Friday, December 6, 2013

An MD's thoughts on medical education

Here’s an email I received from a surgeon who asked that his name be withheld. I have edited it for length.

I practiced general surgery for 16 years before becoming fed-up with the paperwork, the hours, the unpaid call, the unpaid operations, the contracts, and, eventually, the patients. So, I turned toward teaching anatomy at a medical school.

Over the past 3.5 years, I become increasingly disillusioned with medical education, too. Having lived in a world of "arrogant doctors" being berated by hospital administrators as disruptive, I've had an interesting reflective experience here.

If I hear, one more time, from a PhD, who has never seen, treated, or managed an acutely-ill patient, that "The students need to know THIS (this = piece of anatomical, microbiological, or pharmacological minutiae), I am going to go ballistic. This week, my "colleague" in anatomy said, "It's my job to teach doctors the anatomy they need to know to become doctors." I said, "No, as an MD, it is my job to teach doctors the anatomy they need to know to become doctors. It is your job to LEARN that clinically-relevant anatomy that you need to teach them. It is not my job to re-learn minutiae of anatomy never used in 20 years of practice because "you" know it. This isn't grad school. We're not creating PhD anatomists. If you want me to re-learn, and to teach the anatomical minutiae I've long since forgotten, it isn't going to happen. You're in MY world. I'm not in yours. Go teach at a grad school for a PhD program if you want that. We are training medical doctors. And, you, my friend, have never practiced MEDICINE."

Remember learning the brachial plexus? How many times, as a surgeon, did you need to know that? Maybe a neurologist and a neurosurgeon, but to MEMORIZE this for ROTE INSTANT recall? NEVER in 21 years. Never. I could always look it up, if I needed to. Rotatores? Torus tubaris? Arbor vitae of the cerebellum? (Yes, we tested that on an anatomical practical exam yesterday. The PhD's felt the students needed tested on that—reinforcing this piece of minutiae never used).

I am also tired of hearing: "Cadaver dissection is the GOLD STANDARD by which anatomy is taught!"

Sure, before the advent of anesthesia.

Today, however, we train medical students with PhD anatomists, then two years later, AFTER first-year anatomy, they walk into the operating room as a know-it-all third-year student who doesn't know what color fat is, what the omentum looks like, that the esophagus doesn't have a serosa, that the appendix can be a bitch to find if it is retroperitoneal or retrocecal, or both—if they even REMEMEMBER what "retroperitoneal" means. Did you know when you do a bowel resection it's important to know the vasa-recti are different lengths in the jejunum and ileum? Which one is longer? Now, why at 2 am, during a bowel obstruction case, would I need to know this? Every medical school PhD anatomist thinks this is important for EVERY doctor to know. THIS CRAP MUST STOP.

The gold standard of anatomy education, today is a living, breathing patient under anesthesia. Anesthesia revolutionized medicine AND surgery and SURGICAL EDUCATION, but why doesn't that flow over to the classroom? Have you ever watched the dissection videos on OMG! I wish I had these BEFORE I ever started my cadaver dissection or walked into an OR!

I learned my anatomy in the operating room. No, wait, I "re-learned" my "clinically-relevant" anatomy in the operating room—from surgeons—not from PhD's.

How to fix this system?

Get rid of part 1 of the boards or change them to reflect CLINICAL-relevance.
Early exposure to LIVE anatomy, FIRST, then go back to a cadaver.
Teaching anatomy with CT scans, MRI's, cross-sections. This is what we look at every day.

When is the last time YOU saw a carcinogenically-embalmed cadaver, rigid, stiff, dried out: How can you teach form/function here?

The gold standard of learning anatomy was given to us years ago by the advent of anesthesia. It isn't the cadaver. And medical education, according to the Flexner report is now 100 years out of date. Get rid of our PhD colleagues in medical schools and replace them with MD's.

And you thought I was cranky?


pamchenko said...

cheers to you. you are cranky but make wonderful well though out points that I feel would have been very helpful in my medical education. I feel bad for digressing but I feel your point helps explain partially why kids come out of dental school more ready to practice whereas after medical school you feel like you don't know anything once you step in front of a patient.

how did the discussion with you the PHD go? if he or she outranked you, did you get fired? punished? I doubt they would have backed down. how big was the pay cut from surgeon to anatomy teacher? in an ideal world you would have gotten into an accident, cashed out on a disability paycheck for life and supplemented with anatomy teaching.

Anonymous said...


I still look up the brachial plexus now and the, but it is vastly easier to relearn because I dissected it many years ago.

Kids I know in med school now say that anatomy classes incorporate CT and MRI images. The exams only question major structures.

Shouldn't all physicians have a common frame of reference? As a mere ICU doc, I can't tell a ACL rupture from a form meniscus. But, I think having look at a cadavaric knee joint helps in talking to the orthopod (and also analysis of the latest NFL power ratings).

There will never be many MD's being med school anatomy instructors. Even the PH.D's are mostly non-tenured juniors.

To the OP: it's bad form to rip into your colleagues, esp. when both of you are just employees. Friend of mine have gone from attending docs into business (hedge funds and such).Nobody calls them "Doctor" at work, and kowtows because of their MD.

Doctor Which said...

Perhaps the most important aspect is what cant be taught by a clinician within earshot of an academic teaching center, not just through lack of time but also to conform to the reductionist materialistic, know-it-all scientific axiom. It is the academic that are teaching the importance of hard empirical data collected by technology and abolishing clinical acumen.
You can barely write that the way a patient moves or smells is an important part of clinical diagnosis. Such things are only found in the oral tradition that academics are systematically eradicating.
In outlying hospitals, clinicians taught me such theories as DNA cannot be everything before the emergence of Epigenetics. Academic geneticists still dont like that one. I was also taught of the power of the mind, particularly the emotions as a placebo or antiplacebo in health, even of placebo surgery. This is where real scepticism is learned to question what science hopes is true and instead, develop rational, pragmatic working theories to explain what clinicians see and use in real life outside the laboratory or dissection room.

Anonymous said...

Epigenetics have been part of standard science for years.

The placebo effect has been shown to be effective long-term only for chronic pain.

Clinicians may over-estimate their bedside acumen. I was an intern rotating thru Cardiology when Echo was just coming into widespread use. One of the younger, good-humored attendings would make "murmur" rounds with us, making a diagnosis of heart disease based on his stethoscope. My recollection is almost half of them did not match the echo results. He gave up those rounds shortly after. (He was a superb cardiologist.)

My experience is not that there is too much scientifically-proven rote in the practice of medicine; it is that there is too little.

It is disingenuous to say that medicine is based on science and then ignore best evidence because the doctor just knows better.

Skeptical Scalpel said...

Pamchenko, I can't answer your questions. I contacted the author of the mail that the post is based on. I hope he will respond.

First anon, I don't think he was saying that one doesn't need to know any anatomy. What he said was it should be relevant to what clinicians do. The knee joint is something all med students should study, but do they need to know how cartilage is formed or how much sodium is in synovial fluid?

Last two commenters, interesting discussion. Not sure about the role of epigenetics on bedside rounds.

David Kashmer said...

This blog is an interesting read. Thanks for presenting the anonymized letter. As we all know there are many factors making surgeons question whether practice in the field is sustainable, and pieces with this much candor are really appreciated. Harvard Business Review had an interesting article this year that says if you think you ever may want a second career you need to start to develop it early. The data related to that, coupled with issues like the ones listed, made me begin to develop other work outside my practice in preparation for issues I see in the future of surgery. This hedging a bet / Pascal's bet approach is reinforced by experiences like the ones shared above and I complement the author(s) on having the courage to discuss situations like these. Thanks again.

Skeptical Scalpel said...

David, thanks for the kind remarks. You are wise to start your second career early. I wish I had started my writing career earlier than 3.5 years ago.

anniekey said...

