Changing medical school requirements for scientific medicine

Science has an editorial today discussing a topic near and dear to me, what medical schools should require from undergraduates before admission.

Since I was a bit non-traditional as an undergraduate premed (I was a physics major), I am happy to see that they’ve ignored calls to overload undergraduate education with a bunch of pre-professional courses that prevent people from being anything but biology majors.

How should preparation for medical study be assessed? Medical schools generally determine scientific readiness for admission by course requirements and scores on the MCAT, which mainly reflects the traditional content of those courses. In contrast, medical schools have long evaluated readiness for medical practice in terms of competency–specific learned abilities that can be put into practice–rather than by mandating standard courses and curricula for all medical schools. The report recommends that scientific readiness for medical school entry be assessed similarly: The current list of required premedical school courses should be replaced with required science competencies. Instead of a nationwide requirement that premedical undergraduates take specific chemistry classes, for example, a required competency might be described as being “able to apply knowledge of the chemistry of carbon compounds to biochemical reactions.” The report suggests competencies for premedical and medical school science education, recognizing that there may be multiple routes to gaining a competency. An integrated approach to both undergraduate and medical education may help both to innovate.

The editorial discusses this report from the American Association of Medical Colleges and the Howard Hughes Medical Institute that suggests what should medical students arrive at medical school knowing. For years, I’ve thought the premedical requirements were absurd. You are required to have a year of physics, a year of calculus, a year of organic and a year of inorganic/analytic chemistry (at least when I went through). While I benefited from having a basic science background before arriving at medical school, I have to say, the only things I’ve retained from organic chemistry class of any importance are that like dissolves like, and hot solvent is great for cleaning. I still can not think of anything valuable I learned from inorganic chemistry that I didn’t get in high school like computing basic stoichiometry or making solutions. Physics? Maybe it was more useful (and for me it was interesting in fun), but mostly as a course of study in rigorous scientific thinking, statistics, error analysis, etc. Calculus? Totally worthless for medicine. Even the biology courses tend to be exceedingly general (which I think is good). You know what’s been most useful? Knowing how to write. Knowing how to research for a paper, whether it’s on history or quantum mechanics. Knowing how to think and teach yourself about subjects rather than just memorize them. That’s what college should do, and that’s what medical schools should select for, rather than those who memorized the most facts in premed science requirements. And the MCAT? Don’t get me started. The smartest people I know did the worst on that test, and some of the most useless do well, because it doesn’t test reasoning or anything useful, just memorization of all that worthless junk in all those premed classes.

The report acknowledges this, and emphasizes a different skill set and set of “competencies” for premed requirements, rather than some rote knowledge on subjects you’ll never use again in your life. This made my heart swell and brought a tear to my eye.

The fact is, the first year of medical school is a great deal of catch-up for many students, even chemistry and biology majors, because the majority of what we learn in college is irrelevant to medicine, and that’s a good thing. College should not be treated as a pre-professional school that merely exists to give you specific knowledge to get you ready to be a doctor. There is great value in young people coming to medical school with a diversity of experiences and knowledge. If you like chemistry? Great! By all means, take 3 years of organic chemistry if that’s what you like, but we shouldn’t pretend it will ever be used again for medical school. I’m still angry about the hours of life I wasted in organic chemistry class, never to be used again, when I could have been learning about something I really cared about, or exploring more of the liberal arts classes at my university.

This is why it’s good that experts in medical school have begun to acknowledge that premed requirements do nothing useful to prepare one for medical school, but only really serve as a barrier to the unmotivated by virtue of being a giant pain in the ass. One could easily imagine a 1 year, or 1 semester course containing all the basic science required for medical school (which should be administered pass/fail). It’s more important that people arrive at medical school knowing how to think, knowing how to evaluate the scientific literature, having knowledge of the world and hopefully having a higher level of maturity. The physiology, pharmacology, anatomy – all of it is available in the basic science years of medical school. There is very little specific knowledge one needs at the start.

I’m glad to see there is talk of finally breaking from the stodgy and pointless premed requirements that generations of medical student hopefuls have had to suffer through (despite some, like Jules Dienstag, defending the premed torture as a “necessary gauntlet”. Let’s just hope they implement some of these changes, save premeds years of excessive study of irrelevant subjects, and maybe, if we’re lucky, burn the MCAT for the useless test that it is.


