I was originally going to let this one lie since I was so late to the game: Jacob Goldstein at WSJ’s Health Blog picked up on a recent NEJM perspective paper by Harvard Medical School Dean for Medical Education, Jules L Dienstag, MD, describing the need and justification for re-examining the pre-med curriculum. In the article, Dienstag notes that the current requirement of 1 year of biology, 2 years of chemistry (including organic chemistry), 1 year of physics and, in some cases, 1 year of mathematics, might be out of touch with today’s required focus on human biology.
Unfortunately, current college courses that fulfill admissions requirements are not adequately focused on human biology; the topics covered in many courses in chemistry, physics, mathematics, and even biology are so removed from human biologic principles that they offer little value to the premedical — or advanced human biology — student and steal time and attention from more relevant science preparation. Does a student, for example, really need a full year of organic chemistry to prepare for the study of biochemistry? Moreover, premedical science courses often fail to achieve sufficient rigor to prepare students for tackling the sciences fundamental to medicine at the advanced molecular level now required. We should expect a higher standard from students who wish to pursue medicine in an era in which genomics and informatics will revolutionize biomedical science and health care.
I note his paper and this general query here for our audience here since the comment thread at the WSJ Health Blog post is still going strong six days later.
PharmGirl, MD, turned me on to this post which then led to quite a lively discussion between us Friday evening. She scored at C and C+ in her two respective semesters of organic chemistry at an exceptionally highly regarded undergraduate institution. Those grades kept her from being accepted into the medical school associated with that institution. She had to “settle” for acceptance into a lower top 10 US medical school, where she then excelled and claims to have never used an iota of organic chemistry.
I claim, in turn, that many aspects of organic chemistry are used often by physicians without them recognizing it. The fact that opioid analgesics often cause nausea in patients is derived from the fact that many are structurally-comprised of dopamine, a neurotransmitter known to stimulate vomiting in the chemoreceptor trigger zone. Doxorubicin (and mitoxantrone to a lesser extent) are both cardiotoxic anticancer drugs because their quinone moiety can redox cycle together with iron in the heart, producing irreversible and cumulative cardiac damage.
PharmGirl concedes these points but notes that one needn’t have had organic chemistry to recognize the basis of these concepts, much less apply them in the daily practice of medical oncology. (I am not an MD nor do I teach organic chemistry so I don’t really have a dog in this fight, although I do direct research on small organic molecule therapeutics.).
The question one must ask is how much of the pre-reqs can be jettisoned before one is no longer prepared for medical school.
An old professor bud of mine compared professional education to building a retaining wall. One first digs a trench and put several layers of pilings in the whole which are then covered up. No one sees them, but they are the foundation upon which the rest of the wall stands. How easy is it then to decide what pilings are needed for success in today’s physicians?
The arguments for and against organic chemistry as a med school prerequisite also include the proposition that o-chem weeds out medical school applicants. Isn’t there a better way for weeding out students that is more relevant?
Dean Dienstag notes:
Responding to the same concerns about premedical science education, the Association of American Medical Colleges and the Howard Hughes Medical Institute have undertaken a joint, comprehensive assessment of the continuum of premedical and medical science education. Themes likely to be included in their recommendations are the importance of introducing synergy and efficiency through cross-disciplinary and biologically relevant teaching; of educating “inquisitive” physicians, who understand not only medical knowledge but also how it is acquired; and of establishing a habit of scientific thought on which to build the practice of medicine. The recommendations are likely to favor scientific competencies over specific discrete courses, implying that premedical requirements for rigid, 1-to-2-year, discipline-specific science courses should give way to more creative and innovative courses that span and unite disciplines, offering a glimpse of the way biologists and physicians actually navigate real-life problems.
Creating such new, cross-disciplinary science courses may well be difficult for colleges, which vary in the availability of resources, depth of faculty, and political will of traditional departments to address these curricular demands.
Dienstag also provides a 12-page PDF to accompany the article which details the review of the curriculum and recommendations of Harvard Medical School for Harvard’s undergraduate curriculum.
I believe one reason for the lengthy discussion and interest in this topic at the WSJ Health Blog is that so many physicians today are coming from much more diverse backgrounds than in the past. As tools are needed in medicine today (like business, economics, communications, and the well-rounded persona afforded by liberal arts training), students arrive in medical school with varying degrees of science preparedness. Very much like the academic research enterprise, academia is under pressure to show direct impact and accountability of coursework. The days of a comprehensive science education are gone; the question is whether this course will help you get a better job or get into a better medical or graduate school. Academic research must increasingly justify its relationship to improving human health and the timeline on which the investigators expect this to occur.
I’m not sure this is the correct way to proceed. Just as many medical advances have come from observations of serendipity by highly-prepared minds, the best physicians I have know possess an incredible breadth of knowledge that includes seemingly esoteric basic science. No, they might not know how to run a Grignard reaction but they can tell you why digoxin and digitoxin have vastly different half-lives (and why one is rarely used today).
I do agree with Dienstag on the general issue that preparative training for medicine must be revised and updated to reflect the advances in genetics, cell biology, and physiology that permeate today’s patient care. A more focused and medically-relevant treatment of organic chemistry might be a good compromise – I find that many students entering pharmacy and medical school don’t really know why they were required to take organic chemistry because it was rarely presented in the context that was relevant to medicine or other aspects of everyday life. But when one uses organic chemistry to illustrate why some drugs have longer or shorter half-lives, why some produce reactive metabolites, or why racemic mixtures might be just as useful (or not) as pure (and much more expensive) enantiomers, one has the opportunity to impress upon students the relevance of the discipline.
But no, there doesn’t have to be a cause-and-effect rationale for everything one learns in the pre-med curriculum. Remember that perhaps only 10-15% of individuals pursuing a pre-med focused curriculum actually make it to medical school. Such a curriculum should provide a strong foundation in the sciences that prepares the student for the greatest number of options.
But it sure wouldn’t hurt if professors took a little more time to emphasize the potential practical utility of the subject matter while contributing to that solid foundation.