Perspectives in Biology and Medicine

BASIC SCIENCE AND THE UNDERGRADUATE MEDICAL CURRICULUM THOMAS HUDDLE* Introduction; The Present Dispute Current commentary on medical education is full of complaints about the basic sciences. These subjects are said to include too much detail taught in a dead, rote fashion. In their present form they bear little relation to the clinical work that follows them. Teachers and students alike lack enthusiasm; students wish to get on to the clinical subjects, and teachers prefer graduate students to medical students. If the present-day medical curriculum is too reductionist, overspecialized, and fragmented, the basic sciences are said to deserve much of the blame [1-8]. Contemporary critics propose various remedies; they suggest that the scope of the basic sciences be curtailed, that they be taught in an interdisciplinary fashion, and that they be taught at the college level and so eliminated from the medical curriculum in their present form. One proposed solution is to integrate them with analogous graduate school teaching. Others have favored less attention to content and more to problem solving and the experimental method, or ending the separation between basic and clinical subjects by interweaving both approaches throughout the curriculum. Defenders of the basic sciences in their present form argue that physicians use basic science in medical practice (or at least should do so) and that, anyway, physicians must know scientific principles to avoid becoming technicians. Some even advocate aggressively expanding the The author expresses gratitude to Sankey Williams, Robert Aronowitz, and Charles Rosenberg for commenting upon early versions of this paper, and to Paul Anderson for drawing his attention to the Baumgarten Family Papers at the Washington University School of Medicine library. *Division of General and Preventive Medicine. School of Medicine, University of Alabama , LIAB Station, Birmingham, Alabama 35294.© 1993 by The University of Chicago. All rights reserved. 0031-5982/93/3604-0823$01.00 550 Thomas Huddle ¦ The Medical Curriculum basic science component of the curriculum because "biological science is medicine." Students should spend more time in laboratories "where biological science is revealed in well-planned, well-executed experiments that require problem solving" [9]. Some also suggest that only a thorough understanding of basic science will enable the physician to apply the fruits of scientific advance to future medical practice [9, 10]. Further , a thoroughgoing approach to basic science is necessary to foster future medical researchers among current students. Less often voiced but also important is the conviction that basic science serves a necessary gatekeeping function. Failure rates on National Boards Part I, the NBME (National Board of Medical Examiners) test of basic science knowledge, are higher than those for the clinical Part II, suggesting to some that academic rigor is best upheld in the medical curriculum by the basic sciences. Current disagreement over basic science continues a long tradition of discomfort among physicians and medical educators with this part of the medical curriculum. The continued urgency of the dispute is suggested by the attention it presently attracts from bodies such as the Robert Wood Johnson Foundation, which has funded a Commission on the Sciences in Medicine to address the problem. Part of the frustration engendered by the controversy lies in the tendency of both sides to talk past one another, arguing from conflicting presumptions about the nature of science and medicine, of which each side seems only dimly aware. I will examine this controversy by exploring the historical roots of the present-day rationale for the basic sciences in the medical curriculum. In so doing I will try to illuminate some of the assumptions made by those on opposite sides in the present conflict by uncovering their continuity with assumptions made by those fighting similar battles in the past, I will go on to suggest that the modernjustification for the basic sciences in the medical curriculum is seriously flawed, and that some of our current difficulties stem from the role we have long believed these subjects to play in medical thinking and practice . While what I have to say may have more force for some than for others of these subjects, I wish to consider all of the present-day basic sciences in the following analysis. In conclusion I will consider why physicians study science...