34 responses to “Changing medical school requirements for scientific medicine”

  1. synapse

    I wasn’t a premed, but I found that o-chem and calculus, as well as linear algebra and quantum mechanics, introduced different ways of thought. Of these, the most important is probably calculus. I wouldn’t want as a doctor the kind of person who can’t understand the abstraction involved in adding an infinite number of infinitely small things and getting a finite number.

    In many countries, medicine is an undergraduate degree. Presumably, in these countries, students primarily take courses relevant to medicine. Do you believe this is a more effective way of educating doctors?

  2. Flavio Casoy

    Great post. I agree completely. I have long toyed with how I would restructure premed requirements. Here are some current thoughts:

    1 Semester – Intro to Bio
    1 Semester – Genetics
    1 Semester – Immunology
    1 Semester – other biology
    1 Semester – Biochem
    1 Semester – Statistics
    1 Semester – Intro to Epidemiology
    1 Semester – Bioethics
    1 Semester – Intro to Health Care System/Health Policy
    4 Semesters – Spanish/Mandarin/Sign language
    2 Semesters – class that involves intensive writing or public speaking

    15 Semesters total. Assuming a student takes 4 courses per semester for 8 undergraduate semesters, there is still time for students to complete a major.

    The other component I would add is a requirement for service learning/service projects. I am not sure how this could be quantified though.

    Thanks for the post!

  3. I think the problem is thinking there is only one way to get to that type of thought. Does it really require a year of calculus, courses designed for physicists and engineers, to understand concepts like differentials and integrals? I took two years of calculus, diffEQs, and linear algebra, not to mention quantum mechanics, thermodynamics, electromagnetism, advanced mechanics, etc. and I can tell you, it’s interesting great stuff, but useless for the practice of medicine. I wish instead I had taken more statistics, which I got mainly through my physics classes, and have brushed up on periodically in medical school.

    In US medical schools the first two years are devoted to basic sciences. I believe a sharp history major with some pretty basic college science classes (molecular bio, or a pre-med specific prep) could more than understand these courses, or catch up on their own if they have the more valuable skill of self-learning. Another issue that may be a misconception is that medical school is particularly difficult. It isn’t, or at least the concepts are not difficult. What is challenging is the sheer mass of information one has to assimilate (it’s compared to trying to drink out of a fire hose). But the individual concepts are quite easy and accessible to anyone with a solid college education.

    After having done it, I truly feel that much of my time in chemistry classes was wasted. I needed the math and physics more by degree, and was interested in those things. But I’ve never had to apply them. The things I apply as a scientist and a physician are mostly learned from my first year human physiology course, my experience with error analysis, and statistics from physics, and physical experience working in research labs and reading and writing scientific papers. O-chem? Totally useless. Can’t think of a single time I’ve used it. Calculus? Same thing. You could take similarly challenging courses that teach you to think in subjects that you’re interested in. There is no need for a set curriculum that is a “necessary gauntlet”, people should be free to chose any gauntlet they like.

    More disappointing to a medschool admissions committee would be a student who hadn’t challenged themselves at all in college. I don’t think making the requirements more flexible would result in dumb students, but they would be students who had a better college experience, and would likely be better learners.

  4. chezjake

    I agree on the general uselessness of o-chem and calculus. OTOH, I think a good statistics course and a course in logic/critical thinking should be mandatory.

    @flavio: I defy you to find a decent liberal arts college in the US that offers any of the following:

    1 Semester – Intro to Epidemiology
    1 Semester – Bioethics
    1 Semester – Intro to Health Care System/Health Policy

    I also fail to see why any liberal arts college should teach any of those subjects (general ethics or an “ethics in science” course, yes). All of those courses should be taught in med school.

  5. Colin

    This is an interesting post since I am in the middle of applying to med school for 2010. My background is electrical and computer engineering and I didn’t take a lick of biology in college or chemistry beyond the one-semester required class. I have since, however, taken o chem and anatomy & physiology at a community college for the sole reason of getting the rest of the pre-reqs.

    Contrary to a lot of people I found o chem to be rather fascinating, mostly because of it’s applicability to life (food, cleansers, etc.) and deciphering an ingredient list on packaged food. 🙂 I bought a used biochem book (“for fun”) and find some of that equally fascinating for similar reasons. Though I am a bit of an “odd ball” because I find pretty much everything interesting, except maybe art history.

