Do Doctors really need to know the Krebs cycle?

Painful though it was to learn (both times - see later), the answer must be yes. But how much time should be spent on learning such basic science, at the expense of clinical experience? Or indeed, instead of other basic sciences such as pharmacology? After a previous glib comment on this, I received a long communique from a new reader who has a strong interest in pre-medical basic science. I'll reproduce it in full then add my comments later.

I am glad to have a discussion with you regarding the role of the basic sciences in premedical and medical education. This is the focus of my career, such as it is, but please take into account that I am not a medical doctor. I can only point to a mountain of work I have done in the wild west of MCAT preparation, helping United States premedical students master the undergraduate science curriculum in the United States before their big exam. Long ago I decided to put off medical school indefinitely to pursue this work because I felt it could be beneficial to others and it immerses me. I hope your readers will forgive my lack of credentials and look at my ideas in themselves. It is valuable for me to share ideas with you. In fact, I am going to be proposing myself as an applicant for a few MD PhD programs next year in the hopes of dedicating the PhD portion to development of reformed premedical curriculum and looking at the first two years of medical school to see how I might be helpful as well. I am beginning to work my courage up to contacting potential advisors at various institutions who have similar interests, so the opportunity of discussing these ideas with you is really valuable to me.

In the United States, medical school starts later than in the United Kingdom because students must first earn their four year undergraduate degree before they can begin medical school. Although a premedical student can major in any subject, all students must complete a full year each of college physics, chemistry, organic chemistry and biology. There is also strong encouragement for calculus, biochemistry, physiology and molecular genetics as well. Most premedical students are biology majors and take many other science courses. Medical school itself in both the United States and the UK is probably analogous to a severe hazing ritual, but the educational custom in the United States leads doctors to start practice three or four years older than their UK counterparts which probably makes our doctors more self pitying.

Alfred North Whitehead in his great essay 'Science in the Modern World' pointed out that the explosion of knowledge in modernity made the 'Renaissance Man' no longer possible, and that to be effective, a modern person had to content themselves with being a specialist, and this was in the 1920's! I think this predicament of modernity creates a real tension for medical education, especially, because the human body is a microcosm of the universe, of the whole of science, not only in the sense of complexity but in the sense that a person's health is bound to it, so it is very difficult for any person studying medicine to leave off something potentially important just because the mind has limited capabilities. Furthermore, there is a tradition which makes it hard for any teaching generation to make things easier for today's students than they themselves had it in their own education. However, the rate of increase of the knowledge base means that even if the discipline doesn't change, the disposition towards the knowledge among educators has to change. You can't learn everything. In biochemistry, as you mentioned, today's medical students are asked to retain an incredible amount of information regarding mechanism after mechanism, but this was true even twenty years ago. However, in the intervening years students have been given a new encyclopedia to learn in the field of molecular biology. Within the field of eukaryotic gene expression alone, there are now elaborate signaling pathways and mechanisms like alternative splicing and RNA interference which have been elucidated only in the past ten years. So there needs to be a lot of debate about what to teach and what not to teach.

Of course one important standard is whether a piece of information is relevant to clinical judgment. You mentioned the Krebs cycle, which is likely only important in clinical practice for a subset of metabolic disorders. Within every clinical specialty there are fundamental principles from basic science which are important for understanding of symptoms and treatment on a daily basis, but not for other specialists. Bernoulli's Principle and Poisseuille's Law for the cardiologist. Solution and acid-base equilibria for the nephrologist. Hooke's Law for the orthopaedist. An infectious disease specialist is not going to think about these things very often I suppose. In fact, the specialists themselves probably don't think about them too much on a daily basis, except in difficult cases, but the knowledge must be there in the first place for the specialist's education to have been coherent when they received it. This is where I have an issue with choosing the Krebs cycle as an example of irrelevant information, which to me is like the wheel at the center of the living system. Understanding the flow of energy in metabolism makes a great deal else a medical student must understand coherent, although I have big problems with how the Krebs cycle and a lot of biochemistry is taught. If instructors felt they could use the field of reference of physics and general chemistry in a sophisticated way to animate the presentation of the Krebs cycle, it would mean a lot more to students.

You mentioned the greater emphasis on clinical experience and communication in recent educational trends, at the expense of basic science. There is a lot of similar talk in the United States. Maybe medical educators are giving up on making medical school an experiment in finding the maximum possible amount of information a human mind can hold. It may be that there is good cost benefit to teaching doctors to be better communicators because it leads to better outcomes for patients without too much trouble. Convincing people to quit smoking has done more against cancer than understanding the mechanism of histone acetyl transferase, at least so far.

However, the proposition that animates my own work is that a more effective curriculum at the earlier stage would prepare entering students significantly better for the challenges of understanding and retention they face in medical school, whether the A-levels in the UK or the undergraduate level in the United States. I mean the fundamental level of physics, chemistry, organic chemistry and biology. Medical school would be more vivid. I think it is ridiculous that undergraduate students in the United States do not learn the fundamental physical and biological sciences within a combined curriculum that builds on itself, but within disconnected modular courses. How can a person understand free energy change in chemistry without mechanics, electrodynamics, and thermodynamics from physics? How can you understand oxidative metabolism without oxidation reduction? Being a person who has worked very closely with many small groups of premedical students, taking them through the basic sciences in review more times than I want to admit, I'm burdened with knowing how little conceptual fluency students actually possess after their undergraduate years that would help them unify the enormous encyclopedia already in their heads, and what is coming, which would make the facts coherent and memorable.

So I made the WikiPremed MCAT Course at www.wikipremed.com because I hoped it would benefit people as part of the whole movement to make education more accessible and I hoped it would be a way to share some ideas I had about rearranging the basic science curriculum for future doctors at the undergraduate level. The sequence of topics and goals in the course represents my best effort at what a unified, interdisciplinary, spiraling curriculum for basic science would look like (without lab component). I think medical school would be more interesting and enjoyable if students were prepared by a science program that followed a sequence like this one I have come up with, where chemistry comes out of physics and the biological sciences out of the physical sciences. If anyone is interested, they can go visit, if at least to see what a person is capable of who gets so deep in a project they can only double down. I'm too close to the work to see it's many problems clearly, so please make criticisms, as long as they are fixable.

Personally I'd love to know more about molecular chemistry and thermodynamics, for my own interest and general education. Perhaps one day I will. But do I think it will make me a better doctor? Maybe, but not much. I studied for the USMLE exams a couple of years back, covering biochemistry topics I hadn't looked at for nearly 10 years. It was painful. I remember being 19 and wondering "Will I really need to know how many ATP molecules are produced from each stage of this reaction when I'm a doctor?" At the time, I guessed I wouldn't. 10 years later I knew it wasn't any use.

Clearly there are significant differences between US and UK medical education. I don't think ours is anywhere near as much of a 'hazing' ritual as it is in the States, as the longer time period (5-6 years), lower expectations of students, and longer post-graduate 'apprenticeship' training make the whole experience much less intensive. And I think UK medical education has already moved focus away from basic science more than in the USA, which probably makes it easier too...

So the focus in the two systems is different, but I think both could be criticized for not stressing the more clinically useful basic sciences - physiology and pharmacology especially. I'd go back to my medical school lectures on those topics if I could. I'd probably get more out of them now, too.

So there you are. Medical school - wasted on medical students.