Fractures in Flexner’s in Medical Education
Foundation
Recommended
Changes
Dear Dr. Whelan: The recent editorial by Dr. Estabrook in the August issue of The FASEB Journal prompted me to write thisletterof concern. I have alsohad the opportunity to listen to Dr. Estabrook when he addressed a joint meeting of the Chairs of Physiology and Anatomy Departments in 1991. In addition, I have read the Robert Wood Johnson Commission report and various other articles and comments related to this report. The essence of the editorial is that there is a need for “fundamental changes” and “thorough reform” in the education of medical students. There is also the recurring suggestion that the perceived problems are related to current departmental structures that “fail to meet today’s needs for planning and implementing a program of medical education” I must admit that I am astonished by the failure on the part of those that keep insisting that our system of medical education is in such disarray to provide solid evidence in support of these sweeping statements. Instead, we are exposed to a contrived message that refers to a new “paradigm for biolgical science” and a need for the “integration of science education across disciplines.” How this will actually solve the problems that exist is never really explained. Indeed, itisnot clearthat the solutions deal with the realproblems that existin the health care sector. First of all, if medical education has been so pitiful for these past years, why are the products of medical schools and the associated graduate schools doing so well? One need only pick up lay or professional newspapers and journals to realize that the medical education system and the biomedical research enterprise of the United States have consistently provided major leadership to the world of medicine. There have been countless accomplishments in all areas of medicine and medical research, including advances in biomedical technology and therapeutic innovations. We can consider examples in transplantation medicine, treatment of cardiovascular diseases such as hypertension, and immunology. Are the talented physicians, surgeons, and scientists who have participated in these activities the products of an educational system that is in such dire straits? Indeed, it seems that there are more bright, talented young physicians interested in biomedical research than our research enterprise can support. Our tragic dilemma is the limited funds available to provide young investigators with the resources they need to fulfill their potential. I have personally known many excellent young physician-investigators who had originally made a serious commitment to enter biomedical research but finally chose to go into private practice because of the problems and hassles related to obtaining research funding and walking the tightrope of biomedical research. The educational system did not fail these bright young minds. It prepared them for exciting careers at the forefront of medicine either as practitioners or investigators in biomedical research. With regard to actual health care, we hear of many problems related to the access, costs, and distribution of health care to all Americans, but there is general agreement that the quality of health care that American physicians provide is among the best in the world. In essence, the problems are not related to the training and competence of physicians, but rather to the distribution of health care and to the incredible bureaucracy that has developed around the health care industry. Incredibly, these problems seem to be blamed on the inadequacies of the education of medical students. Where are the data that lead to this conclusion? It would seem prudent
that, before we destroy what is considered by many of us to be the finest medical education system in the world and replace it with unproven and highly inefficient approaches, we take careful assessment of what may be lost. I should hasten to emphasize that my comments should not be construed as being against continuous improvement and upgrading of educational approaches and techniques. I firmly believe that allof us in medical education should be highly
FOUNDATIONS OF MEDICAL EDUCATION
Correction
of Dysfunctional
Processes
Mechanisms Responsible for Disarray of Life Processes Interactions Between Living Systems and Drugs Responses to ExternalAgents and Invading Pathogens Chemical Processes Dynamics
In Living Systems
of Life and Mechanisms
of Homeostasis
StructuralElegance of LivingSystems and Human
Body
responsive to the changing times and should incorporate techniques and approaches made possible by recent technological developments in education and communication. In addition, I agree that it is very stimulating for students to be exposed to various patient-oriented problems in order to allow them to achieve a greater appreciation for the importance of learning fundamental principles. However, it is naive to believe that all of the foundations of medicine that have to be inculcated during the early years of medical school can be achieved by such an inefficientand cumbersome approach. The main point I wish to emphasize is that while our current system of medical education should be continuously improved, modernized, and refined, it certainly does not deserve the chastisement that it is currently receiving nor does it require upheaval and total restructuring as is inferred by the reformists from the Robert Wood Johnson Commission. Those of us who have been in the trenches of medical education through the years continue to realize that, as always, serious in-depth learning remains a challenge that requires commitment, discipline, and long hours of study. We can certainly help to make learning more enjoyable and rewarding but it is always going to be demanding and is always going to require dedication on the part of the student. Medical students must continue to work just as hard as their predecessors.This idea that students previously were taught with “passive learning” approaches is ridiculous. In fact, all learning is “active learning” and so-called “passive learning” is no learning at all! We must also realize that one of the most fundamental aspects related to efficiency of learning is to divide the total challenge into manageable sections in order to make a seemingly impossible task appear to be within grasp. Many of us feel that it is essential to establish a sound foundation by providing the student with the opportunity to learn the information and concepts in an orderly and logical sequence rather than a haphazard one. Consider the simple elegance of a pattern of learning that establishes a solid foundation as illustratedin the enclosed figure.While the listisincomplete, it illustrates that there is a clear, sound rationale for the tradi-
