The learning environment and the clinician scientist

Clin Invest Med 1997;20(4):248.

The physiologic discoveries of the early and mid-20th century, the biochemistry that blossomed in the post-World War II years, and the molecular biology that has exploded since 1953, have provided great insights into the workings of the human body. I will make an unproved assertion that, while useful knowledge about the biology of man grows at an unprecedented speed, physicians in general share less and less of this knowledge. While the assertion may not be proved, it is not without support. Less basic science is taught in the undergraduate years than previously, the gap between what is in the standard texts and what is in the journals grows ever wider, and the growth of what has perhaps been misnamed "evidence-based medicine" has suggested that less reliance should be placed on an understanding of pathophysiologic mechanisms when physicians make clinical judgements. Negligible understanding of basic medical sciences is required for final MD examinations, and I would surmise that, where basic scientific understanding is concerned, clinical specialty examinations are both limited and narrowly focused. The Medical Council of Canada licentiate examination requires no basic science, except for a limited number of content items closely related to clinical practice.

Does this matter? Where insight is available into the workings of the human body, biological or behavioural, most patients would feel comforted to know that their physicians shared these insights. While many physicians might score a passing mark in anatomy, and the physiology and pathology of a decade back, I suspect the failure rate would be high in biochemistry and molecular biology (including immunology), where advances have been most dramatic. Drugs, almost without exception, act at a molecular level, and it is hard to understand how physicians can critically appraise the drugs they use without insight into their mechanisms of action.

Possible reasons for this state of affairs are complex. First, there has been an explosion in information. Yet the teaching of basic science has failed to make the transition from teaching facts to teaching skills and the concepts that there should be skill in using. Second, the separation between "basic" and "clinical" studies has permitted the basic sciences, as they are being taught, to remain distant from clinical decision-making. (The growth of integrated teaching programs and problem-based learning, were intended, inter alia, to counteract this, but appear to have had limited success.) And third, the clinical faculty who have most contact with both undergraduate students and residents have been steadily retreating from any active involvement in laboratory science.

It is this last point that is relevant to the present topic -- the training of the clinician scientist. Older academics will remember when a research program was virtually de rigueur for a professorial appointment at a school of medicine. It was common for such research to involve operation of a "basic science" laboratory. Similarly, academics 1 or 2 decades younger will remember being influenced by these individuals, who were enthusiastic about the scientific underpinnings of medicine, and whose questions at case conferences, or around the bedside, were as likely to deal with enzymes as with clinical trials.

If we lose clinician scientists, we lose a vital cadre of academics -- those teachers who are themselves students of science, and who inculcate curiosity and enthusiasm for human biology to learners at every level. This implies a shift in the culture of schools of medicine, a shift that has implications far beyond the quantity or type of research pursued.