A JAUNDICED VIEW FROM THE EDITOR:
THE DUMBING OF MEDICAL EDUCATION

In a recent interview published in the Journal of Investigative Medicine 1, Dr. Michael Brown, co-recipient with Dr. Joseph Goldstein of the 1985 Nobel Prize in Medicine for their work on cholesterol homeostasis, stated the following:

?[..] there is a very serious problem […] in the relation between the basic science curriculum and the clinical curriculum. Along with the emphasis on primary care […] has come this question of relevance of basic science. If we’re going to train primary care physicians, then why does a primary care physician have to know how DNA replicates? […] That’s a valid question, and it’s a difficult question, but it brings us to the danger that medical schools are going to evolve back to a pre-Flexner era, where the physicians are trained only in the practice of medicine […]. if the basic scientists are considered irrelevant (in other words if the powers that run the medical school think that what the basic scientists are teaching is sort of irrelevant to the overall purpose), then there’s going to be less and less emphasis on the basic science teaching. […] The clinicians want to start teaching clinical medicine earlier and earlier in the curriculum, and so you run into serious problems.?

Indeed, teaching basic sciences has never been as challenging as it is now, on the threshold of the 21st Century. Besides the progressive erosion in the perception of the value of science education in the medical curriculum, the growth of science in general and of biomedical science in particular, presents another very serious challenge to those trying to teach basic science to medical students. The response of some, as clearly pointed out by Dr. Brown, has been to restrict the scope of basic science in medical curricula to what is immediately applicable to clinical medicine. This tendency finds a parallel in the misplaced efforts to rationalize secondary education which have resulted in the dumbing of curricula beyond recognition. Perhaps it is time to regroup in defense of science, recognizing that there are practical limits to what can be taught, but not apologizing for our love of science for science sake, and resisting as far as possible any tendencies that can result in the exclusion of non-utilitarian material.

The ever increasing data base, the high level of complexity of modern biology, the fast growth of some areas of knowledge, are problems that need to be dealt with in a rational fashion. It is our obligation to push the significance of basic science and to make sure it is not just used for window dressing. For the sake of argument, let’s consider three examples of the need to pursue basic science issues in our curricula:

Example No. 1 – Conjugate vaccines. The impact of the conjugate Haemophilus influenzae vaccines in clinical medicine has been dramatic. After introduction of these vaccines in the U.S., H. influenzae meningitis has become a rarity. In one of my last turns of duty as a facilitator in a PBL-based curriculum, we had the opportunity to discuss a case of meningitis in an infant. Immunoprophylaxis was obviously an important learning issue, and it was also an excellent opportunity to discuss conjugate vaccines, which in turn are a great platform to introduce the concept of T dependent vs. T independent antigens. However, such gentle prodding to basic science issues is not easy when the facilitators are not experts and the textbooks used by the students are somewhat antiquated.

Example No. 2 – Transport-associated proteins. An in depth discussion of the role of these proteins in promoting the association of cell-synthesized peptides with MHC-I molecules would likely be classified as unnecessary esoterica by most multidisciplinary curriculum design groups. However, the repertoire of TAP proteins of a given individual may be a major factor determining whether the individual becomes tolerant or susceptible to autoimmune diseases, such as insulin-dependent diabetes mellitus, and whether intracellular infections are properly controlled by the immune system, as suggested by a special form of immunodeficiency in which TAP proteins are deficient and the presentation of peptides synthesized by intracellular organisms is significantly impaired.

Example No. 3 – Calcineurin and the activation of nuclear binding proteins. Again, the most likely response to non-experts to the relevance of including discussions on second signal cascades and nuclear binding proteins involved in T lymphocyte activation is one of hesitancy, if not outright negative. However, the mechanism of action of cyclosporine A is intimately associated with the inhibition of calcineurin, which in turn results in the inactivation of nuclear binding proteins, down regulation of IL-2 and other cytokine synthesis, etc.

These examples are obviously drawn from my areas of expertise, but analogous examples can be drawn from any specialty. What is common from these three examples is that it can be argued that physicians may be perfectly able to function without that knowledge. The obvious counterpoint is that all these concepts are intimately related to common situations in clinical practice. Should a physician be happy to immunize without knowing why one type of vaccine is superior to another? Should a physician be able to prescribe potent immunosuppressant drugs based on generic information, such as cyclosporine will depress the immune response? It is admissible that a physician’s understanding of the role of genetic factors in insulin-dependent diabetes mellitus may be limited to the concept that “diabetes has a strong genetic component?? I submit that although no one will ever be able to know all the relevant basic science facts and concepts underlying his or her practice of medicine, an effort needs to be made to teach as many of these mechanisms as possible and to make the medical student appreciate the importance of trying to understand such mechanisms, even when the significance is the pure intellectual satisfaction of understanding why something happens the way it happens.

The watering down of basic sciences is more acutely felt in curricula exclusively based on case-based teaching. The role of the basic scientist in many of these programs is that of a partner in a process in which they have had very little input. Clinical faculty have the predominant role in designing the cases on which the curriculum is based, and the general learning objectives are directly related from the nature of the cases. To compound the problem, the tendency to use facilitators that are not content experts limits the ability of the basic scientist to direct student learning at more than a superficial level. But even in the traditional curricula, the pressure to reduce course content is tremendous. Given the time constraints and the expanding database, cutting is inevitable. But cutting should be a very judicious process, targeting obsolete areas in favor of the new, emerging science — even if teaching the new emerging science is more challenging to teachers and students. Relevance for medical practice is an important factor in the equation, no question about it, but one needs to take a broad view of it, relevance may be seen from the point of view of the general education of a physician, not necessarily from the daily practice of a generalist. And future relevance (as difficult as it may be to foresee) is more significant than present relevance.

For the sake of medicine and of our students, it is essential that the basic scientist reaffirm their identity and defend the need to impart a solid basis of scientific knowledge in our future physicians. Science cannot become window dressing for a curriculum more concerned with tasks than with intellectual development and basic scientists cannot accept a role of junior partner in the educational process. We need to defend our case with solid and rational arguments. We need to give up quantity, but not quality. The alternative is to sanction the dumbing of medical education and collaborate in a process that we know is not right.

REFERENCE
I.The JIM Interview: Michael S. Brown, MD and Joseph L. Goldstein, MD. J. Invest. Med., 44: 14, 1996