Fixing health care – making the basic science years basic – the 1st year

Perhaps I should have written this essay before I wrote the piece on the premed curriculum.  I hope that these comments will clarify some of my thoughts on the premed curriculum.

As an internist, I always stress diagnosing a problem prior to treating it.  As I talk with 3rd year students and reflect on my own experience I am always struck by the emotional drainage that the first 2 years of medical induces.  I was never more unhappy with education than I was during my first 2 years of medical school.  (I was never more happy than during my 3rd and 4th year.)

Second year students on average are miserable.  The rigors of the curriculum weigh heavy on their emotions.  Yet for all the studying, they get to the 3rd year and have only spotty knowledge.  They often know things that will not help them, and generally have little clue on how to think and act like a physician.

My proposals may help that some, but at worst should decrease the emotional drain.

We need to determine what is basic.  While I suspect that I will be a bit incomplete, here goes.

The most important subjects in the first year are physiology and anatomy.  We should teach the fundamentals of physiology (or as I call it physiology 101.)  One cannot really understand most diseases if one cannot correlate the physiology.  We should focus our anatomy teaching on the big issues, not the 3rd branch off the 2nd artery (hopefully you get my point.)  We need not have students be able to identify dried out cadaver structures.  Rather we should learn functional anatomy – e.g., the structures and causes of shoulder pain, the types of knee injuries, the correlation of DVT with clinical findings, intra-abdominal  anatomy, how specific brain lesions impact patients.

To support these 2 very important courses we need to learn enough cell biology and histology to understand the cellular components of disease.  We also need to know enough biochemistry to support the physiology course.

I would add a cognition course throughout the first year.  This course would teach logic, evidence based medicine and principles of cognition (as Jerome Groopman champions.)  The course would stress thinking.

Somehow we should try to avoid multiple choice testing.  I know that the USMLE uses multiple choice testing, but I would hope that might change also.  We currently reward test taking skill as much as we reward knowledge and application of knowledge.

Finally, we should continue to teach (and pay clinicians to teach) an introduction to clinical medicine.  This course must stress history taking as well as physical exam skills.  One can start the fundamentals during the first year, but the second year will allow better correlation with those courses.

My first year plan would decrease the depth in these courses, but hold a higher standard for knowing the fundamentals very well.  Too often we become enamored with the depth of these sciences, and our students suffer.  We need to insist that our 1st year students really understand physiology and anatomy.  We should not design courses and testing that encourages cramming and regurgitation without retention.

I continue to learn medicine (as do all good physicians.)  I cannot afford to memorize and not learn, as I may need this knowledge when I see my next patient.