The Aha! Factor

In one of my pathology lab courses for second-year medical students, we were reviewing the gross and microscopic findings from the autopsy of a patient who had died following acute pulmonary embolism. As I was going through the features that help one distinguish an ante-mortem thrombus vs. a postmortem clot, one of my more outspoken students said sardonically, "This will help me take better care of my patients!" That comment raised, at least in my mind, a question that I've been wrestling with over the last several years: Why do we teach what we do? It is interesting how much my own attitude toward this question has changed over the years. There was a time when I felt that a thorough grounding in basic biological knowledge is absolutely critical to being an adequate physician. This premise, that understanding the basic vocabulary of biology is critical to a physician's education, underlay my attitude toward the basic biomedical curriculum for many years. I was convinced, for instance, that genetic information would have such a major impact on understanding pathology, predicting prognosis, and designing therapy that a thorough grounding in molecular genetics was critical to be a well-informed physician in the 21st century. It is ironic that even as I thought this, I was not paying heed to the fact that much of what had been taught to me during my medical school training as the "cutting age" of biological research has, by and large, turned out not to have a major impact on the practice of medicine. For instance, during the first two years of medical school, I was taught about protein synthesis in great detail. I was told about the structure of messenger RNA, the structure and processing of the ribosomal RNA, the A and P sites in the ribosome, the mechanism of protein synthesis and how antibiotics act to terminate protein synthesis in prokaryotes—all those wonderful details that almost no one remembers today. The rationale then is very much like the rationale of today—we were told that antibiotics that worked against bacteria did so by inhibiting discrete steps in protein synthesis, and therefore it was critical for us nascent physicians to understand the mechanism of protein synthesis in detail. I am willing to take a bet that even the infectious disease specialists, who use antibacterial agents most often, do not remember (and have no need to remember) where the P site is on a ribosome. Physicians slightly removed from infectious disease have even little reason to understand the structure of the ribosome. In retrospect, I am led to conclude that much of what we teach today as the latest and greatest and most current in research in biology, as facts that physicians must know to be good doctors tomorrow is based on specious logic. I would be surprised if the details in molecular genetics is more relevant to the practice of medicine tomorrow than details of protein synthesis has turned out to be for my generation of doctors. Does this mean that everything that we teach medical students during the first two years is by and large superfluous? I suspect the answer is yes, even though many of my basic science colleagues will probably be outraged by my saying so. However, there are reasons that compel me to think that some exposure to basic science is indispensable for medical education. One can visualize medicine as the purely technical craft, one that can be taught in a vocational school not unlike those that turn out plumbers or electricians. It is possible that one can be a perfectly adequate physician simply through apprenticeship. This model would be sufficient if medicine were as mature a craft as plumbing or electrical wiring. One has to face the reality that many of the therapeutic strategies in "modern medicine" are appalling and primitive. We look back on the practice of medicine 100 years ago and are amused or dismayed (depending on our temperament) by treatments that were "state of the art" 100 years ago. Thus, how else would we react to the use of leeches for the treatment of gout? Or evaluating the course of illness by tasting the urine of patients? Or strapping patients with emotional illnesses in straight jackets and incarcerating them in insane asylums? These and other remedies seem outrageous to us today, but I suspect physicians of 100 years from now will probably look upon our treatment of malignancies as no less barbaric. Is it really reasonable to kill every dividing cell in the body to rid someone of a malignancy? Is it noble to subject patients to the horrendous graft vs. host reactions that occur following myeloablative therapy and MHC-mismatched transplantation? Medicine is forever changing, and progress can only be made by our willingness to confront the extent of our ignorance. Almost any craft, however interesting it might seem initially, becomes progressively boring if every day is the repetitive administration of known nostrums. Medicine has the unique opportunity to provide its practitioners a chance for poetry. All human beings need some expression of their own creative juices, whether carving images on the walls of caves or composing songs even in the middle of a war zone. For those of us who lack the artistic ability to paint or compose, this artistic drive comes from those rare moments of epiphany, when we really understand something. When confronted with a patient who reacts to a standard regimen of erythromycin with vomiting, it would be easy to accept it as a known side effect. But when one realizes that this is because erythromycin has a specific gastrointestinal motility promoting aspect to its pharmacology, then one has a moment of understanding that makes the craft worthwhile. The real question is whether all medical students really need this knowledge base to make the practice of medicine worthwhile. It is my suspicion that a vast majority of our students really do not. Today the mechanics of being a physician is so time-consuming and tiring that most physicians do not have time to enjoy these moments of epiphany, and those who do need these creative moments probably get it elsewhere. In every medical school class there is probably a small cohort of people who are genuinely driven by the need to know. I suspect that this group of people will work out any avenue through which to exercise this need to know, this overpowering curiosity to find out how things really work. It is difficult, if not impossible, to inculcate in those who do not want to know, the curiosity to know; I think it is also impossible to kill this need in those who really want to know. I suspect that this group does not exceed a small handful in any medical school class. The problem seems to be that basic biomedical curricula are designed largely for the sake of this minority. Even if you never had this training, that handful would drift into academia. So, after having wrestled with this problem for years, I have come to the conclusion that it doesn't really matter what we teach. Most medical students will promptly forget the P site of the ribosome, or heterotrimeric G proteins, or microsatellite polymorphisms—or whatever the current rage is in biomedical circles. And the small percentage of people want to find out about the things will find a way to learn even with the most attenuated basic biomedical curriculum. T.V. Rajan, MD-PhD (rajan@neuron.uchc.edu), is chairman, department of pathology, University of Connecticut Health Center, Farmington, Conn.

The Aha! Factor

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