I was taught anatomy by a retired surgeon, and while I was expected to learn all the minutiae, he definitely succeeded in placing the emphasis on structures and areas that are clinically relevant. I also agree that cadaveric anatomy is NOT the best way to learn, because real live organs look little like the shrivelled up raisins oft seen in cadaveric specimens. Perhaps getting medical students to attend or assist with an autopsy or two would be beneficial, as autopsy organs do look very much like the real thing.

Anonymous said...

Thank you for your comments. I did not get fired, nor reprimanded. I am lucky the school's administration are mostly clinicians and support my beliefs. It is their lack of the ability to ENFORCE those beliefs on the faculty's PhD "minutiae" crowd causing frustrations among clinicians and students.

Pre-medical education is no different. We were required to take 2 semesters of organic chemistry, 2 semesters of physics (the 2nd semester is usually "electricity"), and our pre-medical "biology" consisted of a quarter of BOTANY. Calculus, too, is required, under the pre-tense it will be "needed" or "necessary" in some element of our practices. This simply is not true. I remain insulted when someone tells me, "the data suggests if you can pass and succeed in organic chemistry, you will be able to 'handle the rigors' of medical school." Huh? Organic chemistry--a science based on aldehydes, temperatures above 98.6%, and mostly carcinogenic materials--not "life science-carbon-based biochemistry" is being used to gauge my ability to become a doctor? a surgeon?

The MCAT is another example of an examination, have little to zero relevance, to the practice of medicine or the prediction of one's success in medical school. Again, we see an examination, generated by undergraduate-teaching PhD's, who have never practiced medicine, have no idea what it takes to do the same, yet INSIST organic chemistry, physics, calculus, and botany are requisites for medical school. I would argue every student entering medical school should be required to take: (a) two semesters of basic chemistry, (b) a semester of biochemistry, (c) a semester of organic chemistry [not 2], (d) 2 semesters of human anatomy and physiology [college level], (e) one semester of cellular biology, microbiology, or (and I'm very ambivalent about this one) genetics.

For too long the medical educational process has been held "hostage" by PhD's teaching and reinforcing minutiae at the undergraduate levels, and in medical schools, reinforced by medical schools "accepting" an MCAT based on non-relevant topics of medicine, and NBME part 1 based on "basic-science" minutiae.

I believe annikey has also offered an excellent suggestion: participation in autopsies of (fresher) cadaveric specimens. My point: anatomy can be taught better. The entire medical school curriculum can be taught better--without PhD's involved in the pre-medical or pre-clinical component. That's why your third-year student shows up and has no idea what he/she's doing.

Thank you for your comments.

Oh, and by the way, my disability claims (I won't give the details because I do not want any identifying information here) were denied by our professional organization's "occupation-specific" insurance company: The American College of Surgeon's endorsed New York Life.

Skeptical Scalpel said...

Annie, that's a good idea, but the autopsy rate in the US is way under 5%. It's unfortunate but true.

Kenneth James said...

Skeptical Scalpel:
Can you please elaborate on "arrogant doctors" being berated by hospital admins? Are you referring to the conflict in some healthcare settings between physicians and businessmen? Will you talk about this in any future posts?

Vamsi Aribindi said...


As a current medical student I feel I have learned a lot of valuable things from the largely Ph.D. staff. Erb-Duchenne Palsy's presenting symptoms and cause (birth canal trauma) and Klumpke paralysis' presenting symptoms and cause (upward jerk on the arm) make sense because I studied and understand the brachial plexus. Will I use it every day? Probably not, but it helped me learn the pathology behind several symptoms. The neuro-anatomy content was integrated with both the neurological exam and radiology, and I am quite thankful for it.

I know that I may not be as prepared for surgical anatomy as I might be, but at the same time, I don't regret learned extra information. I've always sought to understand why, not just memorize facts, and a basic-science focused anatomy course helps that. Of course, we have a pretty awesome anatomy faculty who have pared down the content significantly to the point where the majority of structures we learn are quizzed using clinical content questions.

Vamsi Aribindi
Keck School of Medicine of USC

Anonymous said...

Thank you for your insightful comments. It appears your anatomy faculty is "on-board" with teaching clinical relevance and reinforcing that relevance. Your comment, ". . .pared down the content. . .using clinical content questions" is my point exactly.

However, you learned about Erb-Duchenne Palsy and Klumpke paralysis (I suspect from the way your blog is worded) from PhD's who, also, looked this up in a book and reiterated it to you under pressure from adminstration to keep content "clinically-relevant". You do not say specifically whether this teaching of anatomy was, indeed, performed by clinical faculty (MD's/DO's) with EXPERIENCE in these birth canal complications.

We run into the problem of PhD's "attempting" to put clinical relevance to their topics--and many times--mutilating that content and presenting it incorrectly.

Thank you for your comment and insight.

Anonymous said...

Mr. James:
Thank you for your inquiry regarding the comment about "arrogant doctors."

I did leave this open-ended for interpretation; I apologize for this.

The comment is in reference to how in the world of American Medicine a physician who supports a great-deal of the responsibility and liability for patient care (especially surgeons) is often reprimanded, or labeled as 'disruptive', when he/she attempts to correct the behavior of a colleague (fellow physician, nurse, operating room technician, laboratory personnel, etc.) or teach that colleague how to prevent/avoid an error or complication. In most American hospitals, such physicians are labeled as disruptive.

I never was that doctor. In 20 some-odd-years in the operating room, I had personality conflicts with hospital personnel, perhaps, 3 times--resulting in my frustrations being demonstrated by raising my voice.

In my new academic setting, I have found those frustrations to be demonstrated almost daily. I have found such incredible arrogance and "resistance to change" among PhD colleagues--claiming they "know what it takes to be a physician" it is akin to me professing to Albert Einstein that, because I took a high-school physics class, that I know "what it takes to be a physicist" (even though I have never partaken of those job duties).

In other words, my frustrations in academia would get me labeled quite easily as "disruptive" if those same frustrations were actually shown in my years of practicing medicine.

Thank you for asking for the clarification.

Anonymous said...

Multidisciplinary teaching is needed, just like there are multidiscplinary clinics, e.g. Tumor Boards. Each medical student will have its own favorite teacher, role model. The best teacher does not work in isolation defending his own turf or significance, but instead refrains from offering lists of 'facts' that need to be memorized by students. Most medicine, clinical wisdom is gained by seeing and carrying responsibility for patients; none fitting the lists of facts or the Krebs cycle in intricate detail.
Just like learning a new language has evolved from memorizing vocabulary and irregular verbs, to watching video's of native speakers and 'emersion' visits to foreign countries, modern day teaching of medicine should focus on the more effective and lasting multidisciplinary learning opportunites offered by modern technology. Teachers and students will educate and enrich each other and underline the essential element in any learning experience: It has to be fun, at least most of the time.

Anonymous said...

As a career PhD educator in multiple medical schools, I suppose I should be insulted by the comments in this post, but there is much truth in them in my experience. However, the other side of this problem is the great difficulty in engaging many of our clinician colleagues in the educational process (beyond having students accompany them as they see patients -- an undeniably key part of medical education). This is largely because practicing clinicians have to put patient care first (by preference or because they are forced to by their bosses). I would personally be happy to turn medical education over to clinicians -- if they will step up (or are given the opportunity) to do the job.

Anonymous said...

The author of this post seems extremely bitter and rather ignorant.

The purpose of undergraduate medical education is not to produce fully baked clinicians - it is to prepare them for further training and supervised practice as residents who - to varying degrees - will specialize further.

Medical education and pedagogy are studied and researched objectively by many hard working educators. You assume, with your personal experience (n=1) that you know better than the combined and accumulated knowledge that has historically produced the best physicians in the world. Sorry, but I think you are outclassed.

PhD's are subject matter experts. A PhD anatomist is the best person to teach anatomy just like a Neurosurgeon is the best person to teach neurosurgery. Clinical relevance is taught in medical school alongside anatomy. Why must it be taught only by clinicians? Case histories, videos, simulations can all provide clinical relevance without the physical presence of a clinician. And all medical school curricula today have clinical courses - developed with clinician input - that integrate the basic sciences.

