Reader response

Re: “Curricular revision: embracing the journey,” August issue

In a recent excellent ASBMB Today article, Neil Osheroff described how he and others at Vanderbilt University revised the medical school curriculum there, and he highlighted some of the perceived advantages of doing so (1). As Osheroff correctly pointed out, everyone nationwide involved in medical education has felt the push to revise curricula, and that push certainly has stirred a lot of debate. While the changes Osheroff described seem exciting, the educational impacts of such changes are difficult to determine.

Evaluating the success of a curricular overhaul requires close inspection of the details of the curriculum itself and, most importantly, of the outcomes it produces. While it’s not possible to assess the latter for quite some time, evaluating the details of curricula may be enlightening. I can’t speak for all topics in medical school curricula, but I’ve certainly seen changes in what has been taught as biochemistry or metabolism.

When the issue of medical school curricular revision first surfaced, some educators expressed concern that we would be dumbing down the biochemistry. And that appears to be happening. Metabolism once was taught in a 16-week course at my institution. It is now taught in about six days. Sixteen weeks can’t be condensed into six days without losing a lot of content.

Not surprisingly, the curricular-revision discussion has focused on two content issues:

  • What do budding physicians need to know?
  • At what depth do they need to know it?

Some people say that biochemistry, particularly biochemistry beyond carbohydrate metabolism, doesn’t need to be covered in much depth. I’ve even heard it said that an undergraduate course in biochemistry would take care of what is missing from the new medical school curricula. This seems a bit misguided. Undergraduate courses lay a foundation that medical school builds upon; or at least that’s how it used to be.

Some people say that what is eliminated from the first year of medical school will be recovered during clinical years. (This notion often takes exotic names, such as “longitudinal strands.”) But returning to fundamental concepts of metabolism in the clinical years often is more difficult than anticipated, largely because students at that point are focused on patient care.

At some schools, topics like the metabolism of porphyrins, lipoproteins, nucleic acids and amino acids are all but eliminated but related to discussions during the clinical years. If these topics are addressed, they usually are covered in the context of phorphyrias, atherosclerosis and inborn errors of metabolism. No one would diminish the importance of such discussions, but the underlying biochemistry usually is absent. Of course, such concerns usually are countered with the claim that the students don’t need to know a lot of fundamental concepts of metabolism: We are covering what we now know to be important!

If the core mission of the institution is to train students to diagnose and treat people, then there is some validity to the argument that we may have been teaching more than needed. Indeed, this is largely how we train physician assistants, and they diagnose and treat people with great expertise.

However, if the core mission of the institution is to train physicians with a keen ability to recognize new assaults on our health and what could be done about them — that is to say, to not just practice standards of care but establish standards of care — then doing so may require a more in-depth academic training.

This reminds me of an anecdote a friend of mine told me about his years as an M.D./Ph.D. student at Stanford University in the late 1970s. The students didn’t understand why they were learning about retroviruses when there was no known human disease caused by a retrovirus. Then, in 1981, HIV showed up.

Author’s note: Many thanks to Charle s Brenner and Richard Eckhert for their input for this response.