track in it. One of the interesting presentations that is being made is about the incorrect stuff presented in undergraduate organic chemistry.

  38. Adam_Y on the plausibility of homeopathy to all but highly-trained chemists: “Fine then tell me why the vibrational aspect of homeopathy is wrong from a chemistry perspective if you know its so readily obvious that it doesn’t work.”

    I didn’t say chemistry, I said basic math and science. Entropy should cover the vibrational aspect of homeopathy nicely, which I remember learning about in grade nine Physical Science.

  39. phren0logy says:

    In my humble opinion, the world is changing. In a world were NPs and PAs provide quality medical care, the physician has to offer something additional to be worth the added cost to the system.

    I think that this added part should be a strong background in science-based methods and practices, including a robust understanding of how to read and appraise the literature.

    I also hope that others are also doing their part, putting their money where there mouth is, and getting involved in medical student education to help address some of the perceived shortcomings.

  40. moderation says:

    “(1) the current system has produced a lot of MDs who don’t really understand science, (2) PAs, with a much less rigorous education, can do an excellent job of providing science-based medical care.”

    This lack of science knowlege among practicing physicians would seem to argue for more basic science classes, not less. I found a lot of the people who applied to medical school were taking the least difficult classes possible to get their Biology degree in order to maintain their GPA. I do agree that a class focused on the scientific method would be a great idea – either in undergraduate or medical school.

    While there are exceptions to every rule, and I have run into the occasional PA that I would say is functioning on par with the average physician, my experience has been that PA’s are at their appropriate depth when they are exactly that – a “physician’s assistant”. Functioning at about the level of a 1st year resident – as surgical assistants or following patients post-op in the hospital or clinic. Where I have found most of them lacking is in the depth of science-based knowlege necessary to practice primary care or in the ER. PA’s were removed from the ER’s of the large hospital system I worked in specifically due to errors from lack of knowlege base and experience during training. PA school is as short as two years, not all even require a Bachelors degree and some require as little as 500 hours of clinical experience (about 12 40 hour weeks). In medical school my 3rd year internal medicine rotation alone was more than 500 hours.

  41. I’m a little surprised no DO’s (or any MDs for that matter) have replied to my osteopathy school comment yet.

  42. bluedevilRA says:

    Karl, I wrote (about 10 posts up) on DOs and MCAT scores. I am a DO student.

    Another point to add to the MCAT discussion: the reason most medical schools religiously adhere to the MCAT as an admissions standard is because it has a high correlation to a student’s future board scores. Med schools want their students to do well on the boards because it makes the school look good (plus the doctors are likely to go on to be rich and donate money back to the school).

    This does not mean that MCAT score = USMLE score = critical thinker. The MCAT is a rough approximation of how well someone understands the 4 basic sciences that are tested (general chemistry, organic chemistry, physics, and biology). That is it. You can be an evolution denier, a germ theory denier, and/or the worst quack in the world and still do well on the MCAT. Likewise, you can do well in undergrad science courses, med school, and the boards.

    According to Dr. Stephen Barrett at Quackwatch, DOs do seem to have a slightly higher rate of quackery. This may have to do with less scientific backgrounds before medical school or it may have to do with a less scientific currculum in medical school (less emphasis on research and physician-scientist programs). However, it is worth nothing that Quackwatch is merely a list of quacks that Dr. Barrett has compiled over the years, where DOs seem to be overrepresented relative to the total physician population. It is not a rigorous analysis.

  43. qetzal says:

    David Gorski writes:

    Well, we could argue about how much organic chemistry is needed, but I point out that organic chemistry is rather necessary to understand basic biochemistry and pharmacology.

    I agree that understanding the intrinsic chemical behavior of organic molecules is essential. However, that’s not what OChem was really about when I took it. I recall spending the vast majority of time in OChem learning things specific to synthetic organic chemistry. Grignard reagents and alkyl halides and Diels-Alder reactions. I.e. mostly the stuff that synthetic organic chemists need to know.

    For us, at least, the more fundamental stuff that underlies biochem or pharmacol was covered in basic chem & biochem classes. Maybe things are taught differently now; it’s been ~ 30 years for me.

  44. Adam_Y says:

    I didn’t say chemistry, I said basic math and science. Entropy should cover the vibrational aspect of homeopathy nicely, which I remember learning about in grade nine Physical Science.

    Nope. You are thinking of the memory of water.