The education you propose already exists. It's call Physician's Assistant school. If all you wanted was a very narrow clinical and vocational focus you might have been better off going that route. We are all sorry your career as a surgeon did not work out as you had hoped. But if you left out of frustration, why did you file for disability as well? Were you legitimately disabled?

Whatever the case, maybe you should try to cooperate with your colleagues instead of being threatened by them. You both have things to contribute to medical education.

Romesh khardori said...

I agree with the author to a great extent. PhD's cannot provide clinical context which is important for a physician during learning years. Basic sciences like Biochemistry and Physiology even though well suited for a basic scientist (PhD) to teach too suffer when the content is delivered by those not well versed with applying principles with phenomenon observed in diseased state. Students will remember it better when physiology can be linked to pathology and the consequent presenting clinical disorder (that only a clinician can provide). Having said that we also need clinician who understand biochemistry and physiology as well as their PhD colleagues do. That combination is the best thing that can happen to medical education in the long run.
Romesh Khardori, MD, PhD

jynewjersey said...

As a late career Physician Assistant, I always thought that pre-med, med school and MCAT are parts of the weeding out process to locate the top talents who have the most chance to finish MD training. When I was certified as a PA at age 45 without prior medical training, I realized I should have done MD 20 years ago instead of worrying about being "weeded out". And 5 years later practicing hepatology under supervision, I feel more confident I could have done it earlier. Not sure how relevant this is to the anonymous post. Just wanted to share my experience.

Anonymous said...

You are one cranky SOB, all your good and accurate points were overshadowed by your looming diatribe. No need to get rid of the PhDs, but there is good evidence that supports the need for changing the way we teach.

Alice Robertson said...

No "Anger Rooms" at med school? Not even for the teachers?:)
But since the post was about experience I will say I think the original poster was venting about an obvious aspect PhD's are lacking while we wait for a PhD to counterpoint won't boil down to an either/or over the obvious weakness...because the picture is much bigger. PhD's bring a lot to the table (so what if they are your nitpicking evil twin without operating skills?:)

About SS desiring to write sooner. I think the longer a doctor waits the better his writing is. The more experience you bring, the more clarity, the more alluring the writing is, in the bigger picture... your audience. Realizing the internet rarely offers the type of music the words used to create in our hearts and minds (the noisy neighbors keep blocking out the melodies). And while anonymity amidst doctors is supposedly bringing truth to the's also harming the public's view with all it's curmudgeonish that can border on cruelty, while hiding behind bushes throwing rocks, and not becoming the true author the other literary physicians have (with their names next to some pretty gobstopping words that give them far more credibility).

And who better to write than a surgeon? I was completely obsessed with my daughter's surgeon's hands...the scars they created never bothered me because they represented his skill, and her extended life...and my healed heart...all the metaphors that a good writer can surgically use a pen to portray the cords of their own heart. But a true musical conductor needs a meaningful real name:)

Anonymous said...

Interesting blog, in context of recently seeing another article discussing how ill prepared residents are for actual practice I would say it is a golden opportunity for some research into exactly how much trivia type education and testing actually impacts patient care vs what the author proposed. These are debates with finite outcomes that can be measured with well thought metrics.

JO, MD said...

The sometimes conflicting goal of being an MD technician or a practicing medical scientist is intriguing. Too much empahsis on either can be counterproductive. PhDs have much to offer, but they must be under the direction of an MD based curriculum. Gross anatomy is both an intellectual and emotional introduction to the human body. There is a place for it.

Anonymous said...

I think the original writer painted with a pretty broad stroke. He seems to assume that no PhDs are involved directly in patient care. That is far from the truth. I have been a practicing hospital-based surgical pathologist in a major academic medical center for 25 years and teach in the affiliated medical school. I am an MD (and PhD) as one must be to be an MD to be a surgical pathologist. However, many hospital clinical pathology laboratories are run by PhD chemists, microbiologists etc. This is a common practice in Joint Commission and CAP certified pathology laboratories. These PhDs function as physicians, with respect to their laboratory duties, interpreting clinical test results, consulting on patient care, participating in tumor boards, M&M conferences, etc. They are extremely knowledgeable about clinical practice from personal experience. It would be foolish indeed to ban these PhDs from medical school teaching. So it is perhaps more accurate to say that it would be best to have faculty with clinical experience teaching in medical schools, rather than pitting MDs against PhDs.

karmaswimswami said...

I liked the commentary, and find it quite relevant. I am former medical school faculty, and was sickened and frustrated by the infiltration of non-medical people, including PhD's, into medical education. I fear that such people function very much like metaphoric gypsies (not that they wander): gypsies infiltrate situations, steal, sow discord, and then posit themselves as the only people who can fix the situation that they have occultly created. I feel and fear that many PhD's (not all) in medical education are MD wanna-be's very ready to wreak themselves on, and insinuate themselves into, the medical education process as extensively as they can.

----an MD, PhD

Chris Johnson said...

I went to Mayo Medical School the second year it opened (1974). The anatomists there had a novel approach. 1st year students regularly attended autopsies. It was a great way to learn many things -- respect for the dead, some pathology, and practical anatomy of the chest and thorax. The neuropathologist taught us with real brains. Of course one can't dissect muscles and many other things, but it was a great way to see the practical points of surgical anatomy.

I don't think they do that anymore there, though. Also, in those days Mayo had a very high autopsy rate -- often there were 4-5/day. That is no longer the case.

Anonymous said...

"In my 30 years of medical practice, I've never needed to know one single thing about the anatomy of the liver!!! Jesus! Why would medical students need to know where the bile duct is?!" -Dr. I.B. Bitchy, Ophthalmologist turned medical educator.

J Bowen said...

I find this post troubling. It reinforces a stereotype that many surgeons would like to dispel. Needless to say, I don't find anonymous's "argument" persuasive. For example, although not important to him/her, a rote understanding of the brachial plexus is essential to many surgeons and other specialties that deal with lesions in and around the pectoral girdle and the upper limb. On the other hand, there is a lot of stuff taught by MDs in clinical rotations and residency that isn't very useful in practice. My impression is that PhD anatomists have a pretty good understanding of patient careas it relate to the science. Perhaps more so than the anatomy professor who has only an MD.

Skeptical Scalpel said...

Lots of interesting and provocative comments. Thanks.

I'll address a couple. Chris, I'm afraid autopsies are as rare as MEN-1 patients. Unfortunately, autopsies won't be the answer.

I agree that research on the topic of MDs vs. PhDs teaching students would be nice, but I'm not sure how it could be done.

Alice, I have my reasons for staying anonymous. Someday I will reveal my identity. I find it fascinating that some people are very hung up about the anonymity and others seem to not mind it a bit.

Anonymous said...

Hey wait a minute I know surgeons and MDs who have PhDs and the odd one or two double PhDs.
I didn’t read the whole article because the intro wasn’t quite right in my opinion. Perhaps a start along the lines of get rid of PhDs who have never practiced as a surgeon or in been general practice. Not all PhDs are inexperienced half wits.

Charles Laidley said...

Belated comment here: OP in a later post question the value of premed courses like calculus or generics, and also MCAT.

This blog has had discussions on whether pre-med studies need to be 4 years at all. Take it a bit further, and we can drop all premed and the pre-clinical 2 years of med school. Just start at MS III, and I bet the clinical results of these ultra-accelerated matriculants will be similar to present MD's 10 years after graduation.

A big reason for all the preliminary studying is to screen for the smart, driven, conscientious people. Similarly, MCAT is mostly a proxy for an IQ test. Currently, Americans want these kinds of people to end up providing their medical care, and are willing (as a society) to pay them very well, and allot them high status.

American doctors are the highest paid in the world. In many countries doctors are medium. -status and poorly-paid. I would think the ease of entry into the field have something to do with it.

