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Ironically, though many of today's high-school students are learning advanced science and mathematics that my generation studied in college or medical school, U.S. medical schools continue to devote precious time in the preclinical years to elementary-level biochemistry, cell biology, and genetics. With so much new scientific material to cover, medical school faculties must struggle to fit it all in while addressing the needs of students with widely varied levels of science preparation. Pressure on faculty members teaching preclinical courses is intensified by the truncation of the preclinical program at many medical schools to allow for earlier entry into the clinical curriculum. At the same time, many medical schools, recognizing the value of student scholarship, are adding a requirement for an in-depth scholarly project that must also fit into a 4-year curriculum.
Some view the current premedical science requirements — 1 year of biology, 2 years of chemistry (especially organic chemistry), 1 year of physics, and, in some schools, 1 year of mathematics — as a necessary gauntlet that thins out the applicant pool. Unfortunately, current college courses that fulfill admissions requirements are not adequately focused on human biology; the topics covered in many courses in chemistry, physics, mathematics, and even biology are so removed from human biologic principles that they offer little value to the premedical — or advanced human biology — student and steal time and attention from more relevant science preparation. Does a student, for example, really need a full year of organic chemistry to prepare for the study of biochemistry? Moreover, premedical science courses often fail to achieve sufficient rigor to prepare students for tackling the sciences fundamental to medicine at the advanced molecular level now required. We should expect a higher standard from students who wish to pursue medicine in an era in which genomics and informatics will revolutionize biomedical science and health care.
No one is arguing for more time in college devoted to premedical science courses; rather, I support greater efficiency and a tighter focus on science that "matters" to medicine. In addition, because of the growing commonality of language among scientific disciplines, and because human beings are complex organisms whose discrete systems are linked intricately and elaborately within the body and modified profoundly by external influences, we need to teach in ways that reflect this complexity and that stimulate students to synthesize information across disciplines. Unfortunately, asking faculty members to undertake such synthesis defies the long-sacred compartmentalization of disciplines into departmental silos. Such isolation among disciplines has already begun to change, and many medical schools have added new departments of systems biology, which focus on this complexity and the interdependence and interaction among different body systems. A sick patient does not represent a biochemistry problem, an anatomy problem, a genetics problem, or an immunology problem; rather, each person is the product of myriad molecular, cellular, genetic, environmental, and social influences that interact in complex ways to determine health and disease. Our teaching, in both college and medical school, ought to echo this conceptual framework and cut across disciplines.
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Many colleges have successfully incorporated cellular and molecular biology and genetics into introductory biology courses. They have been less successful, however, at increasing the relevance and rigor of premedical chemistry and math requirements. Instead of the current chemistry sequence, colleges could expose premedical students to general chemistry, organic chemistry, and biochemistry in a 2-year sequence that provides the foundation for the study of biologically relevant chemistry. Ideally, instead of devoting time to a second semester of organic synthesis, college students could take a seamless sequence of preparatory organic chemistry and basic principles of biochemistry (especially protein structure and function), completing the study of introductory biochemistry before medical school and building a foundation for medical school courses that begin from and reach higher plateaus.
To provide premedical students with the computational skills required for the advanced study of biology, college math courses should focus on biologically relevant algebraic and trigonometric quantitative skills; require familiarity with calculus and the mathematical description and uncertainties of dynamic biologic systems but not divert attention to the derivation of theorems that have little relevance to biology; and provide adequate grounding in probability and statistics, which are required for an understanding of the scientific and medical literature.
The college years should not be designed primarily to prepare students for professional schools. College should be a time to explore and stretch academically and intellectually; to engage creatively in an expansive liberal arts education encompassing literature, languages, the arts, humanities, and social sciences; and to prepare for citizenship in society. Included in this foundation should be analytic, writing, and communications skills; fluency and a nuanced facility in English; mastery of a foreign language; the basis for understanding human behavior, appreciating societal structure and function, achieving cultural awareness, and facilitating a habit of lifelong self-education; and in-depth, sustained, independent study, which fosters deep reflection, an active role in acquiring knowledge, and scholarly ownership in an area of inquiry. How do we accomplish all this and encourage attention to other scholarly avenues without rendering the time commitment for science courses too burdensome? A reasonable prescription for efficiency and economy would involve refocusing, increasing relevance, setting a higher standard, and encouraging the design of more interdisciplinary premedical science courses.
Responding to the same concerns about premedical science education, the Association of American Medical Colleges and the Howard Hughes Medical Institute have undertaken a joint, comprehensive assessment of the continuum of premedical and medical science education. Themes likely to be included in their recommendations are the importance of introducing synergy and efficiency through cross-disciplinary and biologically relevant teaching; of educating "inquisitive" physicians, who understand not only medical knowledge but also how it is acquired; and of establishing a habit of scientific thought on which to build the practice of medicine. The recommendations are likely to favor scientific competencies over specific discrete courses, implying that premedical requirements for rigid, 1-to-2-year, discipline-specific science courses should give way to more creative and innovative courses that span and unite disciplines, offering a glimpse of the way biologists and physicians actually navigate real-life problems.
Creating such new, cross-disciplinary science courses may well be difficult for colleges, which vary in the availability of resources, depth of faculty, and political will of traditional departments to address these curricular demands. Medical school admissions committees, for their part, will face difficulties in assessing who has met admissions requirements focused more on competencies than on courses. If both colleges and medical schools succeed, however, students will begin medical school with more advanced and relevant preparation in science, ready to tackle higher-level medical science courses. While admissions requirements are evolving, premedical students will face increased uncertainty, but as the standards and rigor increase, their courses will become more relevant and compelling. The competencies evaluated by the Medical College Admissions Test, in turn, will have to be revised. I believe that for students and teachers alike, the positive effects of these changes far outweigh the negatives. Those who teach undergraduates should not shy away from the challenge. Medical schools should stimulate colleges to innovate, and premedical students should demand science courses that prepare them directly and efficiently for the advanced study of biology. Premedical science should never have become a "trial by fire."
In recent years, calls have come from various quarters for medical schools to require and for colleges to teach ethics, altruism, compassion, listening skills, and skills relevant to health policy and economics — at the expense of science requirements. In my view, these aspects of medicine are best reserved for medical schools, where they can be taught in the meaningful context of interactions with patients. Medical educators take seriously their responsibility to equip students for the practice of scientifically anchored medicine. If medical schools are to have the freedom to fulfill that responsibility, students should arrive with a higher level of scientific competence, and colleges can contribute by preparing students more efficiently for the study of contemporary, sophisticated, biologically relevant science.
No potential conflict of interest relevant to this article was reported.
Source Information
Dr. Dienstag is the dean for medical education at Harvard Medical School, Boston.
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