    Adam_Y on the plausibility of homeopathy to all but highly-trained chemists:

    Yeah I’d really hate to scare you but you have more chemistry background than I do.

    1) I am in a very research oriented area of engineering and many engineers in other areas do research too. That’s what the R stands for in R & D.

    Yeah that doesn’t exactly explain anything. My PHD adviser engineer does research with biomedical imaging. Another faculty member is studying metastasized cancer as it travels through the blood stream. I know someone who worked at a synchrotron and researched magnetic materials. I work on fuel cells and energy production devices. We all work in the same department. So pray tell to me how any of us can provide a consistent method of how to do science when it is different between each and every one of us. Its the greatest strength of an engineering degree. If you are good you can do anything you want. You may have to backtrack and fill in the gaps if you go really out there but its not impossible.

  45. ScarySkwerl says:

    I took a Neurobiology course as an undergrad 32 years ago and it was chock-full of historical descriptions of how major discoveries were made (e.g. the ionic basis of the action potential using ion substitutions in the bathing medium). I learned a tremendous amount about proper controls and data interpretation from that course. I teach a Neurobiology course to undergrads today. There is SO MUCH MORE CONTENT today that if I were to include all the same experimental strategy content, students would not get “through the textbook”. It’s a Devil’s bargain, instructing the science student of today. The administrative emphasis is on shorter but higher throughput curricula (“college is expensive! the customer is king! profit through volume!”), when in fact a whole year could be devoted to neurobiology and you’d only scratch the surface. I did develop a freshman seminar on critical thinking about health care in general (reading this web site is one of the assignments) and it’s proven to be very popular; we now teach 3 sections per semester to a class size limited to 30 to foster discussions. You can really tell which students are lacking in CT skills and which already have them.

  46. Mark Crislip says:

    As a grumpy old fart, I notice a shift in medicine that makes an understanding of science less important. Because of protocols and science, a lot of the treatment in internal medicine is standardized. Once the diagnosis is made, the therapy is quasi automatic. Because of the high cost of hospitalization, for complex cases there is no longer a stepwise approach to, say FUO. Everything is done at once as it is cheaper.
    As a result, medicine is becoming more of a trade than a profession, since the treatment expertise of the individual doc matters less. Residents are becoming hospitalists, where they work their shifts for 5 days and go home or they are subspecialists. The science is less important as it is a tool that is not needed.
    Between sophisticated testing and treatment protocols, there is little need, and often less curiosity, in the science behind the dx and rx.
    At my advanced age, I get to bemoan the change and talk about the good old days, but there is no doubt in my mind that care in the hospital is the better for it.

  47. swienke says:

    As a current UC San Diego bioengineering undergrad who intends to go on to med school myself, I’ve seen many of the pratfalls of modern science education firsthand. However, I have to wonder if many of the complaints that others have had about basic science classes being better for critical thinking than engineering classes are specific to their schools. I can confidently say that the reverse holds true here, with many of the biology and organic chemistry classes in particular being nothing but memorization with little or no attempts to explain concepts. General chemistry and physics were better from that standpoint, but the most intensive classes in terms of critical thinking that I’ve taken have mostly been engineering classes. Maybe that’s due to the research heavy focus of bioengineering, or maybe that’s just the reason that UCSD has one of the most highly ranked and prestigious bioengineering programs out there. Either way though, many of the basic science classes are rather pitiful from a critical thinking perspective.

    Perhaps due to the faults of the biology classes here, many of the biology majors I know are either completely lacking in common sense, or are downright hostile to actual critical thinking. And yet they’re almost all convinced that they’ll make great doctors. For all of your enjoyment (and/or horror) I’ll tell you a couple rather indicative stories:

    The first concerns a dear friend of mine who has steadily maintained a 3.7 GPA and aces nearly all of her biology classes. This same friend once asked me (in complete seriousness) if goats are male sheep. As I said before, she has a 3.7 GPA. Let that sink in. She says and does equally astonishing things on a regular basis.

