My interest in medical education has extended over the past four decades, since I entered college as a "pre-med" following service in World War II. While rather striking changes have taken place in pre-medical and medical education, they have been over-shadowed by the "Revolution in Biology" and the advances in behavioral sciences, economics and applied mathematics. Medical education simply has not kept pace with these changes and has at best fitted them into the curricula in a haphazard, piecemeal fashion.
Historically, medicine did not emerge from its Gaelenie traditions and practices until the mid-nineteenth century with the first "revolution in biology," the recognition that the cell is the fundamental unit of most living things. This fundamental insight was incorporated into medicine by Virchow. Bernard and other Europeans, and became the scientific basis of medicine for the next hundred years. In fact, even today the concepts developed between 1850 and the mid 1920s still form the chief scientific base of medicine.
In 1910, Abraham Flexner published the now well-known "Flexner Report" on medical education, which criticized medical schools for lacking admission standards, proper facilities, and qualified instructors. His fundamental idea was that medical education should be based on the learning of fundamental concepts in the field which could be applied by professional doctors.
While the Flexner report was a tremendous help to American medical education, it is also responsible, in large measure, for the lock-step conformity of pre-medical and medical education. The Flexner report, although widely quoted, has apparently seldom been studied. Instead of heeding the concepts promulgated by Flexner. American medical education enshrined his example, like the fable of the magpie, and it remains today the catechism of medical education, the National Boards and forms the basis of liscensure in most jurisdictions, as pointed out in President Bok's recent Annual Report.
After World War II, the second revolution in biology occurred; far-reaching advances were made in the understanding of the genetic nature of the cell (RNA), and other areas. American medical education, having forgotten Flexner's main concept, continues to implement his example; and students continue to learn scientific knowledge by rote memory, instead of the fundamental concepts that doctors need to know.
There can be no argument that to be a physician requires a working knowledge of the sciences which are basic to medicine. This does not imply that to be a physician one must be a biological scientist, anymore than an engineer must be a pure mathematician and a theoretical physicist. On the other hand, it does not follow that a well-trained scientist cannot be a good physician. The practice of medicine, if nothing else, is pluralistic and can accommodate people with wide variety of skills, knowledge and understanding. There are limits to the science which needs to be known and understood to be a good physician, but these are not necessarily those that currently exist. The pre-medical and undergraduate medical curriculum should be re-evaluated in the light of the current realities in science, social science and the humanities. The information, understanding, and concepts of the revolution in biology which has occurred since World War II, should be incorporated into the curricula so that wherever possible basic concepts can displace rote memory. The potential here is overwhelming, yet in almost 40 years, the impact on medical teaching has been minimal.
In a similar fashion, the understanding that a great deal of disease in this country can be prevented by changing people's behavior, has not been exploited. Despite the known risks, people still smoke cigarettes (in fact, the government still supports tobacco farming), drive without seat belts, are overweight, don't exercise, drink too much, ignore the risk of cancer in getting a suntan, abuse drugs and have trouble coping with stress. Here, too, is an area waiting to be exploited by better teaching.
Finally, physicians and all of those who deal with ill people must be sensitive to their needs and their desire to know and understand their own problems, and to be aware that as a physician one must know and understand the ethics of our society and be called upon to render ethical opinions. This, too, is an area of knowledge that must be (supplied and) reemphasized in the process of teaching people to become physicians.
The perfect physician is one who knows all the science and technology relevant to medicine, who knows how to apply it skillfully for the benefit of one's patients, and, at the same time, is a wise compassionate counselor who earns his or her patient's trust and provides comfort in times of illness and need. Perfection may be impossible to achieve but to try always to reach it is the epitomy of the good physician.
Dr. Warren Wacker, Henry K. Oliver Professor of Hygiene, is Director of the University Health Services.