Anonymous said...

Outside of cheering you on, I would say that you are dead on. I suspect the reason why there is a big issue about misdiagnoses, missed diagnoses, delayed diagnoses, is due to the problem you just spoke about. It all starts in training. Just like the psychological beating they do to med students and surgeons.

Question for docs on here: what about MSTP people? The MD PhD's? Would you mind if they taught?

I am FLOORED at the comment on pre med education. I thought I was the only one who questioned taking botany (yes I had to, growing weed to pass the class still mind boggles me now). Calculus. I found out a handful of med schools don't require it and said boy was I stupid. Genetics btw, was a class available to us I LOVED.

and I am truly sorry for the disability issue. Skep and you are a couple of the surgeons I respect. Its hard to know a good Joe got the raw end of the deal. Unfortunately, it seems that is the 'way of life' in medicine.

and that is truly sad.

Anonymous said...

The point is that our medical system is out of date. PhDs have been largely responsible for research and Physicians for advancing medical treatment. Our fragmented health system doesn't require kicking out a group of professionals. It does need better interdisciplinary communication. Physicians barely have time to keep up with the changing insurance & regulatory environment so its unlikely the group could take over the role of the PhD even if they desired to do so.

Anonymous said...

Even academic PH.D's have better things to do than teaching anatomy. Gross anatomy is practically a dead science and no one on a tenure track is going to pursue it. So, most of the teachers are juniors or adjuncts who spend a few weeks reading up on it and looking at cadavers. Sure, post-residency MD's can do it and provide better clinical relevance. But, are they willing to work for non-clinical adjunct salaries?

Skeptical Scalpel said...

Alastair, sorry you didn't read the whole post. He wasn't talking about MD/PhDs. They are OK in his book.

I agree our medical system, particularly educationally, is out of date. I've written about that a lot. I agree there probably aren't enough MDs who would want to or be able to fill the basic science teaching slots. However, if the predicted shortage of residency training positions come to pass, there will be many unemployed MDs out there. Unfortunately, they will all be inexperienced.

Anonymous said...

PhD's in medical schools have a better pay-scale and more free time than fellow-PhD's in undergrad/grad schools. It will not be easy to dissuade them from teaching medical students when that disparity exists. I must say, however, that lots of the minutiae I learned 60 years ago have turned out to be important and relevant in today's world, especially in biochemistry, cell-biology, and genetics.0

Miles French said...

I enjoyed your "rant" Skeptical Scalpel. I am an ER Physician in a small town and I also teach medical student and residents. There is world of difference between the academic towers and being in the muddy bloody trenches.
Perhaps a story ... A few years ago I had this amazing student with me while attending an "emergency" delivery. He went on about the anatomy, physiology, complications and interventions. But then he suddenly stopped and looked a very puzzled. He leaned over and whispered in my ear, "what the hell is that?"
I held back a laugh when I whispered back " that is the babies head."
You can spend a lot of time in the anatomy lab or with a book but I truly believe the best experience is the real thing.

Anonymous said...

Medical schools need to do a better job of teaching female anatomy and the LIFELONG functions of the female organs - uterus, ovaries, and tubes. Medical studies prove that women's organs are never disposable. But practicing gynecology based on this evidence would cause lost earnings for doctors, hospitals, and pharmaceutical companies. So women continue to be harmed through the overuse of hysterectomy and oophorectomy. 76% of hysterectomies do not meet ACOG criteria. Healthy ovaries are removed at the time of hysterectomy over 50% of the time. I wonder what would happen if a man's healthy testicles were removed?! BIG medical malpractice award.

Anonymous said...

My goodness...

The author of this post may be a fine surgeon, and may be an excellent clinical anatomist, but should not be an educator. Period.

I am a PhD who has taught medical gross anatomy for 15 years, and I currently run an undergraduate major serving hundreds of students who will go on to pursue careers in health.

The author fundamentally misunderstands the role of the gross anatomy course. It is NOT to produce fully formed clinical anatomists who are prepared to tackle the most common clinical conditions. It is rather a course designed to give them the tools not only to master those skills as they progress in their training but also to think critically about anatomy as it may relate to conditions that they will NOT see every day. Gross anatomy is the beginning of the learning process, not the end. There is a reason why it is typically taught early in medical training. It provides a framework of many of the other things one will learn in medical school. Can you look up the branching of the brachial plexus later on in your career? Sure. But you can't tell me than an understanding of the branching pattern doesn't help in some sense in understanding the clinical significance of the structure.

Do anatomists love anatomical minutiae? Absolutely! The body is an amazing machine, shaped by evolution over millions of years to function as an integrated whole. A good anatomy teacher will instill that sense of wonder in his/her students. Is it clinically important to know that the greater omentum consists of four layers of peritoneum? Not at all. But that fact is one of the little details that helps you understand why the human gut is organized the way it is (i.e., it relates to the rotation of the gut during development). And knowledge of "why" helps reinforce knowledge of the basic anatomy. It is completely unimportant for a clinician to retain that information, but at the moment it was taught, it might have helped some students make some sense out of the organization of the abdominal viscera. Moreover, I have prepared many anatomy exams. Minutiae accounts for a very small proportion of each test. I think that everyone on this thread will agree that, you know, the LAD is kind of an important artery, and that the rotator cuff muscles might have some clinical significance, and that the size of the pelvic inlet might have something to do with labor and delivery, and that there's a biomechanical reason why female athletes are at greater risk of sustaining knee ligament injuries than male athletes, and a developmental reason why inguinal hernias are more common in men than women. And so on.

Gross anatomy gives each medical student a baseline of knowledge. Some will use it more than others in their careers, and that's fine. But don't insult scholarship. It's what keeps doctors from merely being mechanics.

Anonymous said...

To the PhD above: I teach [future] medical doctors, so, therefore, I am one, too. The author of this post does not argue the need for teaching clinical relevance or embryology. Nor, does he argue the POTENTIAL usefulness of minutiae in 40 years. He does argue PhD's, in ANY discipline, should be wary of trying to implicate relevance where there is none. As an anatomist who has taught for 15 years, you say the author should not be an educator. Why? Because his view differs from yours. That, I believe, is EXACTLY his point.

Skeptical Scalpel said...

Miles, fantastic story and very relevant to the discussion. BTW, it's not my rant. It was sent to me by a surgeon who is now teaching anatomy in a med school.

Next to last anon, good points. Thanks.

Last anon, thanks for your very controlled and sensible comments. This has been a very interesting discussion with some wildly divergent points of view.

Skeptical Scalpel said...

I'm having trouble keeping up with the influx of opinions. Really last anon, thanks for yet another great comment. I had not thought of some of your points.

Anonymous said...

As a physiology graduate student going for my Ph. D., for several years, I emulated what my grand old M. S. degree advisor, a Ph. D., did instructing his medical students in the then (now long gone) dog labs. After the animals were terminated, he proceeded to do a quick dissection of the thoracic and abdominal cavities to show them what real organs looked and feeled like, both outside and in. He felt that not for another two years would the students even see anything close to natural tissue. The intestines were still undergoing peristalsis. The effects of squeezing the gall bladder were starkly evident. The list of clinical correlates goes on and on. For those interested in sticking around for this impromptu demonstration, the reality of it all made a deep impression, and the thanks they gave was immensely gratifying. So, there is some worth to some Ph. D.'s.

Paul Stein

Anonymous said...

