Further thoughts on basic science and step 1


Category : Medical Rants

Over at KevinMD, some commenters have criticized my position on basic sciences. I have spent much time discussing this issue with 3rd year medical students and medical residents. I stand by my position.

Let me make my position clear. We need to understand basic science. The problem is defining how much and at how much depth.

I believe we need to reinvent the first two years to ensure understanding of fundamental physiology, anatomy, microbiology, etc. Physicians do not need Ph.D. level understanding.

For those who read the Curse of Knowledge link, they will understand that too many students do not learn the material, they memorize facts for a test. But excellent physicians need to understand the material. Our current method of teaching the first 2 years does not promote understanding.

We really do try to cram too much into the first 2 years. We need biochemistry – but with less depth. We need a thorough understanding of physiology, but we do not need the latest research.

We need to know how to stay updated. I love renal physiology. I have learned much physiology since graduating from medical school – because understanding it became relevant.

I believe step 1 hinders understanding. The test looms in front of medical students, and becomes a hurdle they must jump. But that hurdle does not encourage understanding or learning. It encourages memorization.

We reteach physiology and pharmacology during the 3 year and during residency. We reteach physiology that everyone should already understand.

So I do support basic science education, but not the way it is currently taught. Remember this definition of basic – “Of, being, or serving as a starting point or basis”

We need to reemphasize the basics of basic science. Students need the tools to understand future advances. We need not make basic science a torture. We need not try to teach everyone new theory during the first two years.

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Comments (8)

I couldn’t agree more. I spent a lot of time talking about the backwards approach that the typical med school takes to teaching basic sciences. If I could go back now, and retake the first two years of medical school, I would learn a great deal more.

Largely, this would be due to knowing what stuff to ignore. There is so much “stuff” thrown at first and second year medical students, who don’t have the clinical background to know what is relevant and what is not. It’s horribly inefficient, and changes many students in fundamental ways (usually for the worse.)

I almost think that students would benefit from doing a semester of coursework, a semester on the wards, a semester in the classroom, a semester on the wards, etc. At least this way, one would begin to develop a framework of clinical understanding around which to build the basic science knowledge.

I don’t have an answer, but I think that clinicians need to be more heavily involved in the development of the basic science portion of medical school.

I think the typical basic science approach also reduces the number of medical students who aim for a primary care career. Everyone who teaches a student in the first two years is a hyperspecialist, with a deep spike in knowledge of a very narrow area. They are excited by the tip of the spike, which they have spent many years getting out to, but the students are starting at the very base. This has two problems: 1) the hyperspecialist often loses touch with what it was like to start at the base, and the lectures are a hodgepodge of facts pulled from all levels of specialization, not just the basic ones; and 2) the hyperspecialist often does not know conceptually related information that is ‘horizontal’ to his/her field and thus cannot teach it.

It is just this broader, ‘horizontal’ understanding that generalists must develop, yet there are no role models for that type of learning. Instead, medical students develop a bunch of ‘mini-spikes’ scattered throughout the fields of instruction, with broad areas of fundamental knowledge about relationships among these concepts totally missing.

The 3rd and 4th years are somewhat better, but in most medical training, even the clinicians are specialists, not primary care generalists. A specialist is going to take, and teach, a fundamentally different approach to a given problem, because in most cases potential diagnoses that are outside of their expertise have been (or are assumed!) excluded by a previous generalist evaluation.

By the end of all this training, a medical student is going to internalize a world view in which deep specialized knowledge is more accomplished and of higher status than generalist and integrative knowledge and skills. And it doesn’t help that specialists are paid more to boot.

What do you think of the upcoming change to the USMLE? Does an exam after 3rd year make more sense than 2nd year? Supposedly, the new USMLE will have less basic science and more clinical questions, which, if true, could inspire medical schools to tweak their curriculum. For many schools it seems, the first two years are teaching to Step 1 and the level of detail that requires (because med schools want successful graduates to be able to boast their matches).

So do you think the changes are reflective of what you’re saying, or a step in the wrong direction?

There appears to be a concessus that the first two years of medical school are not meeting the needs of students. I also sense a realization that the current educational system promotes negative behaviors that become ingrained, and are often not modified, during a doctor’s career.

It is not difficult to understand that sleep deprivation, combined with attempts to assimilate massive amounts of minutia, all under the tutelage of demanding instructors are going to leave some undesirable traits.

Steve Lucas

Let us not forget the bureaucratic realities of these things, though. No matter how forward thinking a school is, if you come to the administration with a new idea, the first questions out of their mouth will be:
How much does it cost?
Has it worked anywhere else?

Not that this helps at all. It just reinforces the reality that we are in.


Let’s not forget the real significance of Step 1. Yes, passing the exam is necessary to gain licensure. However, students do not dread the exam because they worry that they will not become licensed physicians. Students dread the exam because Step 1 scores are the first thing (and if they are not high enough, the only thing) that residency directors look at when evaluating applicants.
And perhaps much of the material that Step 1 covers is not important for practicing physicians. Nonetheless, the traits required to obtain a high score (for example, a willingness to ignore friends and family to spend tremendous amounts of time performing menial tasks) are very similar to the traits required to become obedient and dutiful intern.

Just finishing my first year of medical school, I am completely disappointed. As is stated:
-data learned and used to pass out multiple-choice tests is forgotten in two days
-poor communication between professors, “Did Dr. XXXX talk to you about this yet?” Then continue to explain a topic we’ve had 5 times. Poor use of in-lecture time.
-Summers off? Actual Use: Lie on our ass, travel Europe, drink alcohol. Is this the best use of our time? Why not go to school more days in the year, making the load per day more tolerable/realistic/effective?
-see “PowerPoint Medical Education” here http://forums.studentdoctor.net/showthread.php?t=427612
-When outside the faculty’s office, the unanimous opinion on basic science years is that we as medical students are YOUR captive audience, what actually goes on in the medical school classroom is ignored, and after heirarchical-hazing of medicine it is no wonder we just want to clock in, clock out, and go home.

I’m just finishing my first semester at a Caribbean med school, and would have to agree. I have friends who have gone to medical school in Canada, which does not have a Step 1 equivalent. Their education was much more clinically focused from the beginning of their first week, because they didn’t have to spend the time learning a large amount of tangentially relevant material, in order to forget it all in their third year.

My question is, “In what universe, other than the laboratory, does a physician need to know the names of the transcription factors for DNA transcription?”

Not, I suspect, in many.

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