170
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
MAY, 1976
New Programs of Medical Education and the Basic Sciences* BERNARD J. FOGEL, M.D., Assistant Vice President for Medical Affairs,
University of Miami, Miami, Florida
W E HAVE observed a substantial number of swings in the educational pendulum during the past two decades. What were taken as medical education truisms following the Flexner Reports of 1910 and 1925, became questionable patterns of pedagogy in medical schools during the 60's. Not all of this was scholarly nor engendered by intellectual curiosity. I think it would be fair to state that this was not medical school activism but reactivity to the incentive dollars that were dangled by the government to shorten the curriculum, increase physician manpower, and to meet certain objectives presented in the Carnegie Report, as well as other studies. It is interesting to note that despite the tremendous number of so-called innovative changes in medical education during the 60's and early 70's, many and maybe most schools are returning to rather traditional medical education models in which the basic sciences play a strong role during the first two years, and structured clinical training is the basis for the advanced years. Dr. E. M. Papper, vice president for medical affairs and dean of the University of Miami School of Medicine, tells our graduates at commencement, "that they come with innate intelligence, common sense, integrity and motivation. The school of medicine does not have the ability to engender these qualities in students. Hopefully the system refines and reenforces these qualities as well as providing students with a sound basis for postgraduate education and a life of continuing medical education." To accomplish the goal outlined by Dr. Papper, the University of Miami School of Medicine has made several revisions in its * Read at the 80th Annual Convention of the National Medical Association, Miami Beach, Florida, August 11, 1975.
medical curriculum. Included were a reduction of nearly 33% of the basic science time, early introduction of clinical models, implementation of a vertical clinical-basic science sophomore course, and establishment of an extensive elective program in the senior year. I do not, however, consider these innovative changes; simply refinements of proven educational models that are rather traditional. These refinements attempt to provide students with added time for assimilation, the ability to see the relevance of the basic science to the ultimate practice of clinical medicine, and the capacity to discipline themselves for self-study. In my view this is essential for any good pthysician, especially since many premedical students are used to "spoon feeding" and find it difficult to establish study patterns which do not depend on the usual pedagogical models. Evolutionary changes in the total pattern of our nation's educational system have enabled medical students to make reductions in basic science time without compromising the effectiveness of this phase of training. Specifically I speak of the very nature of the high quality of education that is provided in many high schools and colleges throughout the United States. Students in many large urban areas frequently can take math through calculus, chemistry through organic, and even relatively sophisticated physics courses in high school. Students often obtain advanced placement in college and can in a relatively short period advance through a rather sophisticated biochemistry sequence. Many of our entering students take the national test and place out of the regular biochemistry sequence. This permits them to participate in an excellent course entitled Molecular Medicine. Some medical students also enter the first year of
Vol. 68, No. 3
New Education Programs
school having already taken graduate level courses in physiology, microbiology, and some traditional anatomy. Accordingly it is possible to eliminate some of the time devoted to laboratories (of questionable value) and other basic science experiences allowing the student to enjoy more sophisticated approaches to the basic sciences. Courses such as the previously mentioned Molecular Medicine program, provide the student with an exciting opportunity to see how the basic sciences are applied to diseases such as diabetes, phenylketonuria, sickle cell disease, etc. One drawback to the speeding up of the medical education system is the fact that all too often students' personal maturation falls behind their intellectual growth. Accordingly, certain time constraints must be maintained so that students can adjust and mature into compassionate, understanding physicians. Despite the relative sophistication of many students entering medical schools, there tends to be a preference on the part of students to simplify their educational experience and direct their energies to passage of standardized measurements of performance such as the National Boards. There is also a growing tendency by medical students to establish notetaking services and for students to request that syllabi be provided so that they do not, in fact, have to read textbooks. While satisfactory performance on National Boards is important, it should not be the objective of the educational program. It is my very strong conviction that the basic sciences in medical school should be the place where the selfdiscipline of learning is laid down for a lifetime. Students must be encouraged to read not only textbooks and handout material, but updated periodicals which are germane to the subject matter. The role of the professor is to motivate and guide the student to the type of learning experience that will enable the trainee to enjoy such an experience for an entire lifetime. My own personal bias is that too much shortening of the curriculum (three years) is not advantageous to the student. Although there are exceptions, most students require the full four years of medical school to develop their self-learning techniques and clin-
