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The Times They Are a Changin'

Ben_3Ben Bryner -- Dr Jules Dienstag, dean of medical education at Harvard Medical School, wrote an excellent op-ed suggesting changes to premedical education (free here) in this week's New England Journal. (Contrary to this blogpost’s title, Bob Dylan has not weighed in on the issue. Sorry.) Dean Dienstag’s article has been getting some attention due to his suggestion that a full year of organic chemistry might be overkill, which is kind of like suggesting that a big scoop of ice cream on a hot day might be yummy.

Some people think that organic chemistry is a crucial part of the curriculum because it "weeds out" those who won't be able to hack it in medical school. Of course, this is the wrong approach to designing premed education; there's too much important knowledge to be gained in college and school that setting up barriers without further educational value is a terrible idea. Challenging but useful classes will be the cornerstone of premedical education, and if any "weeding out" really needs to be done, it can be done by the demands that a pre-med be involved in research, volunteering, shadowing, etc on top of classes. Successfully juggling all these demands is more impressive (and more akin to what a medical student has to do) than being able to push around electrons.

I've got no hatred toward organic chemistry; it's interesting on some level and I've had classes that were much worse. But organic chemistry has really only come in handy once during medical school, and that was when I used my textbook to kill a bat that had gotten into my house.

I'm certainly no expert on education. But here would be my suggestion for the ideal mandatory pre-med curriculum, (setting aside the problems of finding enough resources to teach these classes and their compatibility with med school curricula):

1 semester general chemistry

1 semester organic chemistry

1 semester biochemistry

1 semester math

1 semester statistics

1 semester physiology

1 semester cell biology

1 semester genetics

2 semesters of other biology electives

1 semester economics or ethics

2 semesters writing (at least some with a scientific focus)

This sounds like a lot, but it would fit with most requirements for majors (I took statistics and economics to fulfill my major requirement, English was required for everyone, and I still took several more science courses) and is about the same amount of time required in absolute terms. I think it would also be OK for schools to allow some of these classes to be taken during the senior year, with the offer of admission contingent on passing them. And it's pretty reasonable to expect premeds to carry a very full courseload -- it only gets busier from there -– and to take advanced, rigorous versions of these classes.

Dr. Dienstag draws the line at teaching things like ethics, health policy or health economics in college, arguing that med schools are better equipped to do things like that. Sure, colleges aren't going to bring students fully up to speed on those health-specific issues. The problem is that in my experience, med schools have too few resources to systematically teach the general principles of those fields. Instead, ethics and health policy and economics have been haphazardly thrown at us in random hour-long lectures throughout the four years. Part of the problem is the lack of planning and time devoted to the topics, but part of the problem is that lots of students at this stage don't have the background to dive in to a discussion of health-specific economic issues. Thus my suggestion that the fundamentals of some of these areas be required. Also, in the era of evidence-based medicine, med students clearly need a background in stats that med schools aren’t providing.

This gets at the heart of what colleges and med schools do best: colleges are great at helping students build broad frameworks, and med schools are good at adding on specific information in given areas and helping students develop specific new skills. The times that med schools run into a much greater obstacle, in my opinion, is when they try to teach concepts in areas where some people have an extensive background and others have none. (This also extends to the challenge of teaching empathetic interactions with patients, which is another topic).

Dr Dienstag hints at the possibility that the traditional forms of requirements of pre-med education will “give way to more creative and innovative courses that span and unite disciplines.” I hope so. Just as work hour restrictions have forced residency programs to trim as many nonessential activities as possible from their trainees’ routines, premedical education needs to be reshaped into a rigorous but broad program to prepare future doctors. Given the immense amount of time that future physicians devote to their training, and the overwhelming volume of knowledge they need to acquire, there’s really no time to waste.

July 23, 2008 in Ben Bryner | Permalink


Bat killer!

Posted by: thomas | Jul 23, 2008 11:23:05 AM

I think you're still overdoing the science. My ideal pre-med curriculum would include:
1 semester g-chem
1 semester o-chem
1 semester biochem or cell bio
1 semester genetics or evolutionary biology
1 semester statistics
2 semesters other biology
1 semester philosophy, religion, or ethics
1 semester writing intensive course
mastery of a foreign language
4 semesters of non-science electives in addition to above

I frankly think that you learn all of the cell biology, physiology, and biochemistry that you need during the preclinical medical school years. Being exposed to it previously is fine, but not really necessary, in my view. I think that what is missing from pre-med education is a broad based background so that we can relate to people and understand where they're coming from. It also helps to be able to influence policy, economics, and other areas where doctors are woefully underheard.

Posted by: Brian | Jul 23, 2008 3:11:30 PM

I would recommend:

English, Literature or technical writing course
Cell Bio
Latin (or other Romance language)

The first year chem is usually required to take the upper lever stuff, so why require it; just require the upper level stuff. I think Ecology is an excellent way to teach or discover global thinkers. I agree with this post; ethics in med school is piecemeal and patchwork. I'm very glad for the ethics course I took in undergrad; at the very least, it gave me a good grounding. And Latin is such a huge part of learning the vocabulary of medicine, it would make learning much of the terminology significantly easier.

Posted by: Beach Bum | Jul 23, 2008 7:04:57 PM

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