I'm the PhD who posted earlier. Let me put this another way. I don't think the author should be an educator because he/she doesn't seem to understand what education is. There is more to anatomy than what is most clinically relevant. But an appreciation of those non-clinical details may lead to a deeper understanding of what is ultimately clinically important. And the author does not seem to get that. It is true that PhDs should not claim to be an experts on clinical matters, but by and large I do not think that this is widespread. In most functional (as opposed to dysfunctional) anatomy labs, clinicians and PhDs enjoy learning from each other. And my point about clinically relevant anatomy was simply that the focus in most classes is really on the structures that have an important clinical profile. And when there is not a clinical focus, then there is often a compelling functional or developmental reason why the structure is taught. The vastus medialis may or may not be an important structure from a clinical perspective, but it plays a really important role during normal gait in preventing dislocation of the patella. Isn't there value in having doctors understand how the body functions when healthy? Yet, this is undervalued by the author. An educator understands that there is more to simply teaching what a student needs to should also teach things that the student might not need to know from a purely practical standpoint but that nonetheless helps the student learn, contextualize and retain the information they need. It's the difference between understanding and memorization. The author doesn't seem to think this way, but it's the way an educator needs to think.

Anonymous said...

One of the posts is interesting. It suggests the author of the blog should have gone to PA school--somehow implicating the difference between MD school and PA school is the presence/absence of the material presented by PhD's (in the 'advanced MD curricula') and the presumably all-clinical teaching a PA would receive by other PA's or MD's. Interesting. If the only difference between an MD and a PA is the "extra" presence of the PhD-academic-teacher, then do you not inadvertently prove the original author's post? Could MD school be "shortened" to the equivalent of PA school were it not for PhD's implicating "they are needed"? Does PA school, in fact, not prove one can take care of patients WITHOUT the need for the PhD-infused education? I believe it may.

Anonymous said...

The author of this essay makes sweeping generalizations about PhDs as a class, and about the state of current preclinical medical education on the basis of three years of teaching at an anonymous medical school. Perhaps the anatomists at this school are incompetent or lazy, or perhaps our author suffers from something of a God-complex. It is hard to tell. But I personally know PhD anatomists teaching in well over a dozen medical schools around the country, some among the most prestigious in the world, and some rather mundane. Some anatomists are responsible for teaching standard medical gross anatomy, clinical anatomy, anatomy for PT students, nursing students and undergraduates all at the same time. These are full-time teachers, tailoring the courses for the target students under the mandate of an administration to the best of their ability. Many work closely with clinical staff to develop and integrate gross anatomy into a modern problem-based learning curriculum. Almost all that I know work with clinicians to the best of their ability, with the only shortcoming being the willingness of clinicians to devote time to working with the medical school and the anatomists. Many are full-time researchers, as common for other basic-sciences disciplines in modern medical schools, managing active biomechanical, neuroanatomical, and even evolutionary anatomy research programs in both clinical and basic sciences contexts. I have known some incompetent anatomists who act as described by our author. Then again, I have known a fair share of incompetent clinicians and surgeons, and my father, a urologist, used to complain regularly about having to repair the damage done by general surgeons who did not know their anatomy. What this person is saying clearly plays into the opinions and preconceptions of many people on this blog. Then again, just as the author’s report seems to confirm the opinion that many PhDs are incompetent ivory tower academics out of touch with reality, the author’s writing also confirms the opinion of many others that surgeons are insufferably arrogant and extremely difficult to work with. Both cases are certainly sometimes true, but both cases represent a gross distortion and injustice to the majority of people who work hard at their jobs and try to improve medical education on a daily basis. This post, unto itself, is of little value.

Teri said...

As an experienced RN in medical school as an older adult, it was dismaying at many lectures. Not only was there no emphasis on how this could help a patient, there was no framework of the important points. So the ruthless hours and extreme stress were wasted. Even when the lecturer gave gems that were great basics, the avalanche of useless rote memory lost the impact it should have had as a foundation for a competent physician.

It struck me to see this philosophy on the handout of Dr Smith, the director of Med Ed "so the world looking on will know that something profound happened here, even if it didn't". In other words, everyone looking on would see how brutal it was and be awed.

It was brutal. In my class, one young woman had a mental breakdown during a test of the minutiae and all of us saw the instructor leading her robotic body out after the meltdown, ending this sweet person's career. One young man had total body alopecia, one wrote a poem about contemplating suicide. I went through a red light at a busy traffic intersection after a chem test.

Clinical attending MDs can be brutal too. The week I had a 30-hour shift on Monday after a 30-hour shift on Friday, at least 3 attendings had talked about the lazy new generation of docs. A fellow pregnant resident was not allowed to sit down when a patient suggested it because the attending physician said "she's an intern, they're used to abuse."

The point is, this is not a game or a ritual or a servitude. It is the knowledge we need the rest of our lives. We need the intricacies of the amazing human body, yet we need it in a framework emphasizing main points and then adding the rest. Everyone should celebrate 100% of the class knowing these key points.

Half of my class flunked one of the tests. How do you do that to honors students?

PhDs and MDs and students time is too valuable to waste. The thousands of dollars and thousands of hours in medical school, residency, and practice would be so much more rewarding if all of us insisted on a prioritized, evidence-based education. What really counts is how much we remember, not how much we memorize in all levels of education. How do we get evidence-based education is the question.

To his credit, the MedEd director, a PhD, listened and actually helped with MD input in the ongoing curriculum. "Something profound MUST happen here, patients lives depend on it."

Al Bourne said...

Basically it seems to the author of the original posting has simply misinterpreted reality

Anonymous said...

I don't that there is any dispute that medical education can be improved; it is the OP's tone which provoked intemperate comments.

Outside of a clinical setting where you bring in the big bucks (and even there), you are not going to get very far with screaming "I am an MD and you are not!".

Yes, you don't need to know any calculus or physics or chemistry to be a doctor. I bet you can just parachute students into 3rd year med school and their clinical performance would be pretty good 10 years down the road.

Why the premed degree and pre-clinical years, and MCAT? They are screens for high-IQ, ambitious, hard-working, conscientious individuals.

Some years ago, I read a study that concluded that students at Stanford Business School (very competitive and almost automatic entry to the elite) do not actually learn anything in their 2 years there. Instead, what makes them instant 6 figure hires is the fact of their admission (undergrad degrees can be from Art History to MIT AI) and lifetime connections.

Similarly, the hoops jumped for an MD are signalling devices, in the economic sense.

Anonymous said...

To the surgeon turned anatomy instructor: bravo. You are beyond correct. It is idiotic for PhD's to teach future MD's. Amen also to Teri RN.

Do we teach future Joe Montana's by having them sit in a classroom for a decade, memorizing minutae about Super Bowl XII? studying the parametric equations for flight of a football? solving make-believe problems on force and momentum involving collisions of linebackers? Who is kidding whom?

I am a rural general surgeon about a decade into practice. What good does a Grignard reagent do me now? An SN2 reaction mechanism? An intermediate filament? What good are they to my patients? I would trade all those long years and long hours of pre-med and med school, and all the honors and awards, for actually getting to do a few more lap inguinal hernias/colons/spleens, difficult polypectomies, carpal tunnels, or hysterectomies. Why did we have to waste our youth and give our life blood for so many years for 100,000 silly things that don't matter anymore?
There is no reason that residency can't start at age 18. There is no reason that we can't go back to the apprentice system. Our "educational" system is screwed up, beyond repair. Its real goal is the destruction of the creativity and energy of youth, and the formation instead of tamed, obedient, helpless, super-specialized half-wits.

Anonymous said...

Interesting. "Disruptive" is an HR code word for "unprofessional/threatening behavior or communication". How is that a better way to educate? Whether it be in the OR or academic setting.....

Anonymous said...

And people ask about the arrogance of surgeons!

To the last anon, yes, you can train a 18 (or a 16) year old to do a lap chole. There are already simulators where I'm sure many teenagers can excel.

But, society prob. won't pay you $250K if surgery goes back to an apprentice system out of grade school.

Anonymous said...

Actually, knowing that 7* 7 = 49 (did I get that right?) adds nothing to taking out a spleen. I propose that surgeons go immediately from kindergarten to residency. But, kindergarten wastes all that time with useless coloring,

Skeptical Scalpel said...

I have enjoyed reading all the comments. It looks like the issue is settled once and for all . . . or maybe not.

Anonymous said...