171
ical skills. At the University of Miami we attempted to implement a 33-month curriculum. After eight months, 80% of the students and faculty agreed that the program was not the most appropriate for most students. Similar experiences are being encountered nationwide. Many schools hoped that some of the basic sciences could be taught during the fourth year of medical school. Curriculum revisions utilizing the elective system have been implemented in which students were given the opportunity to select training in the basic sciences during the fourth year of medical school. Although broad generalizations are usually bad, it is fair to say that most of these programs have been unsuccessful and the majority of students, no matter how long the postgraduate training period they will undergo, will select clinical services and clinical training programs at the expense of more sophisticated basic science application of clinical models. Therefore, it is my opinion that the supposed changes in medical education that have occurred during the last decade have proven to be a failure. What we have observed is the total evolution of the educational model from elementary school through the continuing education process across the nation. I believe the major change that has occurred in medical schools is that we now fully appreciate what Flexner said in 1910; that we are one part of a lifetime of education of the physician and that we must address ourselves to turning out physicians who are knowledgeable about the care of patients, concerned with preventive aspects of medicine, have warmth and compassion for their patients, and that the specifics of postgraduate education will provide the students with the opportunity to expand and to apply this knowledge as well as provide the best trained physicians in the world. You may wonder whether this somewhat cynical attitude about the so-called changes in medical education is justified. My argument is that we really have not seen any substantial revision in medical education. The fact that they were attempted has paid (Concluded on page 187)
Vol. 68, No. 3
Burkitt's Lymphoma
Case 2 had pyrexia and angular stomatitis on day 7; bleeding from the nose on day 13 (500 ml of fresh blood was transfused); and a rash and itching on day 36. Case 3 developed pyrexia on day 7; bleeding from the gum on day 11 (500 ml. fresh blood was transfused); and a rash on day 24. There was no evidence of parallel toxicity on the platelets and hemoglobin as measured by pcv.
187
that complete bone marrow recovery is possible in about four weeks. In another report by this author, of 146 patients with Burkitt's lymphoma treated with various doses and dose-schedules of cyclophosphamide6 (including these three patients), there was no advantage of large doses over small ones in producing long-term survivals. LITERATURE CITED
DISCUSSION AND CONCLUSION
The dosages of 100 and 130 mg/kg of cyclophosphamide given to these patients were the largest single doses on record in the treatment of Burkitt's lymphoma. There was sufficient bone marrow recovery to allow repetition of another dose of cyclophosphamide at about days 24 to 26. On day 30, the bone marrow was essentially normal, that is, the recovery was complete. Cyclophosphamide was not repeated in these patients because there was complete regression of their tumors. One patient (Case 1) was followed for 41/2 years and was free of the disease without further drug. The other two patients were lost to follow-up, but there was no recurrence of their tumors when last seen. This report indicates that very large doses of cyclophosphamide can be tolerated by the patients with no increase in morbidity, and
1. ZIEGLER, J. L., and R. H. MORROW, L. FASS, S. K. KYALWAZI, and P. P. CARBONE. Treatment of Burkitt's Tumor with Cyclo-
phosphamide. Cancer, 26:474, 1970. 2. NKRUMAH, F. K., and I. V. PERKINS. Burkitt's Lymphoma in Ghana: Clinical Features and Response to Chemotherapy. Int. J. Cancer, 11:19, 1973. 3. BRUCE, W. R., and B. E. MEEKER, and F. A. VALERIOTE. Comparison of the Sensitivity of Normal Hematopoietic and Transplanted Lymphoma Colony-forming Cells to Chemotherapeutic Agents Administered In-vivo. J. Nat. Cancer Inst., 37:233, 1966. 4. BERGSAGEL, D. E., and G. L. ROBERTSON, and R. HASSELBACK. Effect of Cyclophosphamide on Advanced Lung Cancer and the Hematological Toxicity of Large Intermittent Intravenous Doses. Canad. Med. Ass. J., 98:532, 1968. 5. DURODOLA, J. I. Burkitt's Lymphoma in Ibadan: Response to Various Chemotherapeutic Agents and Long-Term Survivors. In press. 6. DURODOLA, J. I. Burkitt's Lymphoma in Ibadan: Response to Various Doses of Cyclophosphamide and Long-Term Survivors. Accepted for publication by European Journal of Cancer.
(Fogel, from page 171)
substantial dividends in refining the process and allowed us to place the undergraduate medical student training program in perspective with the total educational process. Moreover, it enabled medical schools to use advanced educational technology, especially biomedical communications and computerization, in a manner which complements the system and acquaints the student with teaching-learning techniques which will probably
be used to a greater extent in the future. Therefore, I can only conclude the process of "curriculum capers" and the wide swings in the educational pendulum have improved the quality of medical education while making teaching the burgeoning quantity of basic science information more enjoyable and relevant to students who, in fact, have always viewed themselves as clinicians from the moment they entered medical school.