3426 LETTERS TO THE EDITOR Vol. 6 December 1992 www.fasebj.org by Univ Louisiana Dupre Library/Serials Dept (130.70.8.131) on January 15, 2019. The FASEB Journal Vol. ${article.issue.getVolume()}, No. ${article.issue.getIssueNumber
tionalcompartmentalization of the medical education process and for the existence of specificadministration units that assume primary responsibility for the individual components. It should also be recognized that in view of the increased diversity of the premedical training and backgrounds of entering medical students, now more than ever we have an increased burden of responsibility to ensure that all students are provided with the opportunity to obtain a sound foundation in an orderly and logical manner. Only with this approach can we be reasonably confident that they possess an up-todate factual base of knowledge and understand the fundamental principles that are requisite for an intelligent and informed evaluation of their patients. In summary, I would emphasize that we should not be too hasty to discard the current system with its proven record of success. Rather, let us strive to improve it by the application
of innovative and creativenew approaches made
Dear
Perhaps it is not really important; but it is hard to be credible on the subject of medical education while unconsciously putting on a dunce cap fashioned by an old detractor.
Dr.
Whelan:
It is very discouraging medicine” in an article
to see the words “schools of allopathic on medical education (1). “Allopathy” was an entirely fictitous medical doctrine invented over 100 years ago by the homeopath Samuel Hahnemann, and falsely attributed to the regular medical profession in an attempt to place regular medicine on a level with homeopathic medicine. This was bitterly resisted by the medical profession (2), which has never accepted any such doctrine. The word has been kept alive over the years by non-medical practitioners who want to suggest that medicine is just one among several more or less equal alternatives, and by numerous celebrities and literary people with more fame than judgment. The usage has always been false and misleading. Medicine is a science and does not espouse “allopathy” or any other unproven doctrine; it is either ignorant or dishonest, and in any case offensive, to suggest otherwise. Unfortunately, Dr. Estabrook has plenty of company. Apparently, a number of physicians, educators, and others tend to parrot polysyllabic words without much attention to what they might actually mean. The usage has appeared in Peterson’s Guides (3), and even the New England Journal of Medicine seems to consider it a matter unworthy of editorial attention (4-6). (One can imagine how this would strike the 19th-century Boston fathers of medicine, so often and ostentatiously reverenced.)
Author’s
Reply
Dear
Whelan:
Dr.
Response to Dr. L. C. Navar Thank you for your thoughtful comments. I attempted to summarize in my editorial the recommendations we (The Robert Wood Johnson Foundation Commission on Medical Education) hoped would achieve “continuous improvement and upgrading of educational approaches and techniques:’ as stated in your letter. It is extreme to suggest we recommended a path to “destroy:’ “require upheaval and total restructuring:’ and “discard” all aspects of the present system of medical education. We examined many changes in the process of science education now under way at a number of medical schools and we recognized the value of these changes to the learning environment for the student. Central to our report was the theme of integration of science education. The figure included with your letter illustrates to me the importance of learning the sciences of medicine in an integrated curriculum. I fail to see how this scheme “illustrates that there is a clear sound rationale for the traditional compartmentation of medical education.” I applaud your call to
possible by new and developing technology and by incorporation of those aspects that have not received adequate attention. Most important, let us at least apply a modicum of scientific judgment to the reform process lest we rush headlong into modified apprentice-like approaches that expose unprepared students to a tangled spidery web of apparently unconnected and unrelated pieces of patient data before they have an adequate foundation. In closing, I would suggest to my colleagues that it seems important to determine if I am expressing isolated opinions or if they are shared by the silent majority. Now is the time to speak out! L. Gabriel Navar, Ph.D., Chairman and Professor, Department of Physiology, Tulane University Medical Center, New Orleans, LA 70112, USA
C. Dennis Thron, M.D., cology, Dartmouth 03755-3835, USA
Professor Medical
of Pharmacology and School, Hanover,
ToxiNH
REFERENCES 1. Estabrook, R. W. (1992) Fractures in Flexner’s foundation: recommended changes in medical education. FASEBJ. 6, 2887-2888 2. King, D. (1858) “Quackery unmasked: or a consideration of the most prominent empirical schemes of the present time, with an enumeration of some of the causes which contribute to their port.” pp. 297-298, New York, S.S. and W. Wood 3. Graduate Programs in Business, Education, and Health and Law,
Ed (book 6) 1991 Princeton, 4. Mainzer, E. (1986) Allopathy 314, 187
sup-
26th Guides, Inc. homeopathy. N EngL j Med.