"And people ask about the arrogance of surgeons!"
Um, we are talking about our own field. I was not pontificating about how to become a nuclear physicist. If a tennis player gave an opinion about how to teach tennis, you would not jump to call him/her arrogant. Same applies here.
As regards 7^2: of course an apprentice system would need to retain a few necessary elements of the classroom system. My point still stands: we have a dreadfully inefficient system of "education". (And, blast it, the 3Rs can be learned about 100 hours if the student is ready and motivated -- ask me how I know -- that's how long it took me, and many other people with average intelligence.)
Practice makes perfect. The sooner the pupil can start practicing the REAL THING, the better. That doesn't mean that other things can't be picked up on the side.
We're not just talking about surgery. I doubt that internists need to drown in biochem and O chem. The best way to become a good diagnostician is to start seeing a lot of disease cases -- then figure out whether you are motivated to pick up Grignard reagents on the side.
If we didn't have to throw away 15 years to enter the field (and come out 200 K in debt), we wouldn't feel the need to make 250 K, BTW.
Regarding "Stanford" and "weeding out": if someone needs to be weeded out, his/her performance in the REAL THING should be what counts. (We wouldn't weed out aspiring tennis players, based on their ability to memorize Greek verbs.) There is no need for everyone to throw away so many years of life, just to "weed out" some misfits.
It's nice for Stanford to produce an elite product with an elite name -- but Stanford can't produce MDs to serve a nation of 300 million.

Anonymous said...

Well, if you got fed up with your former colleagues calling you an arrogant doctor and now you're (completely unprofessionally) berating and belittling your PhD colleagues...guess who has the problem?

Anonymous said...

Having been at Stanford myself, the MBA program doesn't weed people out. Similar to medical schools, practically no one flunks out. The bottleneck is in admissions. Grads don't get offer $100K to start because of their business school lessons; they get this and millions to follow because they got into the school in the first place.

In a similar vein, doctors get paid $250K ($600K for spine surgeons) partly for the societal premium awarded for admittedly non-relevant academics.

In fact, in some countries doctors are trained out of grade school, and supplement their salaries by driving cabs.

Anyways, we are prob. headed to a non-competitive entry into medicine.

Anonymous said...

The process begins even earlier. Why are PhD's allowed on admissions committees to medical schools? Are PhD's the best to pass judgment on whether somebody has the ability to make it through medical school, residency, board-exams, courtrooms, malpractice, and staying up all night without pay? I think not. But, again, that is just an opinion. I would argue medical school admissions committees should include ONLY MD's or MD/PhD's.

Al Bourne said...

AT last someone has had the nouse to write “ ONLY MD's or MD/PhD's. “ So saying exactly what he meant. The rebarbative use of the nomenclature of PhDs without clarity showed to me that maybe many of the contributors may not be much smarter than non MD PhDs. Clarity and certainty are two of the more important aspect of medicine. It may be a good time ask why haven’t all the moaners made a class complaint about the problems they have with Non medical members of a faculty. You won’t get change posting your complaints on the internet.

Anonymous said...

Thank you.
This is why I vote that medical education hires those of us with master's degrees and years of writing experience. We're not going to pretend we know what the students should learn; we'll ask the MD. And we both resent the PhDs.

Skeptical Scalpel said...

Last anon, I laughed out loud at your comment. Thanks.

Robert S said...

OK, then, so lets say you get through all that anatomists stuff, and wow you get to know and understand the human body, just like when we disected a frog in biology 101. SO? then what? I just served as a consumer reviewer (prostate cancer ) this week, on a panel for prostate cancer research, this was my 4th year and 5th panel, I can tell you that most of the PhDs were the smartest guys in the room , or do you think the urologists were. ? When it comes to drug pathways, nano particles , undersanding the combination of cabazitaxel and K5/DTA or how to add Zirconium to targeted radiotracers to kill metastatic disease, you reallywant an MD teaching that? I am only a prostate cancer patient. But I want the smartest guys in the room to teach the other smart guys. If you were a surgeon and you want to teach , thats great. But its only one small part of the rest of the story. I hope you never need an MD endocrinologist, although I dont want a PhD operating on me.

Anonymous said...

Robert S:
I want you to page the PhD in the middle of the night when you have nausea, vomiting, and neutropenia from your chemotherapy medicine--and have him explain to you to roll over, go back to sleep, because your drug-pathway, nano-particle, and zirconium-radiotracer is acting like it is supposed to--assuming he carries a pager at 2 am.

My point: There is no doubt the author of this post meant PhD's and MD's go hand in hand. He isn't (I don't think anyway) complaining that PhD's are bright--and that anatomy can be taught by others--he's pointing out the huge discrepancy between teaching basic science applications vs. teaching basic science just to show how much one knows. They must work together and respect each others turf: The PhD must not tell the MD "how to be a doctor" and the MD must not tell the PhD "how to wash the test-tubes." Complimentary.

Anonymous said...

The surgeon makes a limited point. But not everyone is going to be a surgeon and he lacks insight in his followup reply. Many surgeons forget most of medicine and many are just great technicians. Maybe these technically competent surgeons should just drop the MD after their name.

Anonymous said...

A wonderful discussion.
The usurpation of medicine by academia has been ongoing for some time.
Increasingly, backwards from the 1970s, major medial journals featured interesting short case histories and brief references, essentially peer-peer communication.
Fast forward to today, articles may exceed 10 pages and 100 references. The will be plenty of statistics that never approach the number 1.0, which is what stands in front of you in the person of a Patient.

Skeptical Scalpel said...

Thanks for the interesting comment about the nature of journals. Another disturbing trend is the proliferation of journals. I wrote about this a couple of years ago.

Anonymous said...

Regarding journals, fortunately there is a self-regulating mechanism already in place. For all physicians, NEJM, JAMA, Lancet, and a few others, articles are taken very seriously. In addition, each specialty has its own prestige journals. Something published in the Proceedings of Jethro County Medical Society - not so much.

Since researchers have to pay to get their studies in print, there is now a thriving internet industry of medical/scientific "journals". The publisher gets a few thousand bucks, and the researcher gets a line in his resume.

Charoo Iyer said...

Well said !

Anonymous said...

I spent countless hours in pre med Columbia University learning things I never use as a surgeon--,I was one of few students to get an A+ in calculus out of 250 freshman in the class. I am sure it helped me get into med school over 30 years ago, but it never helped me take out a nasty gallbladder. What is upsetting is that I think I forgot all of my calculus now 35 years later. What I remember most is the humanities I learned -- philosophy-Kant, Plato, literature,are Monet,Renoir,Picasso,-I laugh when internists or Phd's are the smartest ones in the room. Isn't Barack Obama supposedly the "smartest one in the room". One of the best college professors I had,told us students in an advanced physical chemistry course(all of which I have also forgotten now) was that he wanted us to be able to "think". He said we would forget a lot of what he wanted us to memorize--his main goal was to teach us how to think and analyze problems--he was right. He also said it was not so important as to memorize something but to know where to be able to look it up. The art of surgery is being able to analyze a problem and use your fund of knowledge and experience to take care of it. If you did not know enough about the disease, then look it up in a book,journal or ask a colleague for help.

Skeptical Scalpel said...

Very well said. About 18 months ago, I lamented the fact that after all these years, we still emphasize memorization instead of teaching residents how to think. You can read it here:

Anonymous said...

Completely agree!!

Practicing surgeon

Anonymous said...

To the PhD Anatomist that said, "My goodness...

The author of this post may be a fine surgeon, and may be an excellent clinical anatomist, but should not be an educator. Period."


Your diatribe indicates the common belief held by many of your colleagues: "Because you teach health-care providers" you are able to address anatomy "as it may relate to conditions that they will NOT see every day."

Is it safe to assume that if they, as medical doctors, physician assistants, and nurses, do not see such conditions every day--and they, being the ones FACED with these conditions--that you, as the non-practicing PhD Anatomist of 15 years have NEVER seen, nor treated these exceedingly rare "conditions."

