MEDICAL EDUCATION IS MATURING

I have been struggling to understand the direction education has taken in medical schools and veterinary colleges.  While evaluating a new curriculum in the veterinary college I graduated from many years ago I realized that an entirely new paradigm has developed in professional education. The classic 4 year curriculum in a veterinary or medical school has been the first two years devoted to basic science and the last two years devoted to clinic study with a one-year internship or interdiction to practice. The new curriculum format, in essence, eliminates most of the basic science classes and replaces them with clinical classes—Deans of these colleges will not admit it but that is what is happening. The senior year includes a 12-week externship and multiple year residency programs replace internships. Of course, there is great variability in schools around the country.

The history of medicine and veterinary medicine includes and era where professional education was based on apprenticeships much like hands on apprenticeships to become a plumber or carpenter. The obvious fallacy of apprenticeships is that a physicians or veterinarians education is limited to what their mentor encounters in the usual practice situation. The benefit is that a student receives “hands on” learning; what they like to call practical education—doing what real doctors do. Young students do not seem to realize that the most important product of their education is what goes on in their heads and not with they do with their hands. Hands on nursing entered the picture as long-term caregivers and as physician’s assistants. The same is true of veterinary medicine; however, veterinary technicians are a more recent addition than nurses were.

As basic science knowledge, expanded, formal classroom instruction was the obvious answer. With the logarithmic expansion of basic science knowledge, residency programs developed. The format for residency training  was a repeat of the basic medical school program, meaning the resident in a specialized area studied the new basic knowledge in that special area and then went on to clinical application in that area. He or she expanded what they learned in the first four years of professional school—in other words, they knew things the general population of physicians and veterinarians did not know. Nurses took over much of the hands on application of medicine left vacant by change from apprenticeship programs—recording vital signs, bandaging, taking x-rays, etc.

The sudden 2oth century burst of basic science knowledge seemed to overwhelm the professions. There was more information than could be learned in a four-year medical or veterinary collage curriculum.  In addition, what had been specialized knowledge was becoming expected knowledge for “all” practitioners.  Chemical and physical diagnostic techniques, hundreds of genetic diseases, personalized cancer treatment regimens, hundreds of pharmacological complications to hundreds of drugs including endocrine interactions. In light of the cost of education in both time and money, all of this presented a challenge to medical educators that they had to meet; it was not optional.

The direction college administrators are followed suggests to me that they have given up teaching basic science to future practitioners. They are eliminating basic science from the medical and veterinary curriculum and replacing it with clinical science. To me this means the general medical and veterinary college educators are training the equivalent of nurses and veterinary technicians but retaining the labels of MD or DVM.  Medical knowledge in the general population has reached a point where people know what specialist to go to with out a general practitioner intermediary. Therefore, general practitioners are disappearing and medical specialists are becoming the general practitioners, in current jargon, the primary care physician or veterinarian, who know what laboratory or hospital houses the basic scientist that has the knowledge they did not learn in college—perhaps a highly trained technician or a PhD scientists.  

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