N.J., Peterson’s versus
5. Thron, C. D. (1986) More on reducing medical school classes. N Engl. J Med. 314, 322-323 6. Hughes, R. G., Barker, D. C., and Reynolds, R. C. (1991) Are we mortgaging the medical profession? N Engi. J Med. 325, 404-407
others to speak out and express their opinions. One purpose of an editorial is to present ideas that will serve as a format for further dialogue. Response to Dr C. Dennis Thorn. Your comment criticizing me for use of the words “schools of allopathic medicine” in my editorial was unexpected. I merely quoted the location of those individuals surveyed for their perception of medical education, as originally reported in thej Am. Med. Assoc. article identified. I claim no expertise or knowledge of differences in the educational process providing the sciences required for homeopathic medicine. I quote Webster’s Third New International Dictionary of the English Language. Unabridged (1976): “allopathy-a system of medical practice that aims to combat disease by use of remedies producing effects different from those produced by the special disease treated;” “homeopathya system of medical practice that treats a disease by the administration of minute doses of a remedy that would in healthy persons produce symptoms of the disease treated?’
R.
University
W
Estabroolc, Ph.D., Department of Texas Southwestern
Harry
Hines
Blvd.,
Dallas,
TX
of Biochemistry, Medical
75235-9038,
Center,
The 5323
USA
Vol.by 6Univ December 1992 Library/Serials Dept (130.70.8.131) on 3427 LETTERS THE EDITOR www.fasebj.org Louisiana Dupre January TO 15, 2019. The FASEB Journal Vol. ${article.issue.getVolume()}, No. ${article.issue.getIssueNumber
Foundation
Recommended
Changes
Dear Dr. Whelan: The recent editorial by Dr. Estabrook in the August issue of The FASEB Journal prompted me to write thisletterof concern. I have alsohad the opportunity to listen to Dr. Estabrook when he addressed a joint meeting of the Chairs of Physiology and Anatomy Departments in 1991. In addition, I have read the Robert Wood Johnson Commission report and various other articles and comments related to this report. The essence of the editorial is that there is a need for “fundamental changes” and “thorough reform” in the education of medical students. There is also the recurring suggestion that the perceived problems are related to current departmental structures that “fail to meet today’s needs for planning and implementing a program of medical education” I must admit that I am astonished by the failure on the part of those that keep insisting that our system of medical education is in such disarray to provide solid evidence in support of these sweeping statements. Instead, we are exposed to a contrived message that refers to a new “paradigm for biolgical science” and a need for the “integration of science education across disciplines.” How this will actually solve the problems that exist is never really explained. Indeed, itisnot clearthat the solutions deal with the realproblems that existin the health care sector. First of all, if medical education has been so pitiful for these past years, why are the products of medical schools and the associated graduate schools doing so well? One need only pick up lay or professional newspapers and journals to realize that the medical education system and the biomedical research enterprise of the United States have consistently provided major leadership to the world of medicine. There have been countless accomplishments in all areas of medicine and medical research, including advances in biomedical technology and therapeutic innovations. We can consider examples in transplantation medicine, treatment of cardiovascular diseases such as hypertension, and immunology. Are the talented physicians, surgeons, and scientists who have participated in these activities the products of an educational system that is in such dire straits? Indeed, it seems that there are more bright, talented young physicians interested in biomedical research than our research enterprise can support. Our tragic dilemma is the limited funds available to provide young investigators with the resources they need to fulfill their potential. I have personally known many excellent young physician-investigators who had originally made a serious commitment to enter biomedical research but finally chose to go into private practice because of the problems and hassles related to obtaining research funding and walking the tightrope of biomedical research. The educational system did not fail these bright young minds. It prepared them for exciting careers at the forefront of medicine either as practitioners or investigators in biomedical research. With regard to actual health care, we hear of many problems related to the access, costs, and distribution of health care to all Americans, but there is general agreement that the quality of health care that American physicians provide is among the best in the world. In essence, the problems are not related to the training and competence of physicians, but rather to the distribution of health care and to the incredible bureaucracy that has developed around the health care industry. Incredibly, these problems seem to be blamed on the inadequacies of the education of medical students. Where are the data that lead to this conclusion? It would seem prudent
that, before we destroy what is considered by many of us to be the finest medical education system in the world and replace it with unproven and highly inefficient approaches, we take careful assessment of what may be lost. I should hasten to emphasize that my comments should not be construed as being against continuous improvement and upgrading of educational approaches and techniques. I firmly believe that allof us in medical education should be highly
