Medical Schools: reductionism versus empiricism

Competitive eagerness has reached the medical faculties and now produce batches of new doctors with a higher scientific preparation, priorities arranged by factor of impact, a competitiveness for research funds and, to a lesser extent, clinical practice. Young doctors know that in order to fight for the most coveted places they must show a resume full of publications, while the clinical skills, although present, will not be the differential element. What is observed, then, is that the educational reforms driven by academic success.

These new generations of doctors will go to work in specialized units where, surprisingly even today, more than half of the clinical decisions and treatments 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. And this is why many cardiologists don’t believe in clinical trials that don’t find a relationship between plasma cholesterol levels and mortality from stroke, or many oncologists who are disbelieve the poor results of many secondary prevention programs cancers, or certain radiologists who have not yet accepted that vertebroplasties are not the solution to most spinal problems, or some orthopaedics that, despite the evidence of clinical trials (sham surgery), continue to perform arthroscopies at people with arthritic knees.

The foundations of Flexnerian formation

More than a hundred years ago, Abraham Flexner laid the foundations of the training of doctors. These were times when science asked for progress and it was imperative that doctors and surgeons should leave behind the image of witches and barbers. For this reason, Flexner proposed that medical schools begin the training plans for the basic sciences, to continue the knowledge of the human body, first healthy and then sick, and to end with clinical rotations, as a final touch of reality. Doctors, therefore, in this model still in force learn that the basic sciences are the fundamentals, while the clinics move in environments that are not controllable and difficult to evaluate. Experimentation is an element that is treated as a necessity but not a requisite. 

Vinay Prasad and Adam Cifu’s unconventional proposal 

According to the authors of Ending Medical Reversal, in order to get doctors critical of today's practices and with sufficient communicative and social skills to focus on the patient, the priorities of medical studies must be reversed: pillars no longer have to be the basic sciences but the clinics. Experimentation should become the indispensable element on which all knowledge should be endured, whereas the basic sciences should be necessary only to finish understanding 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 evaluation of scientific literature, scientific trials, concepts of biostatistics and learning to make decisions in environments of uncertainty. Students would develop these subjects from real cases that would be presented by their clinical professors, first with patients with frequent cases and generalists, to increasingly work with more complex and specialized cases. It would be advisable to give a slow rhythm to these first courses so that the tutors could develop the critical spirit of the students.

The sciences that are now considered basic (anatomy, biochemistry, physiology, etc.) would enter at the end of the race, always linked to the discussion of clinical cases. In the last courses, students should work in specific seminars the evidence that supports each clinical decision and, in this environment, 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 Prasad and Cifu's reform of medical training programs is to train more demanding doctors with scientific rigor, more critical practices of low value, more responsive to patient needs and more oriented to the evaluation of the results and, to make this possible, the proposed formula is very simple: the clinical sciences should be the priority while the basic ones (as we understand them today) should be complementary. It’s not a question of studying models to check them (current system), but of doing the opposite: from the learning of the clinic should review (or accept) theories.

Jordi Varela

Editor