    My second year of college I took a mammalian physiology course (for fun), which is supposed to be one of the hardest biology classes available, according to all of my bio major friends. There was a large amount of memorization, but I thought that conceptually, it was very, very easy. However, as we began studying the nervous system our professor made a point about how we should know and understand Ohm’s law (voltage = current*resistance) in order to understand the basic principles of electronic conduction in neurons. Most of the class broke out in a cold sweat: there was nervous laughter, cursing, and a whole bunch of disgruntled muttering about how that was “too hard” or “beyond the bounds of the class,” etc. Ohm’s law is one of the easiest and most basic physics laws out there, and merely memorizing it and understanding how to algebraically manipulate it should be enough to allow one to make sense of a fair amount of electrical phenomena, including the basics of the nervous system. And yet most of the class got less than 50% on the midterm, which focused primarily on the nervous system (I should also note that most of these students had already taken a lower-division biology class that covered much the same material, but in less detail and with less memorization, and yet they still couldn’t handle this). Incidentally, many students began referring to the professor as a total bitch soon after this, which I think says something about many students’ belief that classes are merely something to be aced, not something in which you’re supposed to actually learn.

    I’ve seen similar behavior in many other biology or basic science classes, although nothing quite so extreme. Nevertheless, many of the pre-med students I’ve met prioritize pretty grades and resumes over actual thinking.

    As for organic chemistry, the reasoning behind the mechanisms was never given more than lip service by most of the professors. 90% of the lectures were spent on the professor going over some new mechanisms without any explanation as to why they happened or worked, while the other 10% was spent on the professors’ pet obsessions (like NMR) which, likewise, were never explained. Admittedly, my professor for the first quarter explained most everything, but that’s largely because we only had to cover 10 mechanism for that class, instead of the 40 or so that needed to be memorized for each successive quarter. I learned far more about o. chem. in lab than in class.

    Ah, I’m afraid I’ve ran on for longer than I intended (sorry), but it frustrates me to see the way in which critical thinking is seldom given anything more than lip service in my college, and frustration makes me want to rant a little.

  48. jmm says:

    As a biology faculty member, I have to say that swienke is right, although some of the less premedical bio courses, eg ecology, are much better. And every time we think about reforming the biology curriculum, we find we can’t, apparently because it wouldn’t prepare the students as well for the MCAT. Or simply because the premeds would complain too much that assessing critical thinking was “not fair”. Memorization they perceive as fair, ie something that can be predictably obtained through hard work, and “fairness” is what they prize above all.

  49. windriven says:

    @ twaza

    “I think your attack on EBM was not only irrelevant to your main argument, but wrong. You have reified it into something it isn’t, and criticised it for things that may be true of certain people at certain times but are not true of EBM in general. ”

    The proof is in the pudding, don’t you think? So how do you square the temples of EBM – Harvard, Yale, Duke, Johns Hopkins, et al – pandering splay-legged to the “complementary/integrative medicine” crowd? Is your argument that these medical programs do not offer complementary and/or integrative medicine curricula or that there is ample evidence to support such programs? Either way the, ahem, evidence proves you wrong.

  50. Dr Benway says:

    Knowing how the world works surely can’t hurt a future doctor. A broad exposure to the basic sciences should give a person better problem solving instincts generally.

    Even when the details fade from memory, knowing that one is “rusty” is still preferable to imagining what some field of study must be like.

    If there’s no time to teach critical thinking to doctors, I would settle for imbuing med students with a basic respect for the scientific consensus.

    Too many people seem to feel that absorbing the current scientific consensus regarding some issue is “not thinking for one’s self.” However, the probability that an individual will form a unique opinion that’s more reliable than the current scientific consensus is vanishingly small.

  51. windriven says:

    @ Dr. Crislip

    You may be right for cases where the facts are clear and the diagnosis certain. But how many Gobbets o’ Pus have dealt with unusual situations and uncertain diagnoses? Given a case of the creeping fung I think I’d prefer a professional to a tradesperson.

    And supposing that you are right and AMA becomes a craft guild, who will be left to advance medical knowledge, where will they be trained, where will they hone their knowledge?

  52. weing says:

    I, also belong to the old fossil category. My area is outpatient primary care internal medicine. Critical thinking skills are indispensable here. I do not believe that science is the only way it can be learned. My daughter, who is majoring in English, has to utilize it daily in reading and writing. I recall reading that artists have skills of observation that allow them to more readily note subtle changes in a patient’s mannerisms and appearance that can be helpful in diagnosis. Will we be replaced by NPs and PAs? I hope not. To become an expert in any field, takes about 10,000 hours of working in it. They certainly don’t have that. The protocols that I utilize are the history and physical exam. The protocols used by PAs and NPs are fine if you already know the diagnosis. Their knowledge of the underlying biology and pathology is very superficial. If that ever happens, we will be how China used to be, when all that could be offered to the population were the barefoot doctors and some herbs. Better than nothing, but not good.

