Terra Sigillata

I was originally going to let this one lie since I was so late to the game: Jacob Goldstein at WSJ’s Health Blog picked up on a recent NEJM perspective paper by Harvard Medical School Dean for Medical Education, Jules L Dienstag, MD, describing the need and justification for re-examining the pre-med curriculum. In the article, Dienstag notes that the current requirement of 1 year of biology, 2 years of chemistry (including organic chemistry), 1 year of physics and, in some cases, 1 year of mathematics, might be out of touch with today’s required focus on human biology.

Dienstag notes:

Unfortunately, current college courses that fulfill admissions requirements are not adequately focused on human biology; the topics covered in many courses in chemistry, physics, mathematics, and even biology are so removed from human biologic principles that they offer little value to the premedical — or advanced human biology — student and steal time and attention from more relevant science preparation. Does a student, for example, really need a full year of organic chemistry to prepare for the study of biochemistry? Moreover, premedical science courses often fail to achieve sufficient rigor to prepare students for tackling the sciences fundamental to medicine at the advanced molecular level now required. We should expect a higher standard from students who wish to pursue medicine in an era in which genomics and informatics will revolutionize biomedical science and health care.

I note his paper and this general query here for our audience here since the comment thread at the WSJ Health Blog post is still going strong six days later.

PharmGirl, MD, turned me on to this post which then led to quite a lively discussion between us Friday evening. She scored at C and C+ in her two respective semesters of organic chemistry at an exceptionally highly regarded undergraduate institution. Those grades kept her from being accepted into the medical school associated with that institution. She had to “settle” for acceptance into a lower top 10 US medical school, where she then excelled and claims to have never used an iota of organic chemistry.

I claim, in turn, that many aspects of organic chemistry are used often by physicians without them recognizing it. The fact that opioid analgesics often cause nausea in patients is derived from the fact that many are structurally-comprised of dopamine, a neurotransmitter known to stimulate vomiting in the chemoreceptor trigger zone. Doxorubicin (and mitoxantrone to a lesser extent) are both cardiotoxic anticancer drugs because their quinone moiety can redox cycle together with iron in the heart, producing irreversible and cumulative cardiac damage.

PharmGirl concedes these points but notes that one needn’t have had organic chemistry to recognize the basis of these concepts, much less apply them in the daily practice of medical oncology. (I am not an MD nor do I teach organic chemistry so I don’t really have a dog in this fight, although I do direct research on small organic molecule therapeutics.).

The question one must ask is how much of the pre-reqs can be jettisoned before one is no longer prepared for medical school.

An old professor bud of mine compared professional education to building a retaining wall. One first digs a trench and put several layers of pilings in the whole which are then covered up. No one sees them, but they are the foundation upon which the rest of the wall stands. How easy is it then to decide what pilings are needed for success in today’s physicians?

The arguments for and against organic chemistry as a med school prerequisite also include the proposition that o-chem weeds out medical school applicants. Isn’t there a better way for weeding out students that is more relevant?

Dean Dienstag notes:

Responding to the same concerns about premedical science education, the Association of American Medical Colleges and the Howard Hughes Medical Institute have undertaken a joint, comprehensive assessment of the continuum of premedical and medical science education. Themes likely to be included in their recommendations are the importance of introducing synergy and efficiency through cross-disciplinary and biologically relevant teaching; of educating “inquisitive” physicians, who understand not only medical knowledge but also how it is acquired; and of establishing a habit of scientific thought on which to build the practice of medicine. The recommendations are likely to favor scientific competencies over specific discrete courses, implying that premedical requirements for rigid, 1-to-2-year, discipline-specific science courses should give way to more creative and innovative courses that span and unite disciplines, offering a glimpse of the way biologists and physicians actually navigate real-life problems.

Creating such new, cross-disciplinary science courses may well be difficult for colleges, which vary in the availability of resources, depth of faculty, and political will of traditional departments to address these curricular demands.

Dienstag also provides a 12-page PDF to accompany the article which details the review of the curriculum and recommendations of Harvard Medical School for Harvard’s undergraduate curriculum.

I believe one reason for the lengthy discussion and interest in this topic at the WSJ Health Blog is that so many physicians today are coming from much more diverse backgrounds than in the past. As tools are needed in medicine today (like business, economics, communications, and the well-rounded persona afforded by liberal arts training), students arrive in medical school with varying degrees of science preparedness. Very much like the academic research enterprise, academia is under pressure to show direct impact and accountability of coursework. The days of a comprehensive science education are gone; the question is whether this course will help you get a better job or get into a better medical or graduate school. Academic research must increasingly justify its relationship to improving human health and the timeline on which the investigators expect this to occur.

