MARK R. WICK, M.D.
Now that the new academic year has begun again in U.S.medical schools, I can't help but write something about the way education is evolving. In considering what I have to say, please keep in mind that I am now a 61 year-old "codger," and generational differences have certainly come into play.
Over the past 20 years, a progressive movement has reformulated the curricula at most medical schools, under the direction of the Liaison Committee on Medical Education (LCME) (1). Instead of having first-year students complete systematic courses on anatomy, embryology, histology, biochemistry, microbiology, physiology, and pharmacology, all of those topics (...and more) are now jumbled together in "integrated” or “problem-based” learning exercises (2). It is difficult to build a house if you don't know what nails and hammers are, and I would argue that the same analogy applies here.
We now have second-year students trying to understand pathophysiology before they really know normal physiology, and they are trying to identify morphological abnormalities before they have properly learned anatomy and histology. It is just as concerning that most medical students begin their clinical work with patients despite having no satisfactory training in physical diagnosis or courses directed specifically at therapeutics.
Educators of today are fond of bashing the conclusions drawn in Abraham Flexner's famous report on the status of U.S. medical schools in 1910 (3), decrying as "antiquated" the need for the 2-year curriculum in basic science which he recommended (4). Indeed, a paper published in JAMA by Emanuel & Fuchs in 2012 (5) concluded that medical school education could be truncated by 12 months, as could residency training across-the-board, "without compromising physician competence or quality of care."
I could not disagree more with those assertions. Being a physician used to mean that one had a breadth and depth of knowledge that few other professionals possessed. Today, pragmatists have thrown that personification into the trash heap. Doctors of Medicine will soon be little different--if any-- than Doctors of Nursing Practice (6) or Doctors of Pharmacy (7), with regard to their funds of knowledge or abilities to deal with complex medical problems. And, after all, patients don't know the difference between those various doctorates, anyway.
In the specialty of pathology, the task of training new residents has now become one of rapid remediation, before any real learning can occur. First-year trainees who know little or no anatomy, histology, physiology, or biochemistry certainly are not ready to learn anatomic & clinical pathology. Hence, we currently provide a "cram" course for them on subjects that medical schools used to teach to everyone.
It remains to be seen whether the M.D. diploma-mills of Flexner's day will return to the scene, at least in substance. If and when they do, patients will need to beware, and plaintiffs' attorneys will have more business than ever.
1. http://www.lcme.org (Accessed 9-26-13)
2. http://en.wikipedia.org/wiki/Integrative_learning (Accessed 9-26-13)
3. Flexner A & the Carnegie Foundation for the Advancement of Teaching: Medical Education in the United States and Canada, Bulletin Number Four, Carnegie Foundation, New York, NY, 1910.
4. Duffy TP: The Flexner Report--100 years later. Yale J Biol Med 2011; 84: 269-276.
5. Emanuel EJ, Fuchs VR: Shortening medical training by 30%. JAMA 2012; 307: 1143-1144.
6. http://en.wikipedia.org/wiki/Doctor_of_Nursing_Practice (Accessed
7. http://en.wikipedia.org/wiki/Doctor_of_pharmacy (Accessed 9-26-13)