During the first two years of medical school, students intensively study the sciences that form the basis of medical practice. These courses have traditionally been taught through lectures and laboratories and tested by rote recall of literally thousands of pieces of information. This model hearkens back to a previous era when physicians were expected to master all the scientific knowledge that then existed as the foundation of medicine. The explosion of biomedical science over the last several decades has rendered this once challenging task now frankly impossible.
THINK, AS AN EXAMPLE, of our knowledge of infectious diseases over the last 50 years. In 1944 bacteria and viruses had been discovered, but little was known about how they caused disease. The entire antibiotic armamentarium consisted of sulfa and penicillin. Medicine had nothing else to offer for a multitude of fatal infections.
Today, we know about many thousands of disease-causing organisms and scientists regularly discover new ones. The hospital where I work routinely stocks 47 antibacterial agents, not counting antiviral and antifungal medications that are in their infancy and just beginning to proliferate. The latest edition of a major pediatric infectious disease textbook runs two volumes and 2,395 pages (and it just covers pediatric diseases). A lifetime of study could easily be spent on this one important but relatively small part of medicine. Yet medical students, with a crash course over a handful ‘of weeks, are presented with a vast portion of the current knowledge.
Having had no clinical experience themselves (clinical rotations do not normally begin until the third year of medical school), students cannot separate out of the sea of information what is most critical for them to know. So they try to learn it all. Anywhere from two to four other courses are going on at the same time. Students often feel abject at their inability to master all the material, and these very motivated, intelligent young people flounder at their impossible yet seemingly expected task. It is an understatement to say that student morale is often devastated.
IN ADDITION to the sheer weight of modem medical knowledge, the advent of the molecular age of biomedical science adds further educational challenges. A generation ago, the basic science curriculum of medical school focused on subjects like gross anatomy, physiology and pathology, each of which had a palpable and obvious connection to real patients. The birth of molecular biology has forced these traditional disciplines into smaller segments of the curriculum, while much more abstract studies like cell biology, biochemistry and immunology make up an ever-increasing part of the course load. These newer subjects are indispensable to the modern practice of medicine and no doctor would be considered adequately trained without them, but they bring to medical education a level of abstraction and remoteness from living, breathing, whole patients unprecedented in medical history. Simply put, it was much easier to dissect a diseased lung and imagine, even empathize with, the person to whom it once belonged than it is to study the unseeable molecular mechanisms of lung tissue and feel the same connection.
In no way do I propose that medical students not learn the molecular science that has revolutionized medicine. However, our system of medical education has made no allowances for the new challenge that molecular medicine presents to students. Most who choose medicine as a career do so with the intention of one day caring for sick people, but the heavy emphasis on molecular science from the very outset of medical school without any humanizing patient-care experiences to balance it begins to drive a wedge between the physician-to-be and his or her future patients. The impersonal, sterile, unsatisfying doctor-patient relationship that many of us have experienced has its earliest roots here.
Underlying the first two influences I have discussed–the explosion of medical knowledge and the molecularization of medical science–is a philosophy of scientific materialism that dominates medical school education during the early formative years. The intense study of disease almost exclusively from a molecular, cellular and organ perspective without consideration of the intact patient reduces illness to the level of specific defects. The human being becomes nothing more than a conglomerate of molecular pathways and cellular mechanisms. In principle the whole of the human condition is supposed to be knowable in this way. Illnesses once mysterious and even spiritual, stillbirth or depression for example, are at last giving up their secrets to new technologies and modes of investigation. Why then should not all of human experience–an artist’s genius, a child’s love for her mother, the self-sacrifice of a saint-be a function of programmed molecular processes and no more?
This philosophy of scientific materialism is reinforced by the fact that almost all the first-year courses in medical school are taught by Ph.D. scientists, not physicians. Their perspective differs dramatically from that of practicing doctors and their influence, along with the seeming remoteness of the subject matter from clinical medicine, redefines the self-understanding and goals of many students. Having come to medical school to learn to care for sick people, they begin to see themselves as scientists first and caregivers second, if at all.
The only concession that most medical schools make to the humanistic aspects of the profession is a course in medical ethics taught over a few weeks sometime in the first or second year. A few schools have recently introduced more extensive courses roughly centering on the theme “The Physician and Society,” yet these offerings at most represent isolated and abstract attempts to introduce humanism into the students’ vision, coming as they do buried amid the hard science courses that dominate the students’ time.
PERHAPS EVEN MORE fundamentally, students are subtly but strongly taught in the early years of medical school that the career to which they aspire is foremost about science and only secondarily about people. They lose the sense that while science may be the indispensable foundation of modem medicine, the fundamental goals of science and those of medicine differ. Nowhere in medical school is it stated or even implied that science is about determinism–how process A inevitably leads to result B–while medicine is about freedom–striving to help individuals be as healthy as possible to live out their lives in their essential human freedom.
Much of the depersonalizing approach to patients found in medicine today stems from this early dominance of scientific materialism in medical school. Here are sown the roots of dismissing a man with excruciating pain as “the kidney stone in Room 10” or seeing a dying woman only as a particularly interesting case of breast cancer. Popular medical dramas always portray interactions with demanding or unsavory patients as the root of doctors’ dissatisfaction with patient care, but nothing could be further from the truth. The clinical encounter between doctor and patient remains the ultimate humanizing and empathizing moment in medicine. Unfortunately, doctors routinely reduce patients to their diagnoses and dismiss their humanity because they have been taught from the most formative beginnings of their medical education to think in strictly scientific and not humanistic terms.
The last sweeping change in American medical education came in the mid-19th century, when Dr. William Osler first brought medical students out of the laboratory and lecture hall to the patient’s bedside. Until then, there had been no hands-on clinical training in American medical schools, and caring for sick patients was learned as an apprentice after medical school had ended. Osler’s revolution in teaching formed the basis for the two-year pre-clinical and two-year clinical curriculum that makes up medical school today. As I have indicated, however, this model has become sorely outdated. A new revolution in medical education is needed that would bring the student to the patient’s bedside from the first moment of medical school to allow the humanizing effect of the clinical encounter to flourish. Immersion in the care of real patients from the outset is the only way to counterbalance the influence of the scientific materialism that now predominates. Students will also much more easily gain a sense of what is clinically relevant in the basic science curriculum and can thus direct their own learning more efficiently to deal with the overwhelming quantity of modem medical knowledge.
Some medical schools, most notably Harvard’s, have begun to move generally in this direction. Harvard’s “New Pathway” program introduces medical students to the clinics and hospitals early in their training, but as yet only in small increments. Other schools have followed suit and some may still introduce more radical changes along the same lines. These moves are encouraging and demonstrate that some influential medical educators have recognized the problem. Yet the steps so far have been modest and change slow, as change in medical education is wont to be.
In the end, though, such fundamental change must come. The vast transformation in medical knowledge since Osler’s day is too overwhelming to be taught by the same system without the inevitability of doctors drifting further and further away from their patients. Early immersion in the clinical setting–interviewing and examining patients, observing and assisting physicians, becoming involved in the lives of real patients–is the only answer to the great challenges of medical education today. Otherwise, the exploding quantity of knowledge, the further molecularization of science and the pull of scientific materialism will only more profoundly alienate doctors-to-be from the very people who seek their help.