Posted by: notdeaddinosaur | September 8, 2012

Medical Education; Walking Before Running

My esteemed colleague Dr. Bob Centor is enamored of an interesting essay from which he quotes:

Only you can educate you—and you can’t do it by memorizing. You have to find out who you are by experience and by risk-­taking, then pursue your own nature intensely. School routines are set up to discourage you from self-discovery. People who know who they are make trouble for schools.

Personally, I found it more of a screed against bad education which, taken too much to heart, leads to more useless college degrees in navel-gazing and ever-decreasing mastery of the basics. I wonder how the classically-educated essay author would feel about students who refused to read any book, preferring to watch YouTube versions of Cliff Notes because they’re just “taking control of their education.”

Dr. Centor, though, goes on to apply these thoughts to medical education:

Long time readers know that I dislike how we teach basic sciences in the first two years of medical school.  They also know that I generally love the 3rd year (the clinical rotation year).  I believe that this essay speaks to my biases…

The potential beauty of medicine’s clinical training comes from the opportunity that it provides our learners.  The patients provide learning opportunities.  We who teach those learners can help them if we understand that our main responsibility comes in sharing the thought process.

(Dr. Bob’s full post here)

While I respect Dr. Centor immensely, in this case I think he’s a little bit off base. There is a certain amount of basic knowledge required to make sense of what you see in the patient. That’s why they’re called the “basic sciences.” I think Dr. Centor is forgetting that students must learn to walk before they can run, even as it is our job to mold them into competent runners.

For example, it would be impossible to have a meaningful discussion of an acid-base balance problem (a topic near and dear to Dr. Bob’s heart) before a student has learned renal physiology, plus respiratory physiology (respiratory compensation) as well as perhaps some GI pathology (vomiting and diarrhea). I find myself wondering how much contact Dr. Bob has had with pre-clinical students, beyond the tag-along, see-what-it’s-like experiences so widely touted these days as a means of maintaining students’ idealism and focus on the long term. I have, and I think it has brought me a different perspective.

Recently I had the experience of precepting a first-year student during a required “primary care practicum.” He had been taught the rudiments of interviewing, as well as most of the first year of the basic sciences. No pathology; no pharmacology; only a few parts of the physical exam. And yet he was tasked with taking the HPI on several patients a day, as well as identifying “learning issues” related to the basic sciences he’d already studied. Don’t get me wrong: the student was excellent. He was compassionate, bright, and a very hard worker. But his interviews were stilted and awkward (even though he didn’t take notes, made great eye contact, and had excellent body language). I quickly figured out what the problem was: although he had been taught what questions to ask, he had no idea what kind of answers to expect. And when taking a history, each answer helps you formulate the next question. Without the full complement of the basic sciences, the poor thing was lost.

I believe I was able to teach him a great deal, but most of it felt so superficial as to be almost useless. I invited him to come back again once he’d finished the second year, when at least we could discuss pathophysiology, and again after he’d spent some time in the hospital, to get a better sense of what ambulatory medicine is all about.

I agree that for the student, it is tremendously frustrating to spend hours learning (not memorizing; learning and understanding) all the minutiae that is biochemistry, physiology, pathology, etc. Two years can feel like forever. Still, without a certain level of basic knowledge, all the deep insights of the greatest clinicians will be lost on the learners.

I agree that medical education’s basic science curriculum needs revamping, and would definitely be improved by increasing the involvement of actual clinicians at all stages, from curriculum design to classroom and laboratory instruction. But medical students need to begin in the classroom before they can appreciate the bedside.




  1. You miss interpreted my screed. I never have denied the importance of basic sciences, rather I object to how they are taught! I also object to the focus on “advanced” basic science without making certain that our physicians really understand the basic stuff.

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