And they say surgeons are arrogant. Give me a break.

The author of this post is dead on...attitude or not. We can do better in educating our future physicians--than by having others "tell us" about "rare" conditions and "critical thinking" skills related to those conditions who have never seen, nor treated, those conditions.

I applaud the author and SS for bringing this to light.

Skeptical Scalpel said...

Thanks. I must say that this post has generated a lot of interesting discussion. Thanks to all for contributing.

Anonymous said...

As a retired PhD pharmacologist/epidemiologist educator of future MDs, I find surgeons to top the list as superb technicians but at the bottom knowing other aspects of medicine.

Skeptical Scalpel said...

Anon, I would take issue with that comment. One must have a broad knowledge of many diseases to be a general surgeon. I can think of many other specialties (that I will not name in the interests of keeping peace) who focus on much narrower areas than surgeons.

Anonymous said...

Interestingly, once again, we see a post from a PhD pharmacologist/epidemiologist ("educator of future MDs") expressing knowledge about MD's (specifically surgeons). Let's reword it, and see what kind of reaction it gets:

"As a retired MD (surgeon), and educator of future PhD's, I find PhD pharmacologists to top the list of knowledgeable researchers, but at the bottom knowing other aspects of epidemiology."

See how ridiculous that sounds? Why would I expect a PhD pharmacologist/epidemiologist to know anything about surgery--whether I'm a good (or bad) technician and/or knowledgeable about "other aspects of medicine." When has a PhD pharmacologist ever scrubbed with a surgeon? How does he/she know about a surgeon's technical skills--let alone having made rounds with the surgeon to gauge the knowledge of the surgeon's "other aspects of medicine."

Such posts, while perhaps initially complimentary to a surgeon, are said out of ignorance and prejudice.

When I really have to have a "doctor"...and my life depends on it...I want a surgeon at my bed-side. Period.

Love the comments. It seems the author and SS are, again, only supporting a valid argument.

Anonymous said...

My biggest questions about medical school training has to do with why so many doctors don't seem able to follow the basic rules of scientific knowledge and simple logic.

Medical professionals do not seem to be able to grasp the simple things: A correlation is not a causation. Self-limited population does not equal a proper sample. Anecdotes are not hard data. Just because something is repeated does not make it a fact. Possibilities are not the same as a guarantee.

It is bad enough when this type of stuff pops up in blog posts, but when it occurs in peer reviewed journals, my head starts to spin.

Every time I hear/read "In my practice, I see..." as the justification for some alleged fact, I want to cry. I used to read the blog of a emergency room doctor who one day stated as fact that "there's no such thing as a fat diabetic with good glucose control." The basis for this fact was that in the ER they worked, every fat diabetic the doctor saw had horribly high blood sugars, usually combined with some other illness. Eventually it came to light that the hospital the doctor worked in was in a very poor neighborhood, where few people had any sort of decent health care. Illness can exacerbate hyperglycemia. By the time these people got to the ER they were in a crisis situation. Yet the doctor refused to see that the limited pool of patients in this ER did not qualify for a global conclusion.

A classic example of peer-reviewed studies that "prove" things with no logic behind it are the ones that claimed that weight loss improves cardiovascular health. Patients were put on weight loss diets and encouraged to exercise more. They lost weight, and their blood pressure and cholesterol levels improved. The conclusions drawn was that weight loss caused the results. It wasn't until fairly recently that studies started discovering that it's actually healthy eating and exercising that improves CV health, not weight. Few bothered to see the logic failure that if A and B cause results C and D, there's no proof that result D is caused by result C.

Simple bias is very common in peer-reviewed journals, to the point that it is clear that if the bias conforms to the reviewers bias, nobody notices. My favorite example of this is a study done in the early days of troglitazone (aka Rezulin), one of the earliest anti-diabetic glitazones to come to market. As it was said to work on insulin resistance, a study was undertaken to see if it would also promote weight loss in obese diabetics, as obesity and insulin resistance are often tied together. At the end of the study they found that not only was there was no weight loss, but the patients gained weight instead. The study concluded that there was a flaw in the study, in that they depended on the patients' self-reporting of food intake and that it was highly possible the weight gain was caused by overeating, because, "we all know obese people lie about what they eat."

We now know that weight gain (frequently from edema) is a very common side effect of glitazones. But based on the common bias of "We All Know" medical theory, which rarely has factual basis, this nonsense got published.

Frankly, I'm all for a more practical experience. But I'm also for making sure that doctors (and medical researchers!) are capable of understanding AND FOLLOWING basic scientific concepts and rules of logic.

anonymousstudentdoctor said...

I'm at odds with a lot of the detail we are presented. A recent test asked questions about where on the DNA a mutation occurred. Was it in coding region, UTR, etc. I cannot find any clinical significance in this type of question. Can I see the 5' UTR in a clinic?

This takes up a lot of limited brain space.

Skeptical Scalpel said...

Anonstuddoc, that is a prime example of what the guest poster was talking about. I wonder how many in your class got the correct answer?

Anonymous said...

As an OR RN I can say that some of the most awe inspiring intelligent physicians I have worked with have been general surgeons, anethesiologists, and neurosurgeons. I have benefited from what some may say was useless knowledge, as they could have done these surgeries no doubt without having known the information. However, I believe they were able to provide better clinical care and education to the patient by having a good grasp of the anatomy, physiology, pathology of the disease processes and organs. And while the anesthesiologist may not be operating, they need to know how those surgeries will affect the body, down to levels I can only imagine was taught in an advanced anatomy physiology class. I take issue with someone saying that a PA essentially can perform in the same manner as a physician, just as a NP really cannot take the place of an MD. They all have their roles and there certainly are exceptions to the rule, where there are PA's and NP's better than the MD's collaborating with them. But there is no substitution for an MD with a good foundation and firm grasp of clinical knowledge. I have not the knowledge or experience to speak to whether a PhD is any better than an MD or MD PhD. So I won't. I do appreciate the comment about the professor who told his students he was teaching them to think. I have long held that hypothesis that school was not much more than a tool to teach the brain to think. Yes, you may gain some useful knowledge along the way, but most of it is nothing more than a creation of a neurological highway. Like the opthamologist said, why do I need to know about a bile duct?; but I bet the general surgeon was all about knowing that! Well, unless he wants to cause his patients a life of medical problems when he is removing their gall bladder. Point is, there is probably something for everyone being taught in these classes, just as in high school. The information you don't need is used as a building block to get to the info you do need. Ever wonder why there are grade levels? Why can't you just start reading adult level material when you begin reading? You have to build up to it. So maybe it may help to look at all the minutiae as simply being building blocks to get to the important stuff. I believe that is what is seperating a PA and NP from an MD, the foundation. It isn't just clinical experience that shapes a doctor and his expertise. It is all the mind numbing, useless (to some) info, wasted years, that I think cause most patient's to blindly trust this stranger who just walked into his room at 2 am and is telling him he is going to save their life! Just my opinion.
And don't complain about the need for change; be the change! Start talking to the right people; instead of having a blow off steam rant, create a well worded document with references to back up your statements. It really does only take one person to affect change. I have a great respect for doctors and the time spent to become that. If it can be done for cheaper, with less of a life committment, without truly affecting patient care then I am on board! Be the change!
and just so everyone knows I am not putting down Np's and PA's they all have their roles and importance in medicine!

Skeptical Scalpel said...

Anon, thanks for the thoughtful comments. You make a good point about building blocks. It may be that there are too many of them though. And we certainly aren't making great strides in teaching med students how to think. Let's hope my colleague who wrote this post does as you say and tries to change things.

Robert said...

Well, I unfortunately only just discovered this excellent blog!
I do agree there ought to be more MD's, especially surgeons, teaching Gross Anatomy. We had only two MD's teaching, a retired general surgeon and an ophthalmologist. Perhaps more incentive is needed, financial or otherwise. It should be looked upon with respect; there may be a stigma attached to teaching, as if those who can't do, teach. How awesome would that be to have a faculty composed of various sub specialties - an orthopedic surgeon, neurosurgeon, urologist, ENT, etc. There course could have a rotating faculty along with a core faculty, and each academic surgeon would be required to do a month once a year.