  53. Stuartg says:

    @ moderation

    I was trained outside of the US system so can’t really comment on training within the US. In spite of this, I find it difficult to believe that large changes haven’t been made over tha last few decades.

    There has been a considerable change in both the content and the method of teaching at my own medical school over the past 30 years. Direct comparison between my own experience and that of my son demonstrates huge differences.

    As an example, today there is a much greater emphasis on statistical analysis, which is now compulsory for pre-med but there were minimal requirements when I took the course.

    My son also reports that they now teach scientific thinking by using it to debunk much of the woo!

  54. JMB says:

    There are some practical issues to consider in the argument about the need for hard science in the premedical curriculum.

    The first task of a medical school admissions committee is to select students who will be able to complete the medical school curricula. Science courses in college were hurdles to entrance to medical school because an admissions committee could use them to more effectively predict which applicants could complete medical school. Of course, Drs Muller and Kase are challenging that commonly held opinion. Premedical science courses were a good predictor of medical school success because acquiring a large amount of minutiae and absorbing a large number of conceptual frameworks were skills required to pass the medical school curricula.

    A student who could not complete the medical school curricula was considered a disaster for several reasons. The failed student would usually be emotionally devastated (at risk for suicide and/or needing psychiatric hospitalization). They would have large loans to pay off. The school might be criticized for not graduating enough doctors to meet the needs of the state. Tax payer money would be wasted (I don’t know the current estimate of medical education cost, but I think the government subsidy of a medical education varies from $150,000 + in a state university medical school, to $20,000 or less in private schools).

    There are warning signs in the data presented by Drs Muller and Kase.

    “HuMed students were more likely to require a nonscholarly leave of absence for academic or personal reasons.”

    This leave of absence is typically one step away from abandoning or failing medical school, and is a sign of a distressed medical student. Because of the amount of tax subsidy, most medical schools are obliged to offer much assistance (tutoring and psychiatric counseling) to borderline students so that they may successfully complete the curricula. Medical school faculty are also cognizant of the suicide risk of the distressed medical student or resident.

    “HuMed students had lower USMLE Step 1 scores.”

    I assume that Step 1 refers to the basic medical science scores, I don’t know if that has changed.

    “HuMed students were significantly more likely than non-HuMed students to dedicate a year to scholarly research (28.2% or 24/85 versus 14.1% or 86/606, P = .001) and to be awarded a Doris Duke Clinical Research Fellowship (10.6% or 9/85 versus 3% or 18/606, P = .001).”

    Certainly there is a major percentage of those who select an extra year of medical school for the love of research. Just as certainly, there is a percentage of those who select an extra year of medical school for research because they do not feel they are ready for residency. Anyone who spends a year in research is more likely to win a science award.

    Drs Muller and Kase may be looking at their data too optimistically.

    Obviously, there are those with no science background that are better critical thinkers than most if not all doctors. There are those humanities students who will excel in medical school. But if the hurdles in the premedical curricula are removed, then there will be some distressed medical students who will end up jumping off a cliff (more than already do). Better to trip on a hurdle than fall off a cliff, that’s the practical side of the argument.

  55. jamesmprogers says:

    I agree in general with all the points made but I agree with a previous poster in that I think we need to check some of our underlying assumptions.

    Do undergraduate science degrees really teach students good science? In my experience I don’t think so, most of my critical thinking I have developed independently through my own readings (in particular blogs like this).

    The question being asked here is, of applicants into a medical degree, do science backgrounds give a better basis in scientific thinking than do humanities backgrounds? Most people here have said that they probably do, but is there really any evidence for this, and how big is the effect?

    I don’t think the answer is as obvious as everyone is claiming. I know many humanities students in medicine (common in Australia) who majored in philosophy of science type subjects, and hence are very good scientific thinkers. I also know science students who are absolutely crazy woomeisters.

    Science as it is taught at an undergraduate level is all the “good” bits without any focus on the scientific method. We get taught all the theory and mechanisms, and very little about the experimental methods that lead to these discoveries. I have to say I don’t think a science degree means jack as to whether someone is a scientific thinker.

    How many scientists are really scientific thinkers anyway? I have met many academics with professorial appointments who had some very strange ideas about the scientific method.

    I just think that some of our underlying assumptions (ie. that a science degree or even that the scientific community as a whole demonstrates scientific or critical thinking) are unfounded. Is it better than in the humanities? Probably, but I met some very smart people particularly in the philosophy departments who taught critical thinking much much better than anyone in my science degree did.

