Good Afternoon:
I would like to respond to Dr. Stoddard's email from two days ago.
The issue is the volume of medical information and knowledge has expanded dramatically over the past fifty years and is accelerating, whereas the preparation of applicants to medical school has not kept up and, in fact, has dropped off. It is so bad that I'm embarrassed to say where I went to college which, when I went was the academically most rigorous and selective institution in the country. Now? Every course there has take-home tests, everyone gets an A, and the course work is a shadow of what was expected of my class and this is based on direct examination of syllabuses and books as well as interviews with my professors over many class reunions.
Worse, much of this accelerating expansion of knowledge is greatly biased, flawed, and, often, wrong. Therefore, it is critical that medical students have an adequate educational background prior to acceptance and then, continue to get the kind of education that leads to an appropriate attitude and effective approach to assessing the professional literature.
Perhaps we can look at the following:
- Mathematics
- Critical Thought
- Diversity versus standards
- Certain basics required regardless of what the future offers
MATHEMATICS:
When I was in medical school, we were expected to read the professional literature critically and not accept the statistical 'proof' presented by the author(s) until we had evaluated it. At that time, not all of us had taken a course in statistics but many had. The rest got a crash course during our discussions. Starting in the late 1980's I began to see a trend so I began to ask every single student in each class I taught about their background in mathematics. Here is what I found:
- The number and difficulty of the math courses taken dropped off from about three to one-or-two
- The number with a course in statistics dropped from one course by about 20% of students to about 2%
- Only two persons I quired over three decades had taken a second course in statistics
- For four years I gave a monthly one-hour presentation on critical article reading to fourth year medical students and residents on Internal Medicine rotations. This gave me the opportunity to evaluate other medical schools
- I found all but a few residents from different medical schools were able to understand the simplest statistics
- Over the last twenty years I've noticed that more and more physicians did not understand the difference between statistical 'significance' and 'clinical' significance. Early on most clinicians I knew were wary of or skeptical of statistical 'proofs'
CRITICAL THOUGHT:
From 1980 when I started my residency through my recent retirement, I have had hundreds of 'friendly' disagreements and not so 'friendly' confrontations with my fellow physicians regarding simple logic as applied to well established facts. This started out as a sporadic event occurring, perhaps, once per month and usually involving the same fellow residents or staff members at the hospital I trained at. These were people who tended to stick to their rusty guns because they certainly were not going to be swayed by a pathology resident. By the time I retired, I found myself biting my tongue constantly to avoid confrontations over younger clinician's lack of ability to solve even simple problems. They had difficulty developing a systematic assessment of initial findings and applying simple logic to formulating a plan of action.
In one case, it had to do with the staging of colon carcinoma according to AJCC standards. We were doing it wrong in our tumor board when I arrived at the facility. It took 18 months to 'educate' the tumor board members most of which were many years younger than me. After we were finally properly stagging our patients, I met with each member separately and found that those in my age group had a good understanding of logic and were relieved when my position was finally accepted (so, why didn't they speak up?). None of the young gun slingers had taken a course in logic or philosophy, and none had taken more than the bare minimum in math courses at college; usually simple introductory courses in calculus and trigonometry. No statistics. They just could not understand how I got from a to b to c!
DIVERSITY VERSUS PREPAREDNESS:
I agree that medical schools are admitting a more diverse cohort of learners who arrive with a wider range of qualifications. And this is not a bad thing. My class of 1980 at GWU was experimental in this area and way ahead of its time. However, the school did not drop its standards of education for our class. Many expected us to fail; some due to outright bigotry. No such thing happened. Turns out our diverse class was no less intelligent than those classes full of straight A students with high MCATS. Did some of those chosen for diversity suffer? Yes. But both the student body and professors helped those less prepared, and they all did well during their clinical years. If anything, those who came in with an educational disadvantage rose to the challenge and went on to be highly successful clinicians.
Now, standards are being systematically abandoned both in college and medical schools in favor of diversity so as to be 'socially' just and to not hurt anyone's feelings. This isn't being socially just. It's setting up disadvantaged people to failure which is a new form of bigotry. And, what about the patient's feelings especially those who are socially disadvantaged in our society? Not being as well prepared in college leads to not being able to benefit fully from a medical school education prior to entering residency training and not being held to high academic standards in medical school aggravates this trend.
TIMELESSNESS OF WHAT NEEDS TO BE TAUGHT:
Regardless of what course healthcare takes in the next forty years, there are certain timeless issues that will affect future students. In particular, we need to go back to making sure the three R's are well taught throughout the life of those applying to medical school so that, when they arrive, they are ready to absorb the enormous and growing volume of information and knowledge. These include but are not limited to:
- Being able to read effectively (understanding what they read) and critically (being able to spot falsehoods) to avoid harming patients
- Being able to speak and write effectively to avoid errors of communication and harming patients
- Having experience in mathematics including statistics to avoid applying flawed knowledge and harming patients
- Having experience in logic and, perhaps, in philosophy to apply to this whole matter to avoid harming patients
I have the honor to be, respectfully,
Mark Gusack, M.D.