Rethinking Medical Education

To mold great doctors, we need to broaden the foundations of undergraduate medical training – more Kant, less calc.

I freely and openly admit to being a Bloomist. I have been a devotee since my undergraduate days. For those of you unacquainted with this modern American genius, allow me to introduce you. Harold Bloom is the Sterling Professor of the Humanities at Yale. This is a kid from the South Bronx, from a Yiddish-speaking household, who taught himself English at age six. At age seven, he memorized Hart Crane’s Collected Poems, followed by the standard BA from Cornell and PhD from Yale. He exploded onto the American academic scene as the greatest breath of fresh air in the last half-century.

He is a world-class expert on Shakespeare, the high romantic poets, Gnosticism, and hermeneutics. To call him the world’s greatest polymath would be to sell him short. So why comment on this guy in an emergency medicine rag? Simple. He is the best example of my subject for this month’s diatribe: What should be the real education of people going to medical school to become “real doctors”?

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I was on the phone a few days ago with a friend, a prolific writer in emergency medicine, speaking about some aspect of our lives. He said: “You were trained as a classicist, not a scientist, weren’t you, Greg?” Having more undergraduate hours in Greek temple design than physics and more hours in British romantic poets than biology, I had to confess the sin of having a BA degree and not a BS. “Why do you ask?” I said. “Because you write like a writer, not like a doctor.” “Is this a bad thing?” I said. “No,” he insisted. “But it does make you somewhat hard to read with slant references to Browning or Henry James. And if you make one more allusion to Leaves Of Grass, that’s it; I’m no longer reading.”

Let me state I firmly believe that it doesn’t matter what you study as an undergraduate, as long as you do it with vigor and understand the depth of each and every subject. Other than the basics of organic and inorganic chemistry, physics, life sciences and mathematics, does anyone really care what you have a degree in? Go ahead. Go around the department. Most of them have the usual boring crap, i.e. BA in biology or chemistry, yada yada yada. But it doesn’t make much difference when you actually get out and practice.

Incidentally, we teach the wrong kind of mathematics to go to medical school. If you’re in your third year of calculus and fractal number theory, news flash: What you really need to have is a satisfactory understanding of statistics and its application to scientific analysis of data. The number needed to treat (NNT) is a concept I wrestle with every day. The science of validity should be a required course for anyone going into medicine because it is what separates us from the chiropractors and other misguided healthcare theorists.

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What is actually required to be successful in medical school is a debate. I have friends who are nuclear engineers, nurses, a bass player with the Boston Symphony, all of whom have been giants in their subspecialties. So what is the unifying factor? The one characteristic is they hated dogma. They hated dogma as much as Bloom’s career was built on resisting and overthrowing academic dogma. I don’t think we know exactly what the learning should be before one’s lecture halls start to smell of formaldehyde. But to think everyone needs to have a BS in biology or chemistry is just plain wrong. As an aside, tell me how we define a meaningful career or a successful medical practice. It’s hard to know where to begin if you don’t know where you’re heading.

This discussion organically leads to the greater question: How many years should the entire process take to become a doctor of medicine? Canada tends to work in partnership with the US on this issue – four years undergraduate, four years medical school and between three and seven years of post-doctoral training, which we call house officer-ship. This allows us in our opinion to sit for the “boards” no matter what the specialty is. The rest of the world does not agree with this model. If you’re in Britain, a combined six years – not eight years – is required to be able to take you from post high school to practicing medicine. This is followed in Britain, of course, by about 20 years of house officer-ship – but I jest by at least two years.

But seriously, a debate needs to be held on why people must be without income for two additional years in the United States. Why not the combined six-year program as the norm and not just the odd experiment? The Europeans will tell you that their 17-year-olds are much better educated in the great canons of Western civilization; so they have already been expected to have mastered Plato and Proust before they select a direction for their lives. True or not true – I have no idea. But they certainly don’t seem to have any problem filling their medical schools with qualified people.

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These are questions we are afraid to ask because we don’t want to know the answers. Is all the science and pseudo-science which we cram into the first two years really the way to go? Do all medical students need to know a year’s worth of anatomy or should that vary depending on what field they intend to enter? What do you really need to know to step onto the floors of our teaching hospitals, so you don’t accidentally kill somebody while knowing enough concepts and vocabulary to stimulate learning as opposed to oppressing the learning process?

Where is it that we should teach that medicine is not merely biologic? Where should the basic dilemmas between mind and body be introduced? When do students learn that they are the servant of the patient, trying to help them understand their medical problems and achieve their goals? These are not simple questions. Maybe the Europeans with their long training programs have it right in learning what the role of the physician really is, for “scientific truth” must seamlessly flow into solutions to human problems which are accepted by the patient as a step forward in their own betterment. This is not always easily explained during a third round of chemotherapy and radiation.

Arnold Toynbee, one of these irascible characters like Bloom once commented that if America can be said to have a philosophy at all it is pragmatism. Yet we get sucked into ideas such as our current medical models, i.e. the care and feeding of medical students. And in this educational process we do not ask enough questions about what we want the outcome to be at the end of the learning pipeline. The how and why of providing moral and metaphysical ballast, while maintaining some semblance of scientific correctness must all come together to allow us to be intelligent health advisors. This amalgamation of both scientific and philosophic truth is a “consummation devoutly to be wished.”

But we have no choice to explore what shall be the new medical canon of knowledge leading to some wisdom for the benefit of the individual patient. Can the truly secular postmodern physician actually give a post-humanism dispensation to any patient who has any form of belief structure? We in the practice often isolate and take away hopes of our patients. These are people who live with fears and desires which are beyond rationality. It is what controls the public interest.

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The current debate about the vaccination of our children has taken a “me Tarzan – you banana poo poo” tone. Most people today don’t remember when our beaches were closed during polio season. Parents in the 50’s would do anything to get their child vaccinated. Everyone of my generation remembers the respirators and the iron-lung children. But all of this is now gone. Where do we now get the doctors who have both the scientific knowledge and the compassion and almost mystical skills to herd the non-scientific public back into the light? Who do we choose? Do they study Kant and Darwin? Do they still want to come together to lead? Or will they say “to hell with them if they don’t believe in science”?

Our job is more than science. It’s the revealing of that scientific reality to show how it will mesh with their lives and improve it. We need physicians of both learning and understanding to take us to this desired promised land. I have a suggestion. A physician should have other inputs and other sources to their life than just medical journals. Subscribe to something. I think the best general review of what’s happening in the world is The Economist but that’s my opinion. You need to have something that puts you in line and in touch with the majority of people in the world.

I have another suggestion. Bloom, my hero, has a book called The Western Canon. It is a suggestion and a discussion of what this learning cycle should be to understand the broader aspects of human beings. We are more than just intelligent creatures, disciples of Aristotle, who have figured out the laws of physics. We all speak of the good. The young physicians today want the good life, good company, and good outcomes. But the good should never be confused with The Good. Our new doctors need to be more than those who just got an A in organic chemistry.

“Usus est magister optimus”
Experience is the best teacher