  56. Kultakutri says:

    I’ll start with a digression if you forgive me. I was a problematic kid for various reasons and my mother, who taught some theory of teaching, tried her best to steer me through the education system without much damage to both me and the system… because, as she told me, great majority, over 90%, of people are wired in such a way that it’s easier for them to learn when they are given instructions or orders how a thing works or how to perform a task. The rest, including yours truly, works the other way, heap facts and things upon them and they’ll find out how it works. In practical terms, I’m pretty much impenetrable for any language theory, any stuff along the lines of Use this formula for this-and-that…
    I did want to go to medical school – here people go straight away after completing high school and the only admission criterion is the entrance test in physics, math, biology and chemistry. I have a good working knowledge of these and had even then… but only as far as I can draw it. When the discussion of something went as far as graphs, sketches or whatever, I was okay. I still have better knowledge of the subjects than my age group because I think it all visually (don’t ask what I see at the back side of my brain, please) but it is not a method that works for tests. Which is the main reason why I just didn’t bother even trying to get to medical school (the minor reason is my social phobia, I just don’t touch people and that’s it; I was willing to deal with it somehow as long as I could then stick to some nice research lab… or medical illustration).
    I ended up being art historian. I call humanities Blurry and Indefinable Studies and it is only halfway a joke… and to feed my sciencey bit, I started an undergrad course in biology. I guess that there are certain advantages due to my previous studies, if nothing else, I know decent Latin.

    What I want to say, there are people for whom such a programme may be advantageous without compromising the whole idea of medical school.

  57. Dr Benway says:

    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.

    It might be fair to say that psychiatrists are more woo-friendly than other doctors, or that psychiatrists aren’t as careful in their application of the scientific method. I don’t know if that’s the case or not. But can one say that “psychiatry” lacks a sound scientific basis?

    I’ve understood “science” to be a method of inquiry rather than a particular set of disciplines. That method involves tests of corroboration, falsification, logic, and parsimony, and leads to hypotheses of greater explanatory power over time.

    Do we not see evidence of intellectual progress in the field of psychiatry over time?

    Statistical significance within psychiatric journals is typically defined by a p value below 1/20 –the same standard used in every other medical specialty. While our bad-ass friends in physics and chemistry are setting the bar at p-values below 1/10,000, who among us should feel smug?

    The CCHR has long been pushing the “psychiatry is not like other medical specialties” meme as part of their wedge strategy against the social authority of modern medicine. Notice that while they’re praising you for your hard-headed commitment to real science, they’re also attacking me for my “reductionism,” my “materialism,” my “atheism,” and my denial of the spirit.

    In reality it’s not my softness the woo tribe hates. It’s my hardness. They hate that about you, too.

    Be wary of any anti-psychiatry ego candy that comes your way. The flattery may be more about bruising our friendship than anything else.

    Remember that you are not only a breast cancer surgeon. You’re also a cardiologist, a psychiatrist, a dermatologist, etc. Patients don’t decide to get sick to please our particular social and political divisions. We’re all required to have a basic level of competence across the entire review-of-systems.

  58. interrupted says:

    Science-based medicine (SBM) is not Evidence-based medicine (EBM). EBM is an ideology with an inherent value system. As an analogy, EBM is to SBM what the Libertarian’s Anarchy-Capitalism ideology is to a serious study of Economics.

    * The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years.

    * The USPSTF recommends against screening for prostate cancer in men age 75 years or older.

    * Potential harms from PSA screening include additional medical visits, adverse effects of prostate biopsies, anxiety, and overdiagnosis (the identification of prostate cancer that would never have caused symptoms in the patient’s lifetime, leading to unnecessary treatment and associated adverse effects).

    * The same authors examined health outcomes in 278 men… 26 had died of causes other than prostate cancer.

    For the most common cancer in men – don’t bother doing a PSA screening if he is under 75 and absolutely do not screen men over 75. We would not want to make men undergo the anxiety of an additional medical visit and we certainly would not want to identify ACTUAL PROSTATE CANCER as there is a possibility that the patient may die before showing symptoms.

    * Johnson and Jarow estimated that the cost of screening testosterone levels in all cases of ED is $3624 for every 1 case of hypogonadism detected… the laboratory cost of a serum testosterone level is about $50, which is relatively standard and inexpensive at first glance. However, when multiplied by the annual projection of 600,000 new cases of ED per year, the up-front cost to the healthcare system is $30,000,000 per year just to screen testosterone levels. When the costs of the obligatory follow-up levels of total testosterone, free testosterone, LH, FSH, and prolactin are computed for those who screen positive, the screening cost doubles to $60,000,000 per year—of which $12,000,000 is the result of false-positive tests.