    Flavio’s list of pre-req’s makes my jaw and heart drop. As an engineer, I’d have to take about 13/14 semesters of the 15 to “get in” if that list were true. I work full-time and needing to take 15 classes would put me nearer 40 (I’m 29 this year) before I could think of applying. And I’d have to take a number of them online (bleh!), at the state university (45 minutes away one-way!), or local private college ($$$). If that were the case I can say with certainty that I would *NOT* be going into medicine. Period. End of story. I did not go to college anticipating going to med school and that list pretty much screws me and pretty much all other “non-traditional students” out of going. Flavio, please please rethink it.

    All that said, I see a fair amount of relevance in my engineering classes to medicine in that engineering is the application of science to solve problems. Am I wrong in seeing that engineering is to bridge as medicine is to treatment? While I studied electrical &computer engineering (with a good share of computer science) there is a lot of general overlap in the mode of thinking of an engineer and approaching problems.

    Another thing that comes to mind about pre-req’s is that they pigeon hole you based on your academic background. Usefulness aside, is there really only “one kind” of doctor that a list (albeit “short” compared to Flavio’s list) dictates exists? Why wouldn’t you embrace engineers becoming doctors?

    On a tangent, any words of advice? 🙂

  6. Thanks for this post; its good to hear physicians talk about this. I’m a speech pathologist and am considering applying to med school. Unfortunately, my academic background reflects my preparation for speech, not medicine. So in order to even apply to med school, I still have several semesters of courses to complete. I know I would succeed in med school which makes it very frustrating hear that the content of these prerequisites are useles and yet I have take them. Can’t my analytical and scientific reasoning skills be assessed in another fashion, rather than requiring me to spend even more money and time to take more classes? Nope, not right now anways.

  7. Thanks for this post; its good to hear physicians talk about this. I’m a speech pathologist and am considering applying to med school. Unfortunately, my academic background reflects my preparation for speech, not medicine. So in order to even apply to med school, I still have several semesters of courses to complete. I know I would succeed in med school which makes it very frustrating hear that the content of these prerequisites are useles and yet I have take them. Can’t my analytical and scientific reasoning skills be assessed in another fashion, rather than requiring me to spend even more money and time to take more classes? Nope, not right now anways.

  8. Darren

    I had the same requirements for dental school, though we have the DAT which purports to test reading comprehension and perceptual ability along with the bio, chem, physics and math.

    I’m all for some sort of pre-med/pre-dental competency, but some of those courses make the difference between a competent doc and a great one.

    It is impossible to explain the damage done by radiation without understanding the atomic and subatomic effects that happen, which in my dental school was assumed to be learned in the pre-dent physics and orgo.

    Orgo itself, while onerous and not generally specifically applicable, is very useful in understanding the differences among similar drugs. General chem is useful particularly for understanding the effects of titration, chelation, and acid-base reactions, let alone osmotic effects.

    Don’t get me started on the number of physicians and dentists who can’t or won’t understand the basics of evolutionary theory despite having taken a year of college-level biology before medical or dental school. I don’t think weakening that would be wise. We’re learning more and more about the application of evolutionary theory to modern medicine.

    And someone who can’t do calculus will not be very well-prepared to learn biostatistical analysis. No, it doesn’t involve calculus directly, but calculus seemed a lot easier than biostats. I would prefer my caregivers to be able to critically analyze the statistics in those peer-reviewed articles, not just the summaries and abstracts.

    And while not relevant to all physicians or dentists, there are many specialties where a knowledge of mechanical physics will be very useful – orthopedics and orthodontics both come to mind.

    Like I said, competency is important. I think any method of determining competency on these subjects has to be rigorous and well-adhered to, however the applicant learned the material.

    And I agree that taking the core science curriculum should supplement other majors, resulting in more well-rounded applicants. I didn’t appreciate my liberal arts degree from undergrad until I got to dental school and met many classmates who were appallingly ignorant on many basic subjects unrelated to medicine or dentistry.

  9. medstudent6973

    Changing the standards would be a good thing for those that have the balls to take advantage of it… But for the most part, pre-med students will put themselves through the pain gauntlet to show the admissions boards what they’re made of. In other words, organic chemistry might no longer be required, but it will still be taken by pre-meds because organic chemistry is generally a difficult class that arguably demonstrates your abilities to think scientifically.

  10. You guys must have taken a different O-chem than me. Scientific thinking? Really? I found it to be dreary rote memorization of BS I’ve never used again. Inorganic chem and analytic chem? Total waste. I took AP chem in high school that tought pretty much everything I needed to know about chem for a MD and a PhD. I’m biased towards physics being a major, but I believe you can learn rigorous scientific thinking in more than one way.