FOUNDATIONS OF MEDICAL EDUCATION
Correction
of Dysfunctional
Processes
Mechanisms Responsible for Disarray of Life Processes Interactions Between Living Systems and Drugs Responses to ExternalAgents and Invading Pathogens Chemical Processes Dynamics
In Living Systems
of Life and Mechanisms
of Homeostasis
StructuralElegance of LivingSystems and Human
Body
responsive to the changing times and should incorporate techniques and approaches made possible by recent technological developments in education and communication. In addition, I agree that it is very stimulating for students to be exposed to various patient-oriented problems in order to allow them to achieve a greater appreciation for the importance of learning fundamental principles. However, it is naive to believe that all of the foundations of medicine that have to be inculcated during the early years of medical school can be achieved by such an inefficientand cumbersome approach. The main point I wish to emphasize is that while our current system of medical education should be continuously improved, modernized, and refined, it certainly does not deserve the chastisement that it is currently receiving nor does it require upheaval and total restructuring as is inferred by the reformists from the Robert Wood Johnson Commission. Those of us who have been in the trenches of medical education through the years continue to realize that, as always, serious in-depth learning remains a challenge that requires commitment, discipline, and long hours of study. We can certainly help to make learning more enjoyable and rewarding but it is always going to be demanding and is always going to require dedication on the part of the student. Medical students must continue to work just as hard as their predecessors.This idea that students previously were taught with “passive learning” approaches is ridiculous. In fact, all learning is “active learning” and so-called “passive learning” is no learning at all! We must also realize that one of the most fundamental aspects related to efficiency of learning is to divide the total challenge into manageable sections in order to make a seemingly impossible task appear to be within grasp. Many of us feel that it is essential to establish a sound foundation by providing the student with the opportunity to learn the information and concepts in an orderly and logical sequence rather than a haphazard one. Consider the simple elegance of a pattern of learning that establishes a solid foundation as illustratedin the enclosed figure.While the listisincomplete, it illustrates that there is a clear, sound rationale for the tradi-
3426 LETTERS TO THE EDITOR Vol. 6 December 1992 www.fasebj.org by Univ Louisiana Dupre Library/Serials Dept (130.70.8.131) on January 15, 2019. The FASEB Journal Vol. ${article.issue.getVolume()}, No. ${article.issue.getIssueNumber
tionalcompartmentalization of the medical education process and for the existence of specificadministration units that assume primary responsibility for the individual components. It should also be recognized that in view of the increased diversity of the premedical training and backgrounds of entering medical students, now more than ever we have an increased burden of responsibility to ensure that all students are provided with the opportunity to obtain a sound foundation in an orderly and logical manner. Only with this approach can we be reasonably confident that they possess an up-todate factual base of knowledge and understand the fundamental principles that are requisite for an intelligent and informed evaluation of their patients. In summary, I would emphasize that we should not be too hasty to discard the current system with its proven record of success. Rather, let us strive to improve it by the application
of innovative and creativenew approaches made
Dear
Perhaps it is not really important; but it is hard to be credible on the subject of medical education while unconsciously putting on a dunce cap fashioned by an old detractor.
Dr.
Whelan:
It is very discouraging medicine” in an article
to see the words “schools of allopathic on medical education (1). “Allopathy” was an entirely fictitous medical doctrine invented over 100 years ago by the homeopath Samuel Hahnemann, and falsely attributed to the regular medical profession in an attempt to place regular medicine on a level with homeopathic medicine. This was bitterly resisted by the medical profession (2), which has never accepted any such doctrine. The word has been kept alive over the years by non-medical practitioners who want to suggest that medicine is just one among several more or less equal alternatives, and by numerous celebrities and literary people with more fame than judgment. The usage has always been false and misleading. Medicine is a science and does not espouse “allopathy” or any other unproven doctrine; it is either ignorant or dishonest, and in any case offensive, to suggest otherwise. Unfortunately, Dr. Estabrook has plenty of company. Apparently, a number of physicians, educators, and others tend to parrot polysyllabic words without much attention to what they might actually mean. The usage has appeared in Peterson’s Guides (3), and even the New England Journal of Medicine seems to consider it a matter unworthy of editorial attention (4-6). (One can imagine how this would strike the 19th-century Boston fathers of medicine, so often and ostentatiously reverenced.)