SUPPORT THE SCHOLARSHIP FUND
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
MAY, 1976
New Programs of Medical Education and the Basic Sciences* BERNARD J. FOGEL, M.D., Assistant Vice President for Medical Affairs,
University of Miami, Miami, Florida
W E HAVE observed a substantial number of swings in the educational pendulum during the past two decades. What were taken as medical education truisms following the Flexner Reports of 1910 and 1925, became questionable patterns of pedagogy in medical schools during the 60's. Not all of this was scholarly nor engendered by intellectual curiosity. I think it would be fair to state that this was not medical school activism but reactivity to the incentive dollars that were dangled by the government to shorten the curriculum, increase physician manpower, and to meet certain objectives presented in the Carnegie Report, as well as other studies. It is interesting to note that despite the tremendous number of so-called innovative changes in medical education during the 60's and early 70's, many and maybe most schools are returning to rather traditional medical education models in which the basic sciences play a strong role during the first two years, and structured clinical training is the basis for the advanced years. Dr. E. M. Papper, vice president for medical affairs and dean of the University of Miami School of Medicine, tells our graduates at commencement, "that they come with innate intelligence, common sense, integrity and motivation. The school of medicine does not have the ability to engender these qualities in students. Hopefully the system refines and reenforces these qualities as well as providing students with a sound basis for postgraduate education and a life of continuing medical education." To accomplish the goal outlined by Dr. Papper, the University of Miami School of Medicine has made several revisions in its * Read at the 80th Annual Convention of the National Medical Association, Miami Beach, Florida, August 11, 1975.
medical curriculum. Included were a reduction of nearly 33% of the basic science time, early introduction of clinical models, implementation of a vertical clinical-basic science sophomore course, and establishment of an extensive elective program in the senior year. I do not, however, consider these innovative changes; simply refinements of proven educational models that are rather traditional. These refinements attempt to provide students with added time for assimilation, the ability to see the relevance of the basic science to the ultimate practice of clinical medicine, and the capacity to discipline themselves for self-study. In my view this is essential for any good pthysician, especially since many premedical students are used to "spoon feeding" and find it difficult to establish study patterns which do not depend on the usual pedagogical models. Evolutionary changes in the total pattern of our nation's educational system have enabled medical students to make reductions in basic science time without compromising the effectiveness of this phase of training. Specifically I speak of the very nature of the high quality of education that is provided in many high schools and colleges throughout the United States. Students in many large urban areas frequently can take math through calculus, chemistry through organic, and even relatively sophisticated physics courses in high school. Students often obtain advanced placement in college and can in a relatively short period advance through a rather sophisticated biochemistry sequence. Many of our entering students take the national test and place out of the regular biochemistry sequence. This permits them to participate in an excellent course entitled Molecular Medicine. Some medical students also enter the first year of
Vol. 68, No. 3
New Education Programs
school having already taken graduate level courses in physiology, microbiology, and some traditional anatomy. Accordingly it is possible to eliminate some of the time devoted to laboratories (of questionable value) and other basic science experiences allowing the student to enjoy more sophisticated approaches to the basic sciences. Courses such as the previously mentioned Molecular Medicine program, provide the student with an exciting opportunity to see how the basic sciences are applied to diseases such as diabetes, phenylketonuria, sickle cell disease, etc. One drawback to the speeding up of the medical education system is the fact that all too often students' personal maturation falls behind their intellectual growth. Accordingly, certain time constraints must be maintained so that students can adjust and mature into compassionate, understanding physicians. Despite the relative sophistication of many students entering medical schools, there tends to be a preference on the part of students to simplify their educational experience and direct their energies to passage of standardized measurements of performance such as the National Boards. There is also a growing tendency by medical students to establish notetaking services and for students to request that syllabi be provided so that they do not, in fact, have to read textbooks. While satisfactory performance on National Boards is important, it should not be the objective of the educational program. It is my very strong conviction that the basic sciences in medical school should be the place where the selfdiscipline of learning is laid down for a lifetime. Students must be encouraged to read not only textbooks and handout material, but updated periodicals which are germane to the subject matter. The role of the professor is to motivate and guide the student to the type of learning experience that will enable the trainee to enjoy such an experience for an entire lifetime. My own personal bias is that too much shortening of the curriculum (three years) is not advantageous to the student. Although there are exceptions, most students require the full four years of medical school to develop their self-learning techniques and clin-