    If you read the report, the competencies they suggest are interesting and cover most of what the commenters so far have believed to be important, including an understanding of evolution, physics, statistics, etc. I would like to a see a new system that tests those competencies, and allows people to get to medical school through a variety of paths, not just the dreary pre-med path.

  11. I was just going to add a comment about the MCAT on here. Schools do take a good look at this test and it is rote memorization, but this is precisely why they use it. What was your impression of the boards you took? School want to know they are getting students who can cram it in and perform well on a test that mimics the board format (multiple choice, wide context, time dependent) because they depend on those board scores (which a lot of residency placement is based on) as their means of “ranking” their school. Having high boards and good placements is good for the school and the MCAT is just an indicator of how students will do under those test conditions.

  12. And as an aside, I entered medical school with an English and Biology degree from undergrad. I am finding my English degree is pushing me from middle of the pack to top of the class in many instances, especially filing reports or giving presentations.

    The two people who are doing excellent from my undergrad in medical school were both US History majors.

  13. Well, and when I was a pre-med, I couldnt help but notice the hypocrisy in med-school requirements/admission.

    You have to have a huge list of required courses… But ‘alternative’ students were prized over ‘plain’ biology majors. “Oooh! A music composition major! A history of philosophy of art major! Wacky!… Ugh, bio major, NEXT.”

    The only people who could ‘afford’ to be alternative majors were ones from big cities with AP/college courses available in high school. They basically just had to take organic in college, where my class schedule looked exactly like Flavios list (but ‘worse’). I was lucky to get in a psychology minor.


  14. DVMKurmes

    I think a lot depends on the way the science courses are taught. Sure anatomy or chemistry can be a boring semester of memorization, but a good professor can show how the subject relates to medicine and other professions. One of the best classes I had in undergrad was Comparative Vertebrate Anatomy, taught by a wonderful teacher who went on later to teach anatomy at Brown med school. Admittedly more useful in veterinary school where we learned the anatomy of several different species, but understanding the evolutionary and developmental background of mammalian anatomy made a huge difference. Skills I learned in that one class made life much easier for the first 2 years of veterinary school.

  15. Kagehi

    Have to say… Better to “fix” the courses, so they actually teach what they are supposed to, which is scientific and critical thinking, than erase what “little” science the total cranks and quacks need to take to “get” their own medical licenses. Seems to me a catch-22. You see, all the time, people who grasp why X doesn’t make sense when applied to Y, in “their own fields”, and more than a few people come up here on this blog who can’t even comprehend **that** concept in their own field of expertise, so, what happens if you fail to fix the original problem, which is the failure to teach them how to think rationally, and pull out from under them all the O-Chem and other things that “might” in some very rare cases jog a memory in them, and maybe keep them from doing something more idiotically stupid than what ever crackery/altie BS they are already peddling? Personally, I would like to see them have “more” time spent actually learning how the world works, and I mean “really” understanding it, not less. And that goes for ERV’s experience, where I can easily imagine some moron med-school board going, “Ooh! A theology degree, lets get this one in!”

    Just saying..

  16. BrainGuy

    Disclaimer: I’m not a med student, though at one point I thought about it. I’m now a PhD researcher frustrated at the scientific illiteracy of MDs. For too long medicine has been thought of as an “art” rather than a “science” – and that’s exactly why there’s so much woo being peddled. MDs should be taught how to think scientifically. Too many of them don’t.

    Now sure, MDs don’t need to know the reaction that gets the best yield for 3-oxy 5-methyl whatever. And exactly what should be taught in med school versus pre-med is open to debate. But what they do need is the ability for scientific thinking. They should be able to read and interpret the scientific literature, at the very least. Some knowledge of proper experimental design would be nice too. Yeah, and some statistics. Being able to really understand statistics without calculus? No way. Sorry but many of the MD fellows lack even rudimentary knowledge about all of these things. This is unacceptable to me. How can they be on top of the latest developments to generate the best outcome for their patients if they can’t understand what they’re reading?

    And while you’re at it, cut out the BS expectation of “volunteering” and “shadowing” for med school admissions – merely a way of getting doctors free help.

