Tuesday, June 7, 2016

Changing pre-med requirements and med school curricula

Ezekiel Emanuel, the University of Pennsylvania physician and ethicist, has written an opinion piece suggesting many changes in both pre-medical education and the medical school curriculum.

He would do away with many of our hallowed medical school prerequisites such as calculus, physics, and organic chemistry, feeling that those subjects are simply used to "weed out" certain students. I confess I once believed that such subjects were worthwhile. However, Emanuel makes a convincing argument that rigorous college courses in more relevant disciplines such as statistics, genetics, ethics, and psychology with a special focus on human behavior would suffice.

Regarding medical school, Emanuel points out he was taught the Krebs cycle on four different occasions in college and medical school and never used it once in practice or research. I have made a similar observation in a previous blog post.

He considers pathology, cytology, and pharmacology to be largely irrelevant to medical practice but concedes that some may disagree.

As an ethicist, he feels that bioethics should be taught beyond physician and patient interactions to encompass areas such as "scarce resources, public health emergencies, and basic and clinical research."

A recommendation I strongly support is that statistics should be taught again in medical school. Unless things have changed since I was actively involved with medical students and residents, even those who claimed that they had taken a statistics course had no idea what tests to use for different types of data or how to analyze a research paper.

Emanuel correctly identifies healthcare expenditures as another area that medical students simply have no knowledge of. In my opinion, most med students and residents don't know the difference between Medicare and Medicaid or costs vs. charges, nor do they care.

Making these changes will not be easy. Medical schools would have to agree to revise their admission requirements, and colleges would have shift priorities to provide the necessary courses. The Medical College Admissions Test would also need to be revised to incorporate the new and eliminate the outdated material.

Everyone may not be sold on all of these proposals, but clearly something needs to be done.

By the way, Emanuel’s commentary was published in JAMA 10 years ago.


George Gasman said...

From one of my partners:

"When I was in college, I sat in calculus class and a classmate of mine raised his hand and asked the professor why he needed to know this stuff: 'I'm planning to medical school and I'll never need to look at another differential equation or derivative. Why should I bother with they class?'

The professor replied, 'Because my course saves lives.'

'How is that?' asked the student?

'It keeps the stupid people out of medical school.'"

That anecdote aside, there's probably some validity to the idea of revamping medical education. As you point out, statistics is valuable, and a gaping hole in my knowledge. Educating "healthcare expenditures," while a worthy goal, might not be worth a lot of time (certainly not a whole course), but a few lectures.

Anonymous said...

A joy to hear.

How about courses in nutrition, how to deal with fads that affect health, how to negotiate with patients, how to deal with your own biases, how to make friends outside of medicine, how to recognize when you are approaching burnout and balance your life. Negotiation of contracts, dealing with administration. Money, as in budgeting and some financial info.

How to play kick ball, dodge ball, or basically unlearn some of the gunner mentalities out there to relate to the humans who come to them for treatment.

Ed Volpintesta said...

June 7, 2016
Skeptical Scalpel
Re “Changing premedical requirements and med school requirements” [ posted June 7,2016]
I am a general practitioner, in practice since 1975. For years I have written and spoken publicly and privately about how I considered the time I spent in organic chemistry, physics, and calculus wasted because I have never needed whatever knowledge I was supposed to have gained from them.
Several years ago I had published a letter in my state medical journal mentioning the time wasted on these subjects and was criticized in a follow-up letter by colleagues in family medicine.
Therefore when I received this reference about the article by Ezekiel Emanuel (from a friend who is a surgeon) I felt a sense of vindication.
I know little about medical education but 40 years of practice have taught me that much of time was ill-spent on subjects like the ones that Emanuel had mentioned. Time that would have been better spent on some of those subjects discussed in his article in JAMA that appeared 10 years ago!
Edward Volpintesta MD
Bethel, CT

Anonymous said...

Amen. Those courses (organic chemistry, calculus, physics, etc.) have SOME (albeit minimal) worth and relevance, they mostly serve to pack undergraduate institutions with tuition-paying students so the instructors have job security. Seriously, organic reactions, as taught in organic chemistry, take place with a Bunsen burner. If I remember correctly, BIOCHEMISTRY would be more helpful. Whatever. The system won't change for the very reason Mr. Volpintesta relates to, being "criticized by colleagues".

Korhomme said...

I was taught in a very traditional medical school in the UK in the late 60s and early 70s. Like you I have never applied my knowledge of the Krebs cycle to any patient; nor have I found the anatomy of the nerve to anconeus to be important; and Starling's law of the heart bore no resemblance to the terms and descriptions that cardiologists used.

I'm all for a clinically based course. In addition to what you describe, how about courses in critical thinking? Learning that an association is not a causation would be a start, followed by use of the 'sufficient and/or necessary' argument.

Skeptical Scalpel said...

George, great story.

First anon, I like your suggestions. When they put me in charge, I will implement them.

Ed, thanks for agreeing with me.

Second anon, Emanuel does think some biochem is worth teaching. I agree.