Author’s
Reply
Dear
Whelan:
Dr.
Response to Dr. L. C. Navar Thank you for your thoughtful comments. I attempted to summarize in my editorial the recommendations we (The Robert Wood Johnson Foundation Commission on Medical Education) hoped would achieve “continuous improvement and upgrading of educational approaches and techniques:’ as stated in your letter. It is extreme to suggest we recommended a path to “destroy:’ “require upheaval and total restructuring:’ and “discard” all aspects of the present system of medical education. We examined many changes in the process of science education now under way at a number of medical schools and we recognized the value of these changes to the learning environment for the student. Central to our report was the theme of integration of science education. The figure included with your letter illustrates to me the importance of learning the sciences of medicine in an integrated curriculum. I fail to see how this scheme “illustrates that there is a clear sound rationale for the traditional compartmentation of medical education.” I applaud your call to
possible by new and developing technology and by incorporation of those aspects that have not received adequate attention. Most important, let us at least apply a modicum of scientific judgment to the reform process lest we rush headlong into modified apprentice-like approaches that expose unprepared students to a tangled spidery web of apparently unconnected and unrelated pieces of patient data before they have an adequate foundation. In closing, I would suggest to my colleagues that it seems important to determine if I am expressing isolated opinions or if they are shared by the silent majority. Now is the time to speak out! L. Gabriel Navar, Ph.D., Chairman and Professor, Department of Physiology, Tulane University Medical Center, New Orleans, LA 70112, USA
C. Dennis Thron, M.D., cology, Dartmouth 03755-3835, USA
Professor Medical
of Pharmacology and School, Hanover,
ToxiNH
REFERENCES 1. Estabrook, R. W. (1992) Fractures in Flexner’s foundation: recommended changes in medical education. FASEBJ. 6, 2887-2888 2. King, D. (1858) “Quackery unmasked: or a consideration of the most prominent empirical schemes of the present time, with an enumeration of some of the causes which contribute to their port.” pp. 297-298, New York, S.S. and W. Wood 3. Graduate Programs in Business, Education, and Health and Law,
Ed (book 6) 1991 Princeton, 4. Mainzer, E. (1986) Allopathy 314, 187
sup-
26th Guides, Inc. homeopathy. N EngL j Med.
N.J., Peterson’s versus
5. Thron, C. D. (1986) More on reducing medical school classes. N Engl. J Med. 314, 322-323 6. Hughes, R. G., Barker, D. C., and Reynolds, R. C. (1991) Are we mortgaging the medical profession? N Engi. J Med. 325, 404-407
others to speak out and express their opinions. One purpose of an editorial is to present ideas that will serve as a format for further dialogue. Response to Dr C. Dennis Thorn. Your comment criticizing me for use of the words “schools of allopathic medicine” in my editorial was unexpected. I merely quoted the location of those individuals surveyed for their perception of medical education, as originally reported in thej Am. Med. Assoc. article identified. I claim no expertise or knowledge of differences in the educational process providing the sciences required for homeopathic medicine. I quote Webster’s Third New International Dictionary of the English Language. Unabridged (1976): “allopathy-a system of medical practice that aims to combat disease by use of remedies producing effects different from those produced by the special disease treated;” “homeopathya system of medical practice that treats a disease by the administration of minute doses of a remedy that would in healthy persons produce symptoms of the disease treated?’
R.
University
W
Estabroolc, Ph.D., Department of Texas Southwestern
Harry
Hines
Blvd.,
Dallas,
TX
of Biochemistry, Medical
75235-9038,
Center,
The 5323
USA
Vol.by 6Univ December 1992 Library/Serials Dept (130.70.8.131) on 3427 LETTERS THE EDITOR www.fasebj.org Louisiana Dupre January TO 15, 2019. The FASEB Journal Vol. ${article.issue.getVolume()}, No. ${article.issue.getIssueNumber