I’m not sure this is the correct way to proceed. Just as many medical advances have come from observations of serendipity by highly-prepared minds, the best physicians I have know possess an incredible breadth of knowledge that includes seemingly esoteric basic science. No, they might not know how to run a Grignard reaction but they can tell you why digoxin and digitoxin have vastly different half-lives (and why one is rarely used today).

I do agree with Dienstag on the general issue that preparative training for medicine must be revised and updated to reflect the advances in genetics, cell biology, and physiology that permeate today’s patient care. A more focused and medically-relevant treatment of organic chemistry might be a good compromise – I find that many students entering pharmacy and medical school don’t really know why they were required to take organic chemistry because it was rarely presented in the context that was relevant to medicine or other aspects of everyday life. But when one uses organic chemistry to illustrate why some drugs have longer or shorter half-lives, why some produce reactive metabolites, or why racemic mixtures might be just as useful (or not) as pure (and much more expensive) enantiomers, one has the opportunity to impress upon students the relevance of the discipline.

But no, there doesn’t have to be a cause-and-effect rationale for everything one learns in the pre-med curriculum. Remember that perhaps only 10-15% of individuals pursuing a pre-med focused curriculum actually make it to medical school. Such a curriculum should provide a strong foundation in the sciences that prepares the student for the greatest number of options.

But it sure wouldn’t hurt if professors took a little more time to emphasize the potential practical utility of the subject matter while contributing to that solid foundation.

Comments

  1. #1 acmegirl
    July 22, 2008

    You know, I never forgot how my second semester organic chemistry professor started his first lecture – he wrote in block capitals the letters SDVP on the blackboard and said “This is what organic chemistry is all about.” Then he talked for a while about each letter. S = sex (hormone structures) D = drugs (obvious, but he fleshed it out with examples) V = violence (description of how to make soap and TNT from a cow carcass – pre-Fight Club) and P = a few practical applications (I forgot what he used as an example for that). That semester I worked my butt off for a B, and I certainly don’t call myself any kind of chemist today, but I can’t believe that anyone thinks that the average student who did not take a rigorous class in this topic would just soak up the knowledge from somewhere in the ether. Which reminds me, I’ll also never forget why you have to flame your glassware BEFORE you start measuring reagents for the Grignard…

  2. #2 riptide
    July 22, 2008

    *cough* As tools are needed in medicine today (like business, economics, communications, and the well-rounded persona afforded by liberal arts training)

    I grant you that in the world today a physician could benefit from business training – but
    a) what the frak use is a “well-rounded persona”? and
    b) even granting that it might be of use, what evidence is there that liberal arts training provides a well-rounded persona?

    I don’t know about you, but I would definitely prefer my doctor to be a narrowly-focused autistic who communicates poorly to the communicative French literature major who only took a couple of science classes. Fortunately, med-school admissions committees are biased towards my view of things.

  3. #3 PhysioProf
    July 22, 2008

    I would like to see pre-med students forced to take physical chemistry, rather than orgo. Orgo is basically just fancy logic/spatial puzzle-solving, while physical chemistry provides an emphasis on quantitative reasoning. Many of our first-year medical students–at one of the most selective private medical schools in the country–need remedial instruction on basic shit like “the concentration of Na+ in a solution is .15M, and you have 12.5 liters of solution, how many grams of NaCl does that represent?”

    MORE QUANTITATIVE REASONING!!!!!!!!

  4. I would like to see pre-med students forced to take physical chemistry, rather than orgo.

    I take it that you would like to slim down the ranks of med school applicants considerably, then? :)

    (Not saying I disagree with you, just that most students I know who have had both consider pchem a *lot* harder than organic.)

  5. #5 Rhea Miller
    July 22, 2008

    I think orgo provided me a TON in terms of learning how things interact and work. i learn complex ideas much better after i have an understanding of the basic reactions. Without organic i cant imagine learning as much from Biochem. Chemistry takes a long time to learn and absorb…so whats wrong with having more of it?? esp if your doc can then visualize how drugs work and interact together with the physiology of a complex human being…thus possibly foreseeing potential down falls to your regimen?? Besides, i watched a bunch of pre-doc’s drop out after orgo…when it comes to my health i dont really mind the weeding out factor :P

  6. #6 Joe
    July 23, 2008

    “Science” is both a method for studying nature, and the information gained from those studies. Unfortunately, the expectation for chemistry graduates is that they will have a large store of that knowledge, which leaves little time for teaching how that knowledge was acquired. Unfortunately, most (intro and organic) chemistry courses must be pitched to the needs of chem. majors, even though they are in the minority.