Kor, I've been advocating that residents be taught to think since I stated blogging in 2010. Here are a couple of links to prove it.



Anonymous said...

Skep teaching docs to think is going to anger admin, just like I do.

Korhomme said...

Skeptical Scalpel; thanks for the links to your earlier posts.

Skeptical Scalpel said...

8:34 anon, my mission in life is to anger administrators.

Kor, you are welcome. Thanks for being a loyal reader.

Ed Volpintesta said...

June 8, 2016
Skeptical Scalpel [response to anonymous June 7, blog]
Probably the worst deterrent to physicians who want to express personal comments that are not mainstream medicine is the risk of being criticized by their colleagues. It can make one feel like a pariah.
It is easier and safer and more respectable to criticize one’s colleagues than to find fault with the way medicine is taught or practiced.
It is good that the Skeptical Scalpel allows physicians’ dissident voices to be heard.
Edward Volpintesta MD
Bethel, CT

Anonymous said...

Do you have me beat? I have risk managers that resign and won't talk to me (so far). That's one hospital only.

Skeptical Scalpel said...

Ed, anyone may comment here as long as the comment is relevant, not profane, and not a personal attack on someone else.

Anon from June 8 11:44 pm, I've never (as far as I know) had an administrator resign because of me. I'm sure some have wanted to.

Anonymous said...

they need to teach how to read and interpret the literature. this however would go against the multiple choice way of teaching in medical school. for example most medical students come out knowing that drug A is used to treat condition B. very few know that in 3/5 trials drug A showed a 20% improvement over placebo (which itself showed a 20% improvement) in patients with condition B who were between 40 and 75 years old, who did not also have condition C & D and who had not already failed drug D. Then they might not be so shocked as to why things in the real world don't work out the way that you were taught.

Ed Volpintesta said...

yeah, anonymous, the academicians have a way of thinking that medicine is not practiced on the ground but up in the rarefied air of the ivory tower.

Skeptical Scalpel said...

Anon-from June 9, I completely agree that students and residents should be taught how to interpret the literature and that multiple-choice testing does not lend itself to nuances.

Ed, it's true that some academicians are not aware of what goes on in real life.

Ed Volpintesta said...

nuance--I like that word. As a GP there are some days that all I deal with are nuances. Not one of which would have any meaning or even be incorporated into a multiple choice test

Anonymous said...

Anonymous Europe: This is interesting. I went to medschool in Europe, and I have the same notions about medical education here. Firstly, the curriculum is littered with irrelevant information, and you can practically finish medschool without ever giving an i.m. injection..... Besides what everyone forgets, -and the way I see it, is a huge problem with Generation Y- is growing up. You spend six-eight years of your life in a library and in the hospital, crunching data and working. By the time you come out you are just a teenager with a dangerous title. Growing up has shifted well into the early thirties which is bad for everyone.
I disagree with the statistics. I have always hated mathematics and have an inborn hatred for anything related. I prefer performing and assisting operations and working in the outpatient unit to crunching some boring numbers....

Skeptical Scalpel said...

Anonymous Europe, I appreciate your faithful reading of my posts, but I must disagree with you about math. Unless you have some understanding of statistics, you will not be able to properly evaluate research papers.

You don't have to crunch the numbers, but you do need to be able to interpret them correctly. I think as time passes you will change your mind about this. I've written many posts about statistics and tried to keep them free of formulas and other distractions.

On the right-hand side of this page is a list of my popular posts. Click on "statistics" and read a few of them. You will find it's less burdensome than you thought.

Anonymous said...

I am USA born and I am loyal to the red white blue, but my parents are from India. I have heard the stories about the indian admission system, which has been in scrutiny lately due to accusations of cheating. However, in the past the system was quite good overall. Everyone interested in medicine takes a test last year of high school to see how they compare to students nation wide. You get ranked nation wide and thats how you are granted admission. My worry about our system does not start with curriculum. My worry is in regards to who we are admitting. Over at University of Arizona in the past they have allowed navajo or native tribe decent admission with lower standards. I have seen favors pulled for people who know people. These are just examples, we can go on and on. Im not saying india is perfect, I know of the corruption that has occurred over the yrs, but the overall premise of scoring well on a logical exam and allowing only a certain amount of students into the system based on their rank seems better to me. Now i have heard the, well, we interview students judge their character yada yada. That is important, but I feel we let a lot of mediocre people into the system here in USA not based on scholastic merit. The admission process is quite a game, what research you did, did you travel to Africa to teach about Aids, etc. Look, I never understood the resume building we teach 19 year old kids. What happen to passion...Alright, I had more to say, got to go to rounds soon. Look, I feel our system might be fine as it as, we need more honest people who are dedicated to this. I have said for long time the 4th yr is a waste, students either already know their high usmle score will match them into ophtho, ortho, derm, etc. They dont take the 4th yr seriously, we need to discipline students, hold them accountable and start bringing in people who do not manipulate the system.

Skeptical Scalpel said...