    * In the current era of managed care and sky-rocketing medical costs, it remains the physician’s obligation to provide the highest quality of care to one’s patients while keeping the costs to society reasonable and appropriate for the disease at hand.

    Don’t perform a $50 test because your patient will probably test negative, or might have a false-positive, or require follow-up testing. More importantly, performing this simple test as an adjunct diagnostic tool costs the “healthcare system” (an abstraction) lots and lots of money.

    Let’s discuss EBM’s obsession with cost-benefit analysis. Not providing me a $50 test is actually stealing money out of my pocket. When offered my current position I was provided with a written offer – a legal contract. The offer included as compensation; my initial annual income, stock & stock options at a set price as a signing inventive, possible bonuses in the form of nonqualified and qualified-incentive options (etc.), in addition to medical, pharmaceutical, dental, and vision insurance… and a few other items. My income, stock options, and medical benefits are all part of my overall compensation package. The EBM-driven doctor for giggles decides to reduce my overall compensation package? He thinks I’m worth $50 less than my company thinks I’m worth? He thinks I’m overpaid, that my medical benefits are too generous for my position?

    Who exactly is this “healthcare system” (an abstraction) that the EBM ideologues are so concerned about? Mr. Healthcare will make less money if you perform a $50 test? If everyone performs a $50 test Mr. Healthcare won’t be able to buy that quant villa in Calais?

    About the “total income/benefits package” provided by my employer, the medical insurance is partly paid by myself and subsidized by my employer. How does Mr. Healthcare figure in all this?

    Let me explain Mr. Healthcare’s role: The multi-national corporation I work for went to several large insurance companies and offered their business saying, “Who wants to wrangle a contract with us to cover our 80,000 employees?” All the insurance companies gleefully jumped up and down shouting, “Me, me, me… pick me.” and in this specific instance, the insurance company that got picked made over $3-billion US-dollars profit in 2009 (of which, a part of that profit was from the contract with my company).

    SBM places the doctor in the role of scientist who can make decisions based on observations and results from thousands of patients. Medicine, as a science, obviously requires formal double-blind studies but not to the exclusion of knowledge gained from actual patient observation.

    In contrast to SBM and the doctor as scientist, the EBM-nonsense works like this:

    STUDY: “Seeking 200 subjects for study comparing anti-depressant medication, must not have history of pi-polar illness, not currently taking medications, can not have co-morbid disorders, no Histrionic or Borderline personalities allowed.”
    RESULTS: Medication #1 at a cost of $200 monthly was moderately beneficial (75%), medication #2 at a cost of $700 monthly was moderately beneficial (82%), medication #3 was least beneficial (35%).
    RECOMMENDATION: Doctors should prescribe medication #1 to everyone complaining of depression. It doesn’t matter that your patient is suffering from trauma and depression as a post-rape victim, that you have extensive experience treating rape victims, and that you have seen positive improvements with a completely different medication. We have a study and did a cost-benefit analysis.

    The most insidious thing about EBM isn’t simply the rejection of doctor as scientist (and demotion to a pharmacy-tech) but also the EBM-adherent’s assertion that the “healthcare system” is the patient and this patient is “healthiest” when the least money as possible is spent on those irritating human-people things.


  59. red rabbit says:

    That can’t seriously be how you see EBM, can it?

    Maybe we simply have different approaches…. my tendency is to whenever possible get the papers and figure out if I buy in. Guidelines aren’t prescriptive; they can provide a framework. But every patient has different needs.

    If you let them be prescriptive, you are no longer exercising clinical judgement (which is the point of all that training), and you may as well let your computer do the work.

    The most important question to any doctor, I would think, is what is best for this person in front of me? It’s what I’m thinking, anyhow.

  60. cthuluforprez says:

    I would just like to thank you for this article Dr. Gorski. As a pre-med student and BA in psychology, I have spent the last two years catching up on the hard sciences while working in an neuroscience laboratory performing tech work. I refuse to budge in my insistence that I need to take rigorous science classes before medical school, as well as improve my understanding of biological systems. I am a regular reader of this blog, and listener of the SGU. Your article is both encouraging and reinforcing.

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