  17. . I’m now a PhD researcher frustrated at the scientific illiteracy of MDs. For too long medicine has been thought of as an “art” rather than a “science” – and that’s exactly why there’s so much woo being peddled. MDs should be taught how to think scientifically. Too many of them don’t.

    The last week of medical school I was working with one of my favorite surgeons (a very experienced guy) who had the exact same complaint. He said this “medicine is an art” idea was a simplistic holdover from the time when medicine was little better than voodoo. Medicine is now an applied science, it’s explaining things to patients, making them feel comfortable and reassured that is the art. You can’t have a doctor who is only an artist, and doesn’t get the science, and you can’t have a doctor who is only a lab rat and doesn’t know how to interact with human beings.

    Now sure, MDs don’t need to know the reaction that gets the best yield for 3-oxy 5-methyl whatever. And exactly what should be taught in med school versus pre-med is open to debate. But what they do need is the ability for scientific thinking. They should be able to read and interpret the scientific literature, at the very least. Some knowledge of proper experimental design would be nice too. Yeah, and some statistics. Being able to really understand statistics without calculus? No way. Sorry but many of the MD fellows lack even rudimentary knowledge about all of these things. This is unacceptable to me. How can they be on top of the latest developments to generate the best outcome for their patients if they can’t understand what they’re reading?

    People seem to think that I’m saying doctors don’t need calculus. Not true. I just don’t think they need two semesters of it. They need to understand integrals and differentials. They need to understand how to read equations, and have a basic understanding of how they are applied. They don’t need the level of calculus that I got, or advanced mathematics. It’s just not necessary. You could teach them what they need to know in about 2 weeks. Same with O-chem. Same with physics. What we need to make sure of is that whatever path they take, they get the basics of the necessary fields, and that they challenged themselves. Taking these requirements is absolutely no guarantee of learning how to think. And being surrounded by other premeds in them will likely make sure you will never think.

    Now, I certainly benefited from a rigorous undergraduate science major, and I most definitely benefited from not being a bio-major stuck with all those awful, grade-grubbing premed students. But that just supports my argument. I took many courses unrelated to medicine or biology and think I am a better student for it because they taught me how to think about science.

    The other thing is that when you make these courses a requirement for premeds, premeds will infest these courses and make them suck. I’ve seen this again and again. There are too many Pre-meds who don’t want to think. They want good grades so they can get into medical school. When too many of these students have to take a class, what invariably happens is the senior faculty foist that awful bunch of nimrods onto the young faculty who often can’t take a tough stand against them. The premeds define the crumminess of the course, it really isn’t the schools’ fault or the professors’ fault. This is why the pre-med courses I enjoyed the most and actually learned something in were with the few experienced professors that had the strength of will to face down pre-meds year after year, and not take their crap. The very best was my molecular bio professor who insisted, year after year, in making his exams entirely essay-based. On the test you had to suggest experiments to test hypotheses, you had to interpret data and describe what you think it meant. It was awesome. The idea that the best we can do is prepare students to take boards is a disastrous one. Taking boards should be a necessary evil, not the focus of education.

  18. willie

    You have it backwards. People go into medicine for the wrong reasons. Money, maybe a few for prestige, but everyone says to help others (on every application essay). NP and PA’s practice medicine as do the vast majority of MD’s. Without the onerous pre-med curriculum and subsequent time cosuming medical education, they perform just as well in their areas of expertise. Do MD’s really require all the courses they do. Does a shrink, need all that anatomy?

    Yes, we need a few elaborately trained MD’s. But we need more people giving health care to the masses. Much cheaper to train and better quality in the limited fields are obvious benefits. For the majority, they need better protocols and access to experienced based information.

    Specialists will be needed and should be trained. They will have to meet a higher threshold of prerequisites and training. Today specialists are typically not busy enough and generalists are working too hard. Salaries are reversed, but no surprise.

    It is not too much math or science. It is get the right people doing the right job.

  19. Do MD’s really require all the courses they do. Does a shrink, need all that anatomy?

    Yes and yes. Doctors have more education because they have more responsibility. A shrink may not have to perform surgery, but they have to understand it. They may not need to operate on the brain, but they need to know its structure and function and what lesions may cause what disorders. A shrink may not prescribe dialysis, or surgery, or antibiotics, but they better understand how they work, what they do, what effects they have on the body because they’ll have patients that are on dialysis, having surgery, or on any number of drugs. My first morning of psych I treated a woman for an asthma attack so severe she wasn’t moving enough air to wheeze (her concurrent anxiety attack didn’t help). My first night on call in the psych ward I treated someone for a heart attack. When you are a hospital shrink, you will be treating all kinds of patients, including surgical patients (I’ve called my share of psych consults already). Now a community shrink who just is doing talk-therapy and not involved in acute mental treatment can let that knowledge slide, but psychiatry requires a strong medical knowledge base and that includes knowledge of all types of treatment your patients might be exposed to.

