Basic science? We doctors don’t need no steekin’ basic science!

RangelMD asks: Do student doctors really need to know anatomy and that other basic science stuff? And Dr. RW chimes in sarcastically, Who needs all that basic science bunk?

Naturally, as you might expect from recent posts, I can’t resist putting my two cents in on this topic as well.

The discussion was provoked by this article:

TEACHING of basic anatomy in Australia’s medical schools is so inadequate that students are increasingly unable to locate important body parts – and in some cases even confuse one vital organ with another.

Senior doctors claim teaching hours for anatomy have been slashed by 80 per cent in some medical schools to make way for “touchy-feely” subjects such as “cultural sensitivity”, communication and ethics. The time devoted to other basic sciences – including biochemistry, physiology and pathology – has also been reduced.

Several senior consultants have told The Weekend Australian they have been “horrified” to encounter final-year medical students who do not know where the prostate gland is, or what a healthy liver feels like.

When asked by a cardiac surgeon during a live operation to identify a part of the heart that he was pointing to, one group of final-year students thought it was the patient’s liver.

A coalition of senior doctors appealed this week to the federal Government to step in, claiming public safety was at stake and that national benchmarks for teaching the basic medical sciences were urgently needed.

The Australian Doctors Fund lodged a 70-page submission with the federal Department of Education, Science and Training this week, listing arguments from more than two dozen professors, consultants and medical academics for a rethink on medical education. The document warned of a “rising chorus of concern across the medical profession” that students were not getting “exposure to the necessary amount of training in anatomy” and other key sciences.

The heads of Australia’s medical schools fiercely contest the criticisms, saying there has been an “explosion” of medical knowledge that doctors need to know, in fields such as genetics and new drugs, and that other areas have to be cut to accommodate the newer topics. They also strenuously deny that they are turning out inadequately trained doctors.

But many students are also unhappy about core science training. One group of students wrote anonymously to two noted academics last year, saying they were “sick of being asked, ‘Didn’t you study anatomy?”‘ by consultants amazed by the gaps in their knowledge.

“How can we learn if we are not taught the basics?” they wrote.


Quite.

None of this was news to me, or, I daresay, to most surgeons. When I quiz third year medical students about anatomy in the operating room, even very basic anatomy, far more frequently than I like, I’m amazed at how little some of them know or, with the exception of students going into surgical specialties, seem to care. I’ve never seen a student quite as clueless as the ones described in the Australian article, but it’s nonetheless clear to me that the deemphasis of anatomy and basic science in medical education is not a phenomenon confined to Australia. Indeed, the above article only echoes and amplifies complaints that I’ve heard for a long time right here in the good old U.S.A.

Here’s Dr. Rangel’s take on the matter:

The critics claim that too much time is being devoted to “touchy-feely” subjects such as “cultural sensitivity”. The medical schools counter that there is so much medical knowledge to learn and only a limited amount of time to do it. Who’s right? Both are.

Indeed, which is why I can’t understand why some medical schools offer electives in art appreciation. Worse, all too many schools are offering uncritical courses that feature the most dubious of alternative medicine treatments. Something has to give to make room for these new offerings, and all too frequently it’s subjects like anatomy, biochemistry, and physiology that suffer as a result. From my perspective, the purpose of medical schools is to train physicians. Period. Anything that does not contribute to the training of an excellent general physician does not belong in the medical school curriculum. Art appreciation is a lovely thing to study and makes for a well-rounded person, but it does not contribute to medical education, with the possible exception of medical illustrators. I’m less dogmatic about teaching medical students about alternative medicine is useful because so many people use it, but far too often such teaching uncritically parrots dubious claims without rigorously looking at the evidence.

Dr. Rangel continues:

But such controversy begs the question; Do most of our doctors really need a liberal medical education? Do patients really give a crap whether or not their physician knows the basic structure of every type of amino acid or where the ligament of Treitz is? I’d take a wild guess and say no. Patients want something to help them sleep at night or to find out what’s causing their stomach pain. Knowing the chemical structure of an amino acid is not going to help one bit.

Physicians traditionally get a liberal education because we have this sense that we should create a well-rounded doc as physician-scientist. In decades past it was believed that physicians should not only be practitioners but investigators on the forefront of a mysterious new field. However, these days physicians are more often seen as “providers” who toil away following practice guidelines. The attitude these days seems to be “leave the science to the scientists. Let them find new diseases and develop new treatments.”