    I agree that the normal organic chemistry course is not good for life science majors (including pre-med). It might seem easy to carve out courses for them; but the schools simply see that as an expense.

    To make matters worse, we set a model of presenting naked information that looks the same in organic chemistry class as it does in quack courses in med school. That is how one gets Orac’s quackademic medicine aggregator.

  7. #7 Joe
    July 23, 2008

    And don’t get me started on the undergrad laboratory courses. The standard exercises are odious.

  8. #8 Melissa
    July 23, 2008

    I think orgo provided me a TON in terms of learning how things interact and work.

    Yeah, well the quant classes I took as an econ-math undergrad like econometrics did too. The problem was that later when I decided I wanted to go to med school, I had to take orgo, which was not necessarily impossible for me material-wise, but it was a huge hurdle in terms of the time it took up. The labs alone were five hours long and involved dangerous chemicals. The people in my class were a mix of pre-med and actual chem majors. Did I need some orgo? Yes. Did I need that level of orgo with the impossible amount of work and long labs? No no no.

    There should be classes tailored for pre-meds, as well as the option to substitute other quant classes.

  9. #9 Joe
    July 23, 2008

    @melissa,

    Tell me what I say

    Tell me what I say right now …

    I can rebuild the the courses, I can make them better. But, without the bucks- no Buck Rogers. That was my offering- schools don’t do what you want, what I want, because it costs more than the status quo.

    I do take exception to the “dangerous chemicals” part. A person can OD on water. I became a chemist back when we did not take many precautions about exposure, and nothing has happened to me (except, I used to be tall and handsome); cyanide really does smell like almonds. (Okay- that rattled me the first time. I did not know what dose I inhaled.)

    And, I asked you not to get me started on undergrad lab courses. They are screwed-up even for chemistry majors.

  10. #10 Mick
    July 24, 2008

    I’m an undergrad at the University of California and I think my organic chemistry courses were the hardest classes I’ve ever taken. I definitely think there should be less organic chemistry and more of a focus on other subjects especially for physicians.

  11. #11 dmb
    August 8, 2008

    relevance?

    hmm… its hard to see the black and white, point a to point b reasoning. but thats the kind of abstract logic that orgo teaches people. its creativity, not being afraid to fail, taking chances and proposing an idea. its arguing with your professor about why not. its seeing tiny details that dictate big picture movement. sure you can get similar things in other classes. but the orgo experience is a special one. it separates the big kids and the little kids.

    its a way of thinking and its valuable for its synthesis of creativity and hard factual knowledge. its something very few people actually just know so you can’t rely on your experience to help you as it might in a history or even bio class. its the experience of taking something totally new and being creative with it.

    its pretty damn amazing.

  12. #12 Joe
    August 12, 2008

    @dmb,

    It seems that you are as fascinated by organic chemistry as I am.

    My point has been that I can tailor fascinating courses for biologists and pre-meds, if I don’t have to address the needs of chemistry majors.

  13. #13 Joe
    August 12, 2008

    “My point has been that I can tailor fascinating courses for biologists and pre-meds,”

    At least, I imagine I can.

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    August 28, 2008

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  15. #15 John
    February 27, 2010

    @dmb-
    I agree totally with you and suggest you go a step further. Organic is one of the only classes left on an undergraduate campus that requires critical thinking skills. It requires you to not only learn the material, but learn how to process the material, analyze a situation and decide which factors are MORE important, etc. It starts from the very beginning with nomenclature. You are not provided a sample of molecules and asked to memorize the names, you are presented the rules, and asked to learn the rules and learn how to apply them in different senarios. Is that not exactly what we expect out of our physicans? Does anyone really want a doctor that simply tells you to take tylenol when you have a fever? Organic is purposely set up in a fashion to show how each and every detail is important and must be considered, not is a linear fashion of “if a than b, but if c then d” but rather in a fashion where the student has to recognize that they have a, b, c, and d; decide which is more important in this case, and predict the results. Sn1, Sn2, E1, and E2 mechanism determinations are the perfect example!!

  16. #16 organic chemistry
    May 3, 2010

    maybe i am being a little ignorant about this, but i would think that it is still very relevant as long as it has the chance of being a large part of one’s MCAT