    No doctor has any business treating patients unless they understand their job and have a pretty good understanding of what other physicians and specialists are doing. Certainly, primary care doctors need a huge amount of understanding of other fields, because they are often the gateway for access to these treatments, and they have to manage the care of the post-surgical patient after they are out of the hospital. They must recognize a surgical emergency just as much as a surgeon does if someone walks in their office with an appendicitis, or a wound infection, or complications of a procedure. Conversely, surgeons need to understand the effects of psych medications, treat the psychiatric needs of their patients while on service, and recognize psychiatric disorders, not to mention, understand the medical needs of patients with a host of chronic diseases.

    Willie, trust me. Doctors need every bit of understanding they can get. NPs and PAs are helpful, and within their comfort zone can do a lot of good, but they’re also supervised. If out of their element they have an MD to go to, and a MD making the final decisions. That breadth of knowledge is vital to receiving competent, organized care.

    Finally, as a medical student, it’s hard to decide what kind of medicine you want to practice. A universal phenomenon you see when people go through their training is that they didn’t really have their mind made up about what they wanted to do until they do it. I thought I’d be an internist. But I ended up liking surgery and pediatrics the best. Medical school is as much an apprenticeship and introduction to the meat and potatoes of various specialties as it is an exposure to the diversity of diseases and treatments they will see and manage.

  20. willie

    Are you a shrink now? Do you not have access to the other specialists in your field. It is nice to think that you can treat everything now. One never knows as much medicine as when you just finish your schooling. How long before your specialty takes precedence and your skills and therapuetic knowledge is outdated in other fields. Medicine has gone way beyond knowing it all. Only the arrogant can say that and then not for long.

    No, I think you need to think long and hard about how we are going to supply care to the millions without, at a price we can afford.

  21. I am absolutely not a shrink. But you have to know when to call them. You have to know what psych drugs will do to your patient. Often, you have to treat people with concurrent mental illness, on a raft of psych drugs. . You have to have experience and knowledge of the medications, the treatments and the disorders. General surgeons, after all, work in the ER, the OR, the ICU, the floor and the clinic.

    The point isn’t thinking you are the master of every specialty, it’s about having general medical knowledge that lets you know when you can proceed, when you need to adjust your plan, and when you need to call for help. Nothing would be more disastrous than a bunch of specialists acting without understanding or care of the other specialists.

  22. I agree with most of what you say, except that calculus and physics are absolutely essential for being able to master the first-year physiology curriculum. And I am sure you will agree that of all the basic sciences, physiology is by far the most important to the actual practice of medicine.

  23. Mark,

    I think you bring up a good point with the way known pre-med classes are structured and how they operate with junior faculty and minimal emphasis on laboratory understanding. I think a big part of this is where you go to school. My undergraduate institution had just over 42,000 students which meant that there were a lot of classes which were overwhelmed semester after semester with too many students. (Size of institution is another discussion for another day though although since I was willing to push myself I had access to any type of research I imagined as an undergrad).

    Many of these classes that were inundated were of course those that were pre-med requirements. That was the majority of our biology majors (we even had a degree for it too, biomedical sciences). Many times courses which I feel could have been much more effectively administered and that dealt with incredibly important basic science topics struggled due to the mass size effect.

    My senior year there were 155 students in a decently advanced biochemistry course, after looking back on the course description I realize it would have taken three more instructors to cover the topics in enough detail as to make a difference to the students. When classes get weighed down like this the curricula always suffers and falls into the memorize and regurgitate mode instead of consideration for processes and how they are validated through research.

    Interestingly enough it is just these types of courses that are the breeding grounds for most of our young physicians. Although there are a multitude of colleges sending kids to med school there are a group of about 80 large schools who are supplying a large percentage of yearly applicants who all receive this same type of instruction.

  24. Size will make things worse, but I went to a small liberal arts university and encountered the same problems. I think the pre-med culture is very stultifying because there is so much emphasis on grades. It’s hard to resist too, I remember going into see a physics professor and asking him how I could get an A because as a pre-med, Bs wouldn’t cut it. It’s a catch-22, because no one wants med students who can’t perform at the highest level of academics, but at the same time, the constant emphasis on grades makes them go a bit nuts.

