With so many medical schools experimenting with their curricula, either by adding small group study alternatives to lecture sections, or bringing patient contact into the first two years, that it’s worth noting the “traditional” curriculum isn’t a curriculum at all. Until approximately a century ago the “traditional” medical curriculum was an apprenticeship.
The curriculum today’s physicians (and most students) are familiar with was instituted following the 1910 publication of Abraham Flexner’s “Medical Education in the United States and Canada,” generally known as the Flexner Report, which excoriated all but a few medical schools for poor teaching techniques, loose admission standards, and overenthusiastic issuance of diplomas. The immediate effects of the report were the closure of the majority of medical schools in the country, and the adoption, uniformly by survivors, of a two-year science curriculum through which students had to struggle before beginning their “clerkship”- the two years of hands-on learning that most closely resembled the traditional apprenticeship of the distant past.
The Flexner Report arrived at a precipitous time, as the sciences of biology and chemistry were themselves undergoing revolutionary changes. The term “amino acid” was twelve years old, and the man who would later go on to win a Nobel for demonstrating that enzymes were made up of amino acids had only just been awarded his Bachelor’s that year. Since then, the revolutions of molecular biology, biochemistry, and genetics have permanently altered medicine and changed even the very cultural idea of disease. Medical schools have struggled to keep up with the constant infusion of rigorously scientific concepts and language into what was once essentially an oral tradition.
But is medicine, at long last, a science? Arguably no. Kathryn Montgomery, in her book How Doctors Think (not to be confused with Jerome Groopman’s very different book by the same title) describes medicine as a science-using practice: “the rational, clinically experienced, and scientifically informed care of sick people.” Like engineering or spaceflight, medicine depends on scientific understanding by its practitioners, but these are not, or are only incidentally, scientists.
Understanding this distinction is key to why I believe the presence of clinical practitioners- or at any rate scientists with clinical experience- is indispensable, even in the two year “basic science” curriculum. Scientists, after all, are tasked with generating new knowledge, through a social practice of experiment and argument. Physicians are charged with applying knowledge appropriately and consistently- and with great efficiency- in case after case, instance after instance. A scientist can explore a disease exhaustively, following up on ever imaginable question or implication to see where it leads; a physician must pick and choose a few questions to answer- what is this person’s A1C? do they have clue cells? what is the QRS morphology in the inferior leads?- and arrive at a literally life-or-death decision quickly.
This ability to discriminate useful information from the momentarily superfluous is called heuristics, and its why computers can’t play Go, and until recently couldn’t play Chess worth a darn. There are simply so many possible moves, and so many possible responses, that the program that can’t distinguish the likely or the relevant gets bunged up in a proliferating tangle of outcomes and can’t quickly anticipate what to do next. Humans, on the other hand, can narrow their options. When asked how many moves ahead he explored the game, grandmaster Richard Reti famously replied “I only see one move ahead. The right one.”
Heuristic skill is, ultimately what distinguishes good clinicians from mediocre, often passing under the guise of “medical intuition” or “gut.” The doctor who worries about an odd heart tone, or who can temporarily ignore persistent vomiting to follow up on a subtle pattern in a patient’s attacks of weakness, may be regarded as a sort of zen master, but in fact all they have mastered is the technique of extracting signal from noise. Far from being a natural intuition, this is a skill that can, and must, be learned, preferably under the tutelage of a predecessor who has themselves developed the ability to a high degree through direct clinical practice. There are automatic responses and algorithms in medicine, but these medical students do not have to learn- they must merely be memorized. I expect that during the panic of my clerkship years we will be doing a lot of memorizing, but right now I intend to take advantage of the relative calm to develop my heuristic- that is, clinical- skill.
Best,
A
PS- Heuristics apply to education as well as practice, evidenced by the numerous series of studybooks offering to make complex topics like immunology “ridiculously simple” or promising only “high yield” information. Left to our own devices, our primary heuristic discrimination would probably be “will this be on the boards?” While this is forgivable, it is also less than ideal; the heuristic of the practicing physician is always “will this make a difference for this patient?” I look to instructors with clinical experience to reinforce this, and worry what would happen were there no-one there.
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