Disease and the evolution of Medicine

On this count, medical schools have far exceeded Flexner’s hopes. In fact, one wonders what Flexner would say if he could see today’s medical curricula. Now medical students are not only exposed to basic sciences, they are inundated with the latest advances by teachers who are subspecialist basic science researchers. At curriculum meetings in every medical school there are battles for students’ time and minds. The microbiologists want more lab time, the anatomists want more too. The pathologists feel they cannot possibly fit their material into a mere forty hours of lecture. The pharmacologists say they will continue flunking 30 percent of the class until they get enough time to cover all the new drugs. The epidemiologists and biochemists and physiologists and psychiatrists and neuroscience experts all want more time, and certainly the students must keep up with the latest advances in genetics. Then they need to learn enough statistics and scientific methodology to be able to read the research literature. And they must somehow learn, before they start their work on the wards, how to talk with patients, how to do a physical exam, how to write up a patient report, how to draw blood, do a culture, a spinal tap, a Pap smear, measure eyeball pressure, examine urine and blood, and, and,… The amounts of knowledge and the lists of tasks are overwhelming, but all must be completed in the first two years of medical school.

How is all this possible? It isn’t. Why set impossible expectations? In part because we naively want our physicians to know everything. Another reason, however, is that no one person is in charge. When a committee decides on the class schedule and every basic science wants more time, the solution is to go on increasing the total amount of class time. Thirty or more hours each week in class is not unusual. After that, the students go home to study their textbooks and notes.

One might think that students’ complaints would lead to reform, but decades of polite complaints changed little. It was technology that finally precipitated some change, technology in the form of the photocopy machine. Instead of going to class, students hire one person to take notes for each lecture, then all of them receive copies. It turns out to be a better survival strategy to stay home and study the notes than to go to class. When only twenty students attend a class for two hundred, professors hit the roof and curriculum reform is born. New attempts are being made, under the strong leadership of some deans, to cut back on the hours, reduce the amount of material, find new ways to transmit it. If these efforts succeed, it will be wonderful indeed.

Such efforts might even make room for Darwinian medicine, except that there are no Departments of Evolutionary Medicine to advocate inclusion of this material and few medical faculty members who know the material and want to teach it. It will take time and further leadership from medical school deans to make room in the medical curriculum for an introduction to the basic science of evolution and its applications in medicine. When evolution is included, it will give students not only a new perspective on disease but also an integrating framework on which to hang a million otherwise arbitrary facts. Darwinian medicine could bring intellectual coherence to the chaotic enterprise of medical education.