Skeptical Scalpel said...

Robert, thank you. I think the biggest deterrent to your idea would be how to pay MDs to teach these subjects. To take a month out of practice would be difficult.

Robert said...

Of course, but these would be academic surgeons - don't they make less to begin with ;)? II think the med school ought to take it out of the overpaid hospital administrators' salaries. It could be a nice break for the surgeon to prevent burnout too.

Skeptical Scalpel said...

Academic surgeons have to pull their own weight these days. They wouldn't be making any money for the dean in the anatomy lab.

Anonymous said...

This is the kind of nonsense thinking that gives us the sorry excuses of physicians I see around me today. How can you possibly say that a medical student shouldn't go into his study of the human body without knowing everything there is to KNOW, not merely what might be convenient for a general surgeon. This is the kind of thinking that leads me to believe my medical education is becoming more like a trades school education, just learn the minimum information you need to perform a procedure, who cares about the rest, who cares about innovation, who cares about curiosity... it's really sad.

Skeptical Scalpel said...

Anon, that's an interesting comment. You have a point, but I don't think it is possible for today's med student to know everything there is to know. And a lot of information we memorized is available on our phones. Many leaders in medical education agree that becoming a doctor takes too long. Compromises will have to be made. Who will decide and what will be left out? I don't know.

Anonymous said...

The issue isn't that we, as physicians, shouldn't try to learn as much as possible to help our patients; rather, it is we need to learn as much as possible THAT IS RELEVANT to help our patients. Example: We all took Organic Chemistry--but was that relevant to the study of MEDICINE where all reactions occur at temperatures much lower than the Bunsen burner provides. I remember learning and memorizing the structure of gasoline--but never used it in medicine and sure do not need to know this to drive my car. Furthermore, that "knowledge" that I needed to know "everything" has long since left my memory banks. We must focus on what we CAN know and be guided by its RELEVANCE rather than knowing for the sake of knowing.

Al Bourne said...

One wonders why people can’t let this go and get on with the job in hand. What one learns at med school soon becomes almost irrelevant as medicine advances and at an ever increasing rate.. One doesn’t really start learning till one gets into practice and the learning leaves med school far behind. Stop squabbling about what you studied at med school and soak up current information, you cannot live in the past. Med training may well be totally different anyway since most of the complainants attended med. Further if the training was so wrong how come there are so many good Drs out there? Simple really they got on with soaking up experience and adapting to new ways. More than anything studies are to prepare one for the future and to develop the ability to research and work things out to a positive conclusion. Who cares what some PhD taught you a med every time you get someone ell using your own self taught skills. For Gods sake I completed training in the 60s and nobody taught me genetics / sequencing I had to seek the training for myself many years alter. My training made it much easier to grasp the intricacies of the subject than had I not had training that allowed me to develop skills later in life. Then came computing and what will come next.

Anonymous said...

"Who care what some PhD taught you. . ."

I do. I was paying for the product. I was paying for my own education. While there is truth in what you say, it is akin to saying, "Let me teach you the structure of gasoline. . .to drive your car." You say, "Forget it...move on...learn something new every day." I agree with the on-going learning and your comment that "What one learns at med school son becomes ALMOST irrelevant as medicine advances and at an ever-increasing rate." And, you are correct, we MUST stop "living in the past" and change the way we teach medicine now. To continue to allow non-clinical PhD's to teach future clinicians IS living in the past: as dictated by that now, outdated, Flexner report.

Time for a new Flexner report. Time for an overhaul of medical education. We ARE living (and teaching) in the past.

By the way, I need to go fill my car up today with unleaded. . .but I'm not quite sure how to calculate that octane rating. I'd better ask the attendant. He'll know.


Anonymous said...


I had to walk a mile through two feet of snow in sub-freezing temperatures just to get to the school bus, too.

Skeptical Scalpel said...

Thanks for the comments. Interesting analogy with gasoline.

ayeekaz said...

I'm currently in my final year of med school, doing an orthopaedics rotation, and what I want more than anything is a cadaver. I learnt anatomy 4 years ago, and had no appreciation for it: mainly because of all the minutiae that obscured the real knowledge. I had excellent anatomy teachers, but what they told me was important for me know has proved to be in contrast with what the clinicians want me to know.

I believe that a thorough knowledge of anatomy and physiology allows one to make clinical inferences and understand disease. In fact, that's my "get out of jail card" in exams: I think about the basics and approach the questions asked from there. But there really is no substitute for a clinician that understands the link between the theory and the practice, and while PhD's have a phenomenal grasp of the theory, they really don't have a clue about the subtleties of practice.

I think it's a rather poor indicator of trends in medical education that as a student in a different country, coming from an undergraduate programme, this article resonates so strongly with me. Globally it seems we have a problem.

And, by the way, although I went from grade school straight to med school, I will still earn a comfortable living from my career. That doctors are paid high salaries goes with the fact that in most cases, they work crazy hours, are highly skilled (not knowledgeable - skilled) and subject to the whims and fancies of the government, insurance companies and patients. At least, that's my opinion.

Skeptical Scalpel said...

Ayeekaz, you are right. In my fourth year of med school elective time, which was 12 weeks, I taught anatomy. It was a great way to refresh my memory about the subject.

It is interesting to know that other countries share our problems.

Unfortunately, I don't see a viable solution.

MBBS in Philippines said...

Good and Interesting Article.

Anonymous said...

Just another anonymous biochemistry PhD here who just stumbled on this fascinating blog. I have no dog in this fight since it has been decades since I've done anything in medical school education. (But do you remember doing problem sets on the acid-base chemistry of amino acids? I might have been your TA.)

I was interested in the comments about medical school admissions committees because I have never heard any PhD talk about being on such a committee. (But I have heard many complaints over the years about being assigned to teach medical students. I have yet to meet a PhD who enjoys it. If MDs were willing to do it, I am sure the PhDs would happily give it up.) Anyway, I wondered how often PhDs serve on these committees.

So this is my quick and dirty look at PhDs on admissions committees. Wash U's committee came up near the top of my Google search. It had a list with pop-up bios of the members so it was easy to find information. Here's a rough analysis of that one admissions committee:

Total members: 74
Total MDs (including MD PhDs): 63
No advanced degree: 3 (university apparatchiks)
Total PhDs (excluding MD PhDs): 8 (all women, for what it's worth)

Drilling down:
Of the 8 PhDs, 2 have substantial experience related to patient care
-One is a clinical psychologist who directs psychotherapy training for psych residents
-one is an assoc director of hospital labs--clinical chemistry, serology, immunology

A third PhD is an associate dean for medical student research.

Another PhD seems to bridge the gap between research and patient care. Just going by her little bio, she does research in hearing loss and speech recognition, she has worked with the deaf and hearing impaired, she has set up rehabilitation programs, and she is also involved in a study of communication breakdown in ORs (Now there's a study I'd like to read!).

The remaining 4 PhDs are basic researchers who don't seem to have experience with patients:
-a microbiologist who works on H. pylori
-a geneticist who studies abnormal lipid metabolism
-a biostatistician interested in community-based research and health disparities
-and, finally, yes, the dreaded anatomy professor who does research on baboons.

So this is just one committee, but it looks to me that there are only 4 PhDs devoted to basic research. That's 5% of the committee.

At least on this one committee, it doesn't look like basic scientists have much influence in medical admissions at all.

Does anyone know if this breakdown is typical?

Skeptical Scalpel said...

Thanks for the interesting comments. Is this Wash U in Seattle or St. Louis?

I'd like to read that OR communication study too.

I am not aware of the composition of med school admissions committees. Although this post has had over 14,900 page views, it's a bit dead at this point. I hope someone else will enlighten us.

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