Bridging the Medical School Gap: Pathophysiology Links Basic Science, Clinical Medicine

In the last 50 years, increasing criticism of American medical education has centered on an overloaded curriculum, inadequate basic science-clinical integration, and limited commitment of the faculty to teach. Curriculum changes at a number of medical schools have not resulted in widespread reform. Our recently published study analyzed these complaints and offered suggestions for improvement. The study (J.J. Smith et al., Advances in Physiology Education, 17:S36-46, 1997) states that the inadequate basic-clinical meshing not only persists in teaching but also is a serious problem in medical research training. We believe that basic science faculty--almost all Ph.D.s--are devoted and competent scientists who have been a key force behind what were probably the greatest advances in the history of medical science. However, in recent years, there has been a marked directional change from human and clinically oriented research to molecular biology. Although the enormous power of the molecular approach is apparent to everyone, the almost total diversion of the study of biological function at this level into molecular biology is detrimental to both medical school teaching and research training. We believe the teaching difficulty is mainly due to circumstances forced on basic science faculty, particularly the necessity--for funding purposes--to direct their research away from human and clinically oriented projects. This was initiated by policy changes of the National Institutes of Health. Since NIH is the major funding support of medical scientists, cellular and molecular biology became the research areas of overwhelming emphasis. It is, of course, scientifically logical to explore the nature of the universe through study of smaller and smaller constituent elements, and such approaches will provide important insights into certain disorders, particularly of genetic origin. But systemic and human physiology have much more medical and curricular relevance, not only for the present but also for the future, when knowledge of genes derived from the Human Genome Project will require thorough organ system and human physiological studies. In any event, this change has exerted a profound effect on basic science teaching. Bruce M. Koeppen, the 1995 Teacher of the Year awardee of the American Physiological Society, wrote: "Today, physiological processes have progressed from the forest to the trees, to the leaves and even the molecules in the leaves; the curriculum must be built around what the students need to know and not the interest and expertise of the faculty" (B.M. Koeppen, Physiologist, 38:117-20, 1995). J.O. Woolliscroft, associate editor of Academic Medicine , agrees; he wrote "Novices in any discipline ... including, by definition, medical students, ... need teachers who possess broad knowledge. For research funding, faculty develop great expertise in very narrow domains ..., but how is this related to teaching novices?" (J.O. Woolliscroft, Academic Medicine, 70:22-9, 1995). Noted Swedish physiologist Bjorn Folkow wrote that some leaders of physiology "have been so carried away by the molecular-cellular bandwagon as to vanish below the cell membrane with their coworkers in a deep dive, presumably never to emerge again." Because of this reductionism, he believes, some physiology departments are no longer able to provide medical students with an acceptable course in medical physiology (B. Folkow, News in Physiological Sciences, 9:93-5, 1994). Medical schools, under financial pressure, require faculty members to provide ever-greater fractions of their salaries from grants, leading to an inevitable time-effort conflict between their research and teaching functions. There has also been criticism of the quality of medical school teaching. Woolliscroft wrote in his Academic Medicine article: "Researchers ... are often ill-equipped to teach medical students ... ; students need teachers who possess required expertise in teaching in addition to content expertise. [Many are] without the benefit of ... disciplines of cognition and education a bout the importance of context in learning." Joel Michael, an experienced authority on medical education, has noted that much progress has been made in the methods of science teaching and the relationship between teacher behavior and student achievement, but this accumulated knowledge has been largely ignored by teachers of basic science (J. Michael, Adv. Physiol. Educ., 1:S14-S17, 1989). It should be recalled, however, that over the years, Case Western Reserve University and other schools have made serious efforts to improve their teaching programs. And in spite of increasing fragmentation and research-teaching conflicts, some progress has been made. Curricular reforms at Northwestern and Harvard universities, for example, have some common features, including attempts to improve student attitudes and skills in communication, medical ethics, human values, and doctor-patient relations. These two schools also restructured their entire basic science curriculum in an effort to improve horizontal (inter-subject) and vertical (basic-clinical) integration; this involved extensive rescheduling so that various basic science presentations (of organ systems) are juxtaposed and interrelated so far as possible. Similarly, in clinical coordination seminars, biochemical and metabolic aspects of diabetes, are, for example, described by basic scientists and accompanied by clinical presentations and analyses in patients. The switch in research emphasis to molecular biology may well have an even greater long-term effect on research training than on teaching. Basic science graduate students have naturally been immersed in the research projects of their mentors. Thus, a large number of future basic science faculty have been trained in an environment with little involvement in human or clinically oriented problems. Kenneth I. Shine, president of the Institute of Medicine, stated that the remarkable U.S. medical scientific achievements after World War II have