Sadly, Dr. Rangel is accurately describing a pervasive attitude in society and even medicine that is, alas, becoming more pervasive. To no one’s surprise, I’m sure, given my previous posts about the woeful lack of knowledge about evolution among physicians and medical students, I strongly disagree with the sentiments described by Dr. Rangel. It doesn’t matter one whit whether patients care whether their physicians know where the Ligament of Treitz is or can draw the structures of amino acids. That’s not the primary question. The real question is whether being intensively exposed to such topics in medical school makes better doctors. I would argue that it does. In particular, I take issue with the attitude of “leave science to the scientists.” Less trained “providers” may seem to provide adequate or even very good care in the short run on a strictly utilitarian basis, but, I will argue, medicine as a profession loses something precious and possibly irreplaceable by devaluing the science behind medicine, something that will also, I fear, will slow the pace of future medical advances.

First off, I can’t believe that anyone would argue that thorough teaching of anatomy isn’t one of the most important components of the training of a competent doctor. It’s one of the very basic core competencies that every doctor should know. Even specialties that rely more on drug therapy and less on therapies where a solid base of anatomic knowledge is necessary (such as internal medicine, family practice, and or even dermatology) should be exposed to an in-depth study of human anatomy at least once, and the best place to do that is in medical school, where a basic knowledge set about anatomy can be taught to every medical student, regardless of future specialty. Anatomy forms the basis of so many human diseases seen by such a wide variety of specialists that it forms the basis of nearly all functional medicine. Why do people get carpal tunnel syndrome, for instance? If you don’t know the anatomy involved, you won’t understand why people get it, why the distribution of the numbness is what it is, or how to diagnose it on physical examination. If you don’t know the anatomy of the lumbar nerve roots, you’ll have a hard time determining which level that a compressing herniated lumbar disc, for instance, is at based on history and physical (you can’t order MRIs on everyone with back pain). Without an understanding of anatomy, a doctor won’t know where an infection is likely to track or to which lymph node basin a melanoma is likely to go first. Or, as a medical student put it:

“If you are assessing (a patient) who has had a stroke, if you do not have a good knowledge of the different parts of the brain, it can be difficult to assess which parts have been compromised and what treatment is warranted.”

Of course, one could argue that none of the above knowledge is strictly necessary, as long as the physician knows when to call in the specialist. However, in vast swaths of this country and others, despite the proliferation of specialists, it is still the generalist or family practice doctor who deals with most medical problems, and access to specialists can require a helicopter flight or long ambulance ride. Also, some medical conditions (such as the aforementioned stroke) are urgent matters that can’t always wait for the specialist.

But what about “memorizing the Krebs cycle” and other arcana of biochemistry? Well, many metabolic diseases manifest their effects through the downstream effects an enzyme deficiency has on different metabolic pathways. If a doctor hasn’t been exposed to these pathways at least once, in medical school, he or she will find it very hard to pick them up on the fly when issues come up. Worse, without a solid grounding in biochemistry, it’s really hard to understand pharmacology and the mechanisms of how drugs work, and I really don’t want a doctor prescribing drugs who doesn’t understand basic pharmacology.

Dr. RW responds and puts it very well:

It’s probably a waste for most of us to memorize the chemical structure of amino acids, but it may be important to know enough about their structure and properties to understand that some are hydrophobic and comprise membrane lipid bilayers while others are hydrophilic and form hydrogen bonds, the basis for the secondary structure of proteins. Memorizing all the steps in the glycolytic sequence and the Krebs cycle won’t make you a better doctor but it could be important to understand how those reactions yield energy, why a molecule of glucose yields only a couple of ATPs in the glycolytic sequence, but an additional 30 some odd in the Krebs cycle, a fact that explains the difference between aerobic and anaerobic metabolism and why folks have to breathe. It’s all about the how and why of health and disease.