Anon, thanks for commenting. Test scores do not directly correlate to physician quality, which is hard to measure anyway. The trend in the US has been to try not to focus on scores alone, but to consider other factors in deciding who gets admitted to med school. Right or wrong, that's where we are headed.

Passion is great, but it is also hard to measure. [See: http://skepticalscalpel.blogspot.com/2014/08/true-grit.html]

I don't have all the answers.

Anonymous said...

Thats true skeptical scalpel, but my point is we teach 18-21 yo to resume build to get admission into med school, law school, MBA school. Volunteer here, research here, but 19 yo johnny really has no passion for the volunteer work or the research or the trip to Africa teaching about Aids. This is all fake if its really not passion. Its just to say you did it, make yourself look good, and get admitted. Then once you are admitted all that fufu stuff from that resume you built all gone, why, you are already in! This is teaching fake character. This is why you have the chairman saying wow johnny was pretty good during interview and his resume, wow! Then when Johnny is an intern, hes doing shortcuts and not giving 100 percent, he's really not passionate about this, it was all a facade. Or as a fourth yr MS leaving rotation early, not reading during 4th yr, hey, I already matched.

Skeptical Scalpel said...

In my early days as a program director, I inherited residents that the previous PD had chosen. Many of them did extremely well on tests like USMLE and ABSITE, but couldn't take care of patients, lacked common sense, and had bad communication skills.

I agree that it would be nice to match with only passionate applicants, but as I mentioned in the post about grit, identifying them is difficult--maybe impossible.

How would you suggest we screen applicants for passion? It's not by interviewing. Anyone can talk the talk.

artiger said...

Passion is a little like pornography...difficult to describe, but easy to identify. There is no way to screen for it, but I think you can screen some out for their lack of it.

Skeptical Scalpel said...

Maybe you could screen them for lack of passion, but I wouldn't know how to do it.

Unknown said...

I question anything the Obamacare architect has to say. What a disaster.

Skeptical Scalpel said...

I'm not so sure. I think he's got some good points especially about statistics for example.

Anonymous said...

I disagree with the idea that calculus, physics and organic chemistry could be removed from pre-medical requirements. I may be an odd duck, but I use the principles I learned in those subjects to analyze clinical data, to shed light on statistics, and to understand the molecular workings of the human body. I built on what I learned in those courses to understand pharmacology, especially pharmacokinetics. I built on what I learned in organic chemistry to understand immunology. I built on what I learned in calculus to understand complex test algorithms. I used what I learned in a fluid hydraulics course to understand principles of circulation.

So yeah, I use that "useless" stuff all the time. But then, I paid attention in every science course I ever took, and I learned the material. The material is useless if you just cram for the exam and brain-dump afterwards. If nothing else, all of those courses provided "hooks" I could hang new, more complex information on, allowing me to make better use of that information.

Skeptical Scalpel said...

Anon, you are the rare example of someone who found organic chemistry and pharmacokinetics useful. It is a good thing you went to school when you did because those courses are dinosaurs.

OnTheOtherSide said...

I am not in the medical profession, but I have spent many years surrounded by it with two sick kiddos. SkepticalScalpel, I wholeheartedly agree with this post; I have seen MDs and surgeons who fall into both categories of "schooling". We lost our oldest at 3 1/2 because her surgeon looked at her symptoms and said "looks like X, so treat it like X". It was a mistake. Our youngest is now 4 and, while he struggles with his rare condition, he was diagnosed because HIS surgeon cared enough to look beyond the textbook/common assumptions of his case and spent 2 months digging deeper and deeper until she found answers. She has worked tirelessly for my son - sent pathology to labs all over the country, talks to surgeons in other countries about care tactics, talks with us and advocates for us. Yes, her skills are tremendous and she is one of the few surgeons I allow near my son, but I cannot tell you the number of battles I have fought with residents, floor doctors, interns, etc. about my son's care because what works for him sometimes does not make sense, and they want to change plans or question my care. NO. Take the time to learn that a textbook only tells you so much. As you said in an earlier response, it's the nuances that tell the story. Well, my son has about 1,000 muances to his case, and they change sometimes daily, so please, please, please look beyond "what you were taught" to the heart of what's in front of you. "Teaching medical students to THINK" - what a novel idea.

Skeptical Scalpel said...

OnTheOtherSide, thanks for your comments. I agree. Teach them to think.

BrIan Buchbinder said...

I'm not a doc or med student. I was a lawyer. Calculus helped me, as did physics, not because of any bearing on my work, but because they told me how the world works, some ways that working might be described, and the habits of mind that go with learning these things.

No matter what courses I took, and no matter what courses prospective physicians take, it will be the way minds are shaped by exposure to Shakespeare, Einstein and the calculus; the habits of mental acuity and flexibility that will well serve those who serve others.

Skeptical Scalpel said...

Brian, I believe we might be able to teach them to think without calculus or physics. Law schools don't require pre-law students to take either of those courses even though practicing law requires some thinking to be done.

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