Map of life expectancy at birth from Global Education Project.

Thursday, September 07, 2006

Hear, Hear!

Ezekiel Emanuel, in the new JAMA, discusses the medical curriculum, and says exactly -- well almost exactly -- what needs to be said. Unfortunately, it's subscription only, and there's not even an abstract, which annoys me a whole lot because this commentary is important not only to doctors, but to all of us on the other end of the doctoring. Consequently, I'm going to steal liberally. I think it's fair use, but JAMA can sue me if they want to. Emanuel writes:

Today, the fundamental components of medicine go beyond the biomedical sciences to include its humanistic, legal, and management aspects. While science is absolutely essential, especially with greater precision in determining disease etiology through genetics and environmental influences, the limitations in practice increasingly result from systematic problems of implementation. Many of the medical services being delivered are irrelevant or harmful 10,11; much of what has been proven effective is not being routinely delivered to patients. 12–14 Consequently, hundreds of thousands are suffering and even dying prematurely while billions of dollars are wasted. 15 These problems are not the result of a few “bad apples,” but of systematic failures to deliver proven interventions to patients. 6,7,12 To apply 21st-century scientific advances effectively in the care of patients requires more emphasis on the humanistic, legal, and management sciences.

He might have added that many people are unhappy with their communication and relationships with their physicians, as some readers have expressed here -- doctors may do okay at curing, but badly at healing. It is usually seen as an intractrable problem that the 4 year medical school curriculum is already far too full of science, and far too demanding, so how can we possibly add all this touchy-feely stuff? Emanuel suggests that the solution begins with changing the pre-med requirements:

Why are calculus, organic chemistry, and physics still premed requirements? Mainly to “weed out” students. Surely, it would be better to require challenging courses on topics germane to medical practice, research, or administration to assess the quality of prospective medical students, rather than irrelevant material. 3


As the mere existence of the Hippocratic oath attests, ethical challenges are inherent in medical practice and research. 17 Yet there is no premed ethics requirement. Students need the ability to distinguish ethical issues from communications, economic issues, or aesthetic issues, to make ethical arguments, and to give ethical reasons that justify their decisions. Requiring a general ethics course is preferable to a focused bioethics course, which should wait until students have experience with actual patients and clinical dilemmas.

Moreover, much of the practice of medicine, as well as dealing with a research team and administering organizations, entails dealing with people and, therefore, human psychology. Requiring that students take a psychology course that provides education about established notions of human behavior, such as the fundamental attribution error, hindsight bias, transference, and moral distancing, could enhance physicians' interactions with patients, colleagues, and employees, not to mention their own families.

I would add that medical school admissions should look for people who haven't just studied ethics and psychology, but who are ethical and empathic people. One way to start is by refusing to take anybody right out of college -- spend a couple of years in the real world, and grow up first, find out what kind of person you are, find out how real people live, and maybe show something about yourself. Then apply to medical school.

And then, there is the question of how much of that medical school "basic science" is really necessary? In fact, I can tell you without any doubt that medical students forget 80% of it the day after the final exam:

Determining what courses are included and excluded from the curriculum is subject to fierce faculty battles. Each professor has a list of what could safely be eliminated, which is usually someone else's offering. Personally, despite being taught the Krebs cycle (twice during medical school as well as twice in college), I have never used it in my practice or research. 8 My drug prescribing habits tended to be influenced by the handbooks I carried around rather than my pharmacology course. A lot of the pathology and cytology courses had virtually no impact either.

He specifically recommends:

the challenge is to ensure that communications and bioethics education is more systematic and thoughtful. 20 In the first year, expert faculty should provide a formal introduction with a guiding framework. During clinical rotations, there should be repeated explicit instruction about practical applications of this framework as ethical issues arise and good communications can be modeled. In addition, in the fourth year a course should explicitly consolidate students' bioethics and communications learning. The “summing up” bioethics course could combine discussions about actual cases students have experienced in their clerkships with relevant readings; using standardized patients, good communication skills could be reinforced.

Of greater importance are areas that lack explicit LCME requirements, or are amalgamated into more vague requirements and may not be formally taught at all. While having statistics as a premed requirement will ensure that entering medical students grasp the basics, a formal statistics course in the first year would reinforce and apply the knowledge to reading the medical literature, analyzing research data, understanding health services research, and improving quality. Some schools teach statistics but most do not.

Health care now consumes more than $2 trillion per year. Health care is more than knowing what to provide. Reimbursement policies often determine what services are provided, and to whom. Practitioners and physician executives must understand how the financing system is structured, what services are covered by private insurance, Medicare, Medicaid, and other payers, and the incentives for clinicians implicit in reimbursement systems. It seems amazing to graduate physicians who have no idea what Medicare Part B is, the data on how copayments affect the use of medical services, how the resource-based relative value scale is determined and affects reimbursement, and why an aspirin administered in the hospital costs $20.

At the medical school with which I am associated, we used to have a course for first-year students called Patient, Doctor and Society that covered all this stuff -- well, not statistics, but everything else. It was team-taught in small sections by physicians and a person like me who studies medicine from the outside. I taught it for four years. But the school ended up eliminating it. Why? Because it was just too much for the students to be writing seminar papers while they were studying for the anatomy final, and none of this stuff was going to help them pass the boards.

The dean had a very unpleasant musculoskeletal disorder in which he was sitting on his shoulders. We need to fix this.


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