But, more importantly, as I have been arguing all along (and as Dr. RW agrees), physicians need to have a firm grounding in basic science for two reasons. First, as my professors used to reiterate almost ad nauseum, a significant fraction of what we learn in medical school and residency will be obsolete in a decade, and one of the main purposes of medical school is to give us sufficient background knowledge and understanding to be able to keep up with new developments, understand them, and incorporate them into our practices. A strong basic science background makes it easier for physicians to adapt to changes in knowledge leading to changes in recommended therapy and provides the conceptual framework against which to evaluate new scientific and medical findings. As physicians we must be constantly learning, from training all the way to retirement, and that learning is much easier if we have a firm background the physiological, biochemical, and anatomical principles involved, even if we quickly forget details like the structures of various amino acids or where Rotter’s nodes are. Second, as I have argued before, a firm grounding in science helps us to recognize pseudoscience when we see it. I have been repeating again and again (likely irritating my regular readers) and providing examples showing that a poor scientific understanding of one area that leads to credulity towards a pseudoscience, is all too often a marker for or harbinger of a tendency to accept other pseudoscience uncritically. I’ve used the example of evolution, in which an acceptance of creationism leads me to worry about a tendency to accept various forms of quackery. Again, Dr. RW says it well:

Knowledge of the basics is also helpful in distinguishing between science and pseudoscience. Consider this page promoting wheatgrass from the Creighton University Alternative Medicine links. (Authorship of this page is not specified, but the main page of the alt med links suggests that the articles were written by Creighton med students and faculty. Some alt med articles are appropriately critical. Although others seem uncritical or even promotional, all contain a disclaimer that neither the university nor the med school endorses the methods). A big dose of biochemistry and physiology might help here. In “explaining” the health effects of wheatgrass the article notes that the plant contains enzymes which “aid the body in digesting foods, building protein in the bones and skin, and in detoxification processes.” Did the author not know that enzymes cannot be absorbed into the body intact? How then are they to participate in bone building or detoxification? (What is the biochemical process of detoxification, exactly?). Also among the “scientific benefits” touted for wheatgrass is its content of chlorophyll, claimed to protect against carcinogens and dissolve kidney stones. Never mind the fact that chlorophyll has no known function in human metabolism. Then there’s this page on the “mechanisms” of Reiki—speaks for itself.

[NOTE: This page is even worse.]

But perhaps the best rejoinder to those who don’t think we need basic science as physicians came from a commenter in RangelMD’s piece going by the ‘nym of Blog, MD:

Someone explain to me how making our future physicians less able and willing to formulate scientific questions based on their clinical observations will benefit us. What exactly is to be gained by making the already deep chasm between MDs and PhDs that much wider by eliminating the common vocabulary? Who do you expect to be able to translate basic research findings into valid, well-designed, well-interpreted clinical trials? NPs and PAs? Physicians with a watered-down scientific education? PhDs?

Exactly! That’s one (of many) reasons that I find the attitude of “leave science to the scientists” described by Dr. Rangel to be the most infuriating aspect of this problem! Simply by virtue of their practical experience treating disease, physicians bring a perspective to medical research that even the most brilliant basic scientists can’t.

For all the wailing and lamentation about whether the 80-hour work week for residents will detract from the training of doctors, I’m far more concerned that the lack of adequate preparation in basic science in medical school will lead to a generation of doctors lacking the background to evaluate and incorporate new findings or to recognize quackery when they see it. Worse, I fear that those wanting to enter academia will in the future have a hard time doing so without going to the additional lengths of getting a Ph.D., not because physicans haven’t been able to be successful researchers in the past and can’t be successful in the future, but rather because future generations of physicians will have even less of an understanding and appreciation for the scientific method than they already do now. As a clinician-scientist or clinical investigator myself, I strongly believe that physicians bring to the table something that a basic scientist can’t: An appreciation for the pathophysiology and clinical course of the disease being studied, a practical understanding of the most pressing problems and shortcomings of current treatments of diseases, and an understanding of the anatomy involved. Perhaps even more important than that, we see the human toll of disease, leading to an urgency to do something about it now that a Ph.D., who has never looked in the face of a patient with stage IV cancer, for example, and had to tell him that there is nothing further medicine can offer to save his life, can never share. Relegating scientific and anatomic training to a much lesser status than it has enjoyed in medical school in the past will hurt patients not just by direct effects on physician competence, but also through the long-term effect it would likely have in leading to the de facto ceding of medical research to Ph.D. basic scientists who, while often having exquisite understandings of molecular mechanisms, don’t know the human cost of the disease they are studying and don’t understand what advances that we as physicians really need to have to be able to treat disease better.