been largely due to the productive partnership between clinical investigators and basic scientists. He decries the recent decline in funds available for clinical research and has proposed a novel plan to stop this decline: a 1 percent assessment on all patient care premiums (K.I. Shine, FASEB Journal, 11:397-403, 1997). But this farsighted idea depends heavily on the availability of basic scientists. And unfortunately at present few are being trained to pursue clinically oriented projects. The current president of the American Physiological Society, Allen W. Cowley Jr., along with the other officers of the society, are also making valiant efforts to obtain increased grant support on behalf of integrative physiology. ( Physiologist, 39:375-88, 1996). James J. Smith is a professor of physiology and medicine, Susan M. Koethe is a professor of pathology, and Hubert V. Forster is a professor of physiology, all at the Medical College of Wisconsin in Milwaukee. The authors acknowledge the strong support and continued assistance of Allen W. Cowley Jr., the physiology chairman at MCW, throughout this study. Previous efforts toward basic-clinical integration have usually involved closely coordinated seminars by clinicians and basic scientists to discuss clinical disorders. But the side-by-side (team) teaching of different aspects of a clinical problem does not really constitute integration. As Woolliscroft has pointed out: "... bringing a series of basic science and clinical faculty members to classrooms and seminar rooms often results in disjointed coverage of material; ... medical students need teachers who can integrate the specific areas of a subject with overarching themes and who can teach at the student level." As Koeppen, Woolliscroft, and others have long emphasized, the key to true basic-clinical integration is pathophysiology. When signs, symptoms, and laboratory findings in a particular patient indicate (as they often do) involvement of two or more organ systems, the physician must weigh the relative importance of the derangements of the different systems. He or she must determine which of these disturbances represent the greatest threats to the patient's welfare, taking into account the patient's age, sex, family history, general physical condition, and past illnesses; the physician then decides on a course of treatment intended to elicit the greatest benefit for the patient's most urgent problems while imposing least harm on the other systems. This is far more complex than learning the symptoms, natural history, and treatment of a single disorder. Such judgments require a good understanding of the biochemistry, physiology, and pharmacology of the different organ systems and how they relate to each other, as well as a sound knowledge of pathology--in other words, the pathophysiology of human disease. Such pathophysiological integration is one of the most demanding tasks in medicine and very difficult for a medical student. But who is to help train students in this art? There are no departments or professors of pathophysiology and almost no texts in a field deemed by many as one of the most important in medicine. There are no training programs and very few medical teachers with both a broad training in modern basic science and a good knowledge of medical pathology. With the increasing complexity of basic science, it seems evident that the traditionally trained M.D. is not really qualified to teach modern basic science. It might be theorized that M.D./Ph.D. training could best bridge the basic-clinical gap; however, the great majority of these graduates go into clinical residencies and are not a significant force in either applied human physiology or career teaching in basic science. Yet our best hope of filling the basic-clinical medicine teaching gap and of applying the future advances in medical research to clinical medicine is to expand the teaching of pathophysiology in our medical schools. To train such teachers, we have proposed a new training track in the basic sciences: a Ph.D. program in pathophysiology. In addition to the usual research program, this track includes courses in biochemistry, anatomy, integrative physiology, and pharmacology; a course in medical pathology; and a course in the teaching of basic science. The conventional basic science graduate program typically takes four to five years. The proposed pathophysiology track would take about one year longer, that is, an average of five to six years. An informal poll that we took suggests that a number of graduate students would not be deterred by the added time; the added cost is modest compared, for example, to that of an M.D./Ph.D. program. Irwin M. Arias, the physiology chairman at Tufts University, has added an optional "Pathobiology" course for his graduate students that has been very successful and continuously oversubscribed (I.M. Arias, New England Journal of Medicine, 321:972-4, 1989). We think there may be still other ways to bring pathophysiology to its rightful place in the medical curriculum. We conclude that many of the current problems in medical basic science teaching and the decline in clinical research training are due to the excesses of the nationwide switch to cellular and molecular research, the growing disparity between the basic scientist's area of research and the needs of his or her medical teaching, and the lack of training of basic scientists and their graduate students in the principles and methods of science teaching. Although some medical schools have improved their teaching programs, they have not really solved the important problem of bridging the basic science-clinical medicine gap and achieving true integration between the two. To do this, we suggest inauguration of a graduate training program for basic scientists in pathophysiology and have described a sample program of this type. We believe such a program will exert a beneficial effect on medical education and on clinically oriented research.

Bridging the Medical School Gap: Pathophysiology Links Basic Science, Clinical Medicine

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