Monday, 12 February 2018

Medical schools: reductionism versus empiricism

The current competitive drive has reached the medical schools to the extent that it now delivers batches of new doctors with higher scientific preparedness whose priorities are influenced by their impact, competitiveness for research funds and, to a lesser extent, clinical practice. Young doctors know that in order to fight for the most coveted positions they will have to show a curriculum full of publications, while the clinical skills, although present, will not be the element that differentiates them. What is apparent is that educational reforms are part of the mechanism which is focused on academic success.

These new generations of doctors will go to work in specialized units where, surprisingly, more than half of the clinical decisions and treatments they will use are not supported by consistent studies. However, most new doctors will embrace the reductionist culture of their specialty and will be unable to open their eyes to the empirical reality of clinical effectiveness. This is how come so many cardiologists do not believe in clinical trials that don’t show a relationship between plasma cholesterol levels and mortality due to heart attack, or so many oncologists are incredulous at the rather poor results of secondary prevention programs of many cancers, or certain radiologists simply refuse to accept that vertebroplasties are not the solution to most spinal problems, or some orthopaedics, despite the evidence from clinical trials (sham surgery), continue to perform arthroscopies on people with arthritic knees.

The bases of Flexnerian training

A little more than a hundred years ago, Abraham Flexner laid the foundations for physicians’ training.  These were times when science demanded progress and it was imperative that doctors and surgeons lost their image of sorcerers and barbers. For this reason, Flexner proposed that the medical schools begin training plans with basic sciences, continue with the knowledge of the human body- first healthy and then sick - and end with the clinical rotations, as a final touch of reality. General practitioners, within this still valid model, therefore learn that basic sciences are the foundations, while clinics move in environments that are difficult to control and difficult to evaluate. Experimentation is a matter that is treated as a necessary element, but not an essential one.

The disruptive proposal of Vinay Prasad and Adam Cifu

According to the authors of "Ending Medical Reversal," in order to train doctors to be critical of today's practices and have sufficient social and communication skills to focus on the patient, the priorities of medical studies must be reversed: the pillars no longer have to be the basic sciences but the clinical ones. Experimentation should become the essential element on which all knowledge should be supported, while basic science should be necessary only to understand everything. With this model, students would prioritize empirical facts ahead of reductionist scientific theories.

According to Prasad and Cifu, the fundamental subjects of the first courses should be: clinical reasoning, shared decisions, search and critical assessment of the scientific literature, scientific methodology (clinical trials), concepts of biostatistics and learning to make decisions in uncertain environments. The students would develop these subjects from real cases that their clinical professors would present to them, first from patients with frequent and generalist cases, and gradually begin to work with more complex and specialized cases. It would be a good idea to give these first few courses a slow rhythm so that the tutors could go on fomenting the students’ critical spirit.

The sciences that today are considered basic (anatomy, biochemistry, physiology, etc.) would be studied at the end of the training, and always linked to the discussion of clinical cases. In the last courses, students should work in specific seminars with the evidence supporting each clinical decision and, in this environment they should study aspects of physiology, physiopathology, cell biology, pharmacology or other basic subjects, from the perspective of the contribution of these matters to the understanding of clinical cases. Specific seminars such as intensive anatomy for surgeons, advanced clinical reasoning for internists, translational research training for students with a predisposition to research, etc. could also be deployed.

The vision of reforming the training programs of the faculties of medicine proposed by Prasad and Cifu is to train doctors that are more demanding for scientific rigor, more critical of practices of low value, more sensitive to the needs of patients and more oriented to the evaluation of results and, to make it possible, the formula proposed is very simple: clinical sciences should be the priority while the basic ones (as we understand them today) should be complementary. It’s not about studying models and then checking them (current system), but about doing it the other way around: theories should be reviewed (or accepted) from the point of view of studying the clinic.

Jordi Varela

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