Is medical education too focused on the “right answer”? Or not enough?
In recent years, many medical schools have made changes to their curricula to provide students a more holistic view of medicine, such as emphasizing the social factors that determine health, giving students more experiential learning opportunities, teaching communication skills, and offering immersive summer programs in arts and humanities topics.
Many students have welcomed these changes, but some doctors perceive these changes as medical schools “stepping out of their lane.” Dr. Stanley Goldfarb, former associate dean of curriculum at the University of Pennsylvania’s Perelman School of Medicine, recently wrote a controversial op-ed in the Wall Street Journal lamenting the advancement of social justice issues in medical school “at the expense of rigorous training in medical science.”
Is it true that the broadening of medical education from “pure” science to social science really damaging for the medical field? Despite Goldfarb’s assertion that social issues only “tangentially” affect healthy, a growing body of research on community conditions has shown the critical links between factors like income, housing, neighborhood safety, and education and long-term health outcomes. Understanding these links and advocating for improvements in community conditions that affect health is an important part of caring for patients. Organizing for better community conditions can also be empowering for clinicians, in a system where clinicians often feel helpless to fix the socioeconomic forces harming their patients on a daily basis.
Goldfarb’s piece created an uproar in response, especially from UPenn students, faculty, and alumni. UPenn faculty members responded in the Philadelphia Inquirer, citing disparities in maternal mortality, the Flint water crisis, and other examples of social issues that directly affect health. “Separating social justice from medicine deprives students of the opportunity to apply concepts into clinical practice and sends the message that these issues are independent rather than intertwined,” wrote Dr. Crystal Zheng and other UPenn Alumni in Medscape.
Dr. Bernard Lown is another example of a doctor who saw the value in tackling social issues for health. In the 1980s Lown co-founded, with Dr. Yevgeny Chazov from the Soviet Union, International Physicians for the Prevention of Nuclear War (IPPNW). They pointed out that nuclear detonation would have a devastating impact on the health of humanity, and were recognized for their work with a Nobel Peace Prize.
As for Goldfarb’s argument that teaching social justice is not leaving enough time to teach “how to cure patients,” many doctors have pointed out that the “bloat” in medical education is not from adding social issues, but from rote memorization on scientific topics (like the Krebs Cycle) that students will never use in their clinical practice.
Can someone explain to me why I had to memorize the Krebs cycle in medical school but never learned about surrogate endpoints and how they are used in trials that affect clinical practice? @VinayPrasadMD @adamcifu pic.twitter.com/kmO0Ww7dzb
— Roxana Daneshjou, MD/PhD (@RoxanaDaneshjou) July 7, 2018
In fact, many doctors have argued that recent changes in medical school curricula have not gone far enough. As Dr. Liyang Pan at University College London Hospitals Foundation Trust writes in a BMJ opinion piece, medical education for her was too focused on rote memorization and getting the “right answer,” rather than understanding the meaning behind the answers.
“Students, myself included, use a combination of acronyms and memory aids rather than understanding that guidelines are recommendations or questioning their underlying evidence,” Pan writes.
This deficiency in understanding often leads to harm, when clinicians follow “one-size-fits-all” guidelines that recommend drug treatments as the first line of therapy. Ironically, the emphasis in medical education on biology, neuroscience, and other basic science topics leads students (and later, doctors) to care more about how a medical intervention works, rather than whether it works at all, writes Dr. Vinay Prasad at Oregon Health and Science University. Prasad and Dr. Adam Cifu at the University of Chicago present an alternative medical curriculum, which emphasizes the clinical encounter and evidence-based medicine rather than basic science topics.
In our book @adamcifu and I spend a couple chapters re-designing the curriculum from ground up, and these days I play around with a figure more like this.https://t.co/mGWg1Ky1F1 pic.twitter.com/hFLQmkWFaB
— Vinay Prasad 2.0 (@VPrasadMDMPH) July 8, 2018