    When I showed up at UVA the first day of class we were told our pre-med days were over. No more nasty competition, no more grade-grubbing. We’re now all members of a team, the whole team has to learn, and the whole team has to do well. If we acted like competitive little monsters, or went crazy over grades, we’d be having a word with the dean. A couple years later, we joined the ranks of most of the medschools around the country and made the basic science classes pass/fail. I wish a pass-fail system could be offered for pre-med as well, but I doubt it would ever happen. I think the culture of medical students in my class was incredibly open, friendly and found these ex-pre-meds to be some of the most excellent people I’ve known. And I have to strongly disagree with Willie, I have yet to meet a medical student who is in it for the money. First of all, they’d have to be retarded. There are faster, easier ways for smart people to make money. Second, there are fields where that may be more of a consideration, but for most docs, money isn’t really in your future, relative to you 250k in debt, and 10 years of post-graduate education. Third, it’s just not in the character of any of the medstudents I’ve ever met, at UVA or around the country.

  25. Kagehi

    The point isn’t thinking you are the master of every specialty, it’s about having general medical knowledge that lets you know when you can proceed, when you need to adjust your plan, and when you need to call for help. Nothing would be more disastrous than a bunch of specialists acting without understanding or care of the other specialists.

    Now, that I have to agree with, to a point. The problem is, people get arrogant, and won’t ask for help. Ironically, probably the best system would be a “team” like on House, with one generalist, driving things, and a lot of specialists to point out when he is missing something. But, we can’t afford to do that. So, your choice is a generalist, who may walk off the deep end at some point, or a lot of specialists, which may miss things. And, that is the problem we see a lot. Even if someone isn’t a “specialist”, they often have one field they are better at, and they end up “focusing” on that field, and sometimes missing critical details. Or, they go to some generalist, who has fallen off the deep end, and they attribute cancer, or a neurological disorder, as “fatigue”, and not only fail to send the person to an expert, but prescribe something completely useless to them.

    Attempts where made to build “expert systems” to do some diagnosis, to help doctors, but they where never, “smart enough”, to be more than hit or miss. But you almost need to have a machine do the initial diagnostic, then send them to specialists, to be “sure” that they see the right ones any more. Its simply gotten too complicated. And the experts have been trying to find ways to help with that for “years” without a lot of success. Its hard to say “what” information may prove important. I mean, saving someone from poisoning, as in one article in one of the science magazines a few years back, by injecting something that the poison was binding to (I don’t remember the details, it was a base, and the acidic compound, I think.., was skin absorptive, and **highly** reactive.), the wrong direction a) saved the guys arm and b) saved his life, but… it should have collapsed the arteries as a reaction to the amount being injected. Now, many “generalists” may not have known how to deal with it, and many would have simply sent the guy to surgery, to have an amputation, because a) they wouldn’t realize the problem in time, and b) standard medical practice says, “If you do this, it won’t work anyway.” And, even in this case, I think they had the label from the stuff doing it, so knew what it was. That might not be the case somewhere else.

    Frankly, our diagnostic tools are, generally, too bulky or outdated, the methods are flawed, most don’t have expert system assist, even if it worked better, and almost nothing, beyond “basics” can be done by the generalist any more, who, never the less, has to “somehow” manage to send them to the right specialist in the first place, instead of the wrong one. Its getting… slightly uncomfortable to imagine landing in the ‘average’ hospital, instead of one of the really good ones.

  26. I don’t know if it’s as bad as all that. The conditions we’ve diagnosed over the last hundred years haven’t really changed. For the most part it’s the same diseases as always. The management, the drugs, treatments etc. have become more complicated (and effective), humans haven’t. Diagnostics isn’t as hard as House makes it out, and of course House commits the sin of all TV doctor shows. That is, every patient only has one problem, rather than 7, like most of our patients.

  27. Kagehi

    Well, true enough. I only used him as an example, due to the fact that its, well… the only example, really. lol But, I would point out that a patient with 7 problems is “likely” to make diagnosis harder in some cases. Ironically, high X could mask low Y, or offset some other condition. And, technically, in same cases on House, you even get cases like that, where trying to treat problem A doesn’t work, because problem B is actually causing/amplifying/hiding it.