171
ical skills. At the University of Miami we attempted to implement a 33-month curriculum. After eight months, 80% of the students and faculty agreed that the program was not the most appropriate for most students. Similar experiences are being encountered nationwide. Many schools hoped that some of the basic sciences could be taught during the fourth year of medical school. Curriculum revisions utilizing the elective system have been implemented in which students were given the opportunity to select training in the basic sciences during the fourth year of medical school. Although broad generalizations are usually bad, it is fair to say that most of these programs have been unsuccessful and the majority of students, no matter how long the postgraduate training period they will undergo, will select clinical services and clinical training programs at the expense of more sophisticated basic science application of clinical models. Therefore, it is my opinion that the supposed changes in medical education that have occurred during the last decade have proven to be a failure. What we have observed is the total evolution of the educational model from elementary school through the continuing education process across the nation. I believe the major change that has occurred in medical schools is that we now fully appreciate what Flexner said in 1910; that we are one part of a lifetime of education of the physician and that we must address ourselves to turning out physicians who are knowledgeable about the care of patients, concerned with preventive aspects of medicine, have warmth and compassion for their patients, and that the specifics of postgraduate education will provide the students with the opportunity to expand and to apply this knowledge as well as provide the best trained physicians in the world. You may wonder whether this somewhat cynical attitude about the so-called changes in medical education is justified. My argument is that we really have not seen any substantial revision in medical education. The fact that they were attempted has paid (Concluded on page 187)
Vol. 68, No. 3
Burkitt's Lymphoma
Case 2 had pyrexia and angular stomatitis on day 7; bleeding from the nose on day 13 (500 ml of fresh blood was transfused); and a rash and itching on day 36. Case 3 developed pyrexia on day 7; bleeding from the gum on day 11 (500 ml. fresh blood was transfused); and a rash on day 24. There was no evidence of parallel toxicity on the platelets and hemoglobin as measured by pcv.
187
that complete bone marrow recovery is possible in about four weeks. In another report by this author, of 146 patients with Burkitt's lymphoma treated with various doses and dose-schedules of cyclophosphamide6 (including these three patients), there was no advantage of large doses over small ones in producing long-term survivals. LITERATURE CITED
DISCUSSION AND CONCLUSION
The dosages of 100 and 130 mg/kg of cyclophosphamide given to these patients were the largest single doses on record in the treatment of Burkitt's lymphoma. There was sufficient bone marrow recovery to allow repetition of another dose of cyclophosphamide at about days 24 to 26. On day 30, the bone marrow was essentially normal, that is, the recovery was complete. Cyclophosphamide was not repeated in these patients because there was complete regression of their tumors. One patient (Case 1) was followed for 41/2 years and was free of the disease without further drug. The other two patients were lost to follow-up, but there was no recurrence of their tumors when last seen. This report indicates that very large doses of cyclophosphamide can be tolerated by the patients with no increase in morbidity, and
1. ZIEGLER, J. L., and R. H. MORROW, L. FASS, S. K. KYALWAZI, and P. P. CARBONE. Treatment of Burkitt's Tumor with Cyclo-
phosphamide. Cancer, 26:474, 1970. 2. NKRUMAH, F. K., and I. V. PERKINS. Burkitt's Lymphoma in Ghana: Clinical Features and Response to Chemotherapy. Int. J. Cancer, 11:19, 1973. 3. BRUCE, W. R., and B. E. MEEKER, and F. A. VALERIOTE. Comparison of the Sensitivity of Normal Hematopoietic and Transplanted Lymphoma Colony-forming Cells to Chemotherapeutic Agents Administered In-vivo. J. Nat. Cancer Inst., 37:233, 1966. 4. BERGSAGEL, D. E., and G. L. ROBERTSON, and R. HASSELBACK. Effect of Cyclophosphamide on Advanced Lung Cancer and the Hematological Toxicity of Large Intermittent Intravenous Doses. Canad. Med. Ass. J., 98:532, 1968. 5. DURODOLA, J. I. Burkitt's Lymphoma in Ibadan: Response to Various Chemotherapeutic Agents and Long-Term Survivors. In press. 6. DURODOLA, J. I. Burkitt's Lymphoma in Ibadan: Response to Various Doses of Cyclophosphamide and Long-Term Survivors. Accepted for publication by European Journal of Cancer.
(Fogel, from page 171)
substantial dividends in refining the process and allowed us to place the undergraduate medical student training program in perspective with the total educational process. Moreover, it enabled medical schools to use advanced educational technology, especially biomedical communications and computerization, in a manner which complements the system and acquaints the student with teaching-learning techniques which will probably
be used to a greater extent in the future. Therefore, I can only conclude the process of "curriculum capers" and the wide swings in the educational pendulum have improved the quality of medical education while making teaching the burgeoning quantity of basic science information more enjoyable and relevant to students who, in fact, have always viewed themselves as clinicians from the moment they entered medical school.
SUPPORT THE SCHOLARSHIP FUND