    But, I think you get my point. Its not the majority of conditions I worry about, its the more obscure ones, which “require” both a) recognizing your out of your depth, instead of presuming it is actually one of the common problems, and b) doing so quickly enough to not kill the patient by delaying proper treatment. The only thing I can a say is that, as things stand, its probably going to be the doctor that hasn’t “seen” such a case in 20 years of practice, or who managed to get through the classes with a completely insane bias against some field/concept in medicine, that does it. Its kind of ironic really, unless someone decides to pull a doctors license, they could practice for 40 years and never have to be re-certified. In nearly all other fields, where lives are at stake, its pretty much required that, at some point, you get rechecked, to make sure you haven’t forgotten things, and can still do your job properly.

    That.. may be one of the issues that needs to be reconsidered even, with respect to the practice. Why should you wait until a doctor goes senile, or loses skill, to asses if they are still competent? People’s lives are more important than one guys career. Yet, much like driving a car, you just about have to kill someone to lose your license, and either its automatically renewed, if it doesn’t look like you hurt anyone, or doesn’t even have to be, at all.

  28. willie

    I am sorry that ignorance of facts allows biased portrayals of real medicine. Doctors are required to take continuing Med Ed. Surgeons who are boarded have to take a test every 10 years, as do most specialties. More and more evidence is accruing for checklist medical care. If you have followed the checklist, any malpractice is defended. The patient will still get no fault payments from the insurance company.

    Why are surgeons routinely described as aloof, and egotistical. Some even take pride in it. Mark, I hope you keep these remarks and reread them after ten years in practice. Life in the trenches is very different than the idealistic, supportive ivory tower.

    General surgery is a fantastic field, but it has changed overnight since 1989. Laparoscopy has changed it and for the better. As for recognition of all that they do, they are accorded little respect from the community. Please go to an ER doc and ask if it is easy to get an orthopod to cover trauma (some regional variation excepted). They want to come on as consultants to a general surgeon, who is to deal with family, order, nursing questions, etc. I wish you well in your current idealism and enthusiasm. I am not sure how far along you are in your training, but enjoy it now for life changes.

    As for House, it is ENTERTAINMENT for the masses. It is not real and never would you see anyone doing the procedures and playing so loose with ethics. But it makes a good story. If you want to see Medicine as it really occurs in training, look at SCRUBS. They use humour to make it entertaining, but the real feelings and concerns are there.

  29. Kagehi, to stay boarded you have to recert every 7-10 years.

    Willie, I hope how Orthopedists practice is not used to castigate all surgeons. They have a reputation for an unwillingness to take care of problems outside their specialty.

  30. Kagehi

    Hmm. Ok. See, wasn’t aware of that, though.. it fails to explain some of the insane things you hear happening with ones that never the less manage to “stay” in the profession. :p

  31. This is controversal. Some will say that there should be specific courses taken that will prepare the student. Others say that everything is already taught in the Med school curriculum.

  32. The MCAT is not a good predictor of how good of a doctor or med student you will be. It is only a measure of how much useless info you can memorize.

  33. Shirakawasuna

    It was mentioned that in many countries, a medical degree is an undergrad. While I’m definitely not familiar with medicine enough to know which ones they are, if they’re in Western Europe then one’s pre-university schooling may be more in-depth than what we have here in the U.S. In Germany, at least, a student attending Gymnasium and taking the math/science path (very common) will have year-long classes in calculus, more in-depth chem, more in-depth biology, etc. That would also be the typical background for someone attending university for a medical degree. In the U.S., you need to be interested in math/science before college and have done independent study in order to have covered the same amount of learning.

  34. James Pannozzi

    Well done post by MarkH and he has set it all, absolutely correct.

    It is curious how ideas of what is supposed to be needed to be known creep into not only academic circles but also into professional ones. As a young programmer in the mid 1970’s, I was denied promotion and blocked from some software jobs because I was a “business” programmer and the accepted criterion was that you had to have studied calculus in order to do scientific/engineering programming. Noting the $20,000 difference in salary, I bit the bullet at age 30 and went to University of Rhode Island and took all of the math courses needed for an E.E. degree, including calculus, differential equations, complex math and advanced calculus. Thus fortified, I returned to my job search and was immediately hired on a military subcontracting job and continued a long career in scientific/engineering and data communications software development afterwards. In 32 years of software development and design work, I used algebra and trig, but never once needed calculus.

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