Pulse: A Message from Dean Edward C. Halperin

Today's medical student must be trained for a world in which molecular biology will herald an entirely new paradigm for medical diagnosis and treatment. Based upon the molecular perspective that is evolving, we can envision a health care future in which medical care will be personalized, preemptive, predictive, and participatory. (1)

Personalized medicine will be based on understanding the individual molecular profile of the particular patient's disease. We already see this in, for example, the management of adult female breast cancer wherein a variety of tumor markers can be identified in the individual patient (estrogen and progesterone receptors, Her-2/neu, tumor differentiation, tumor size) that can help individualize therapy.

Preemptive medicine refers to the concept that the physician of the future will have the opportunity to intervene in the disease process relatively early. By understanding who is likely to get a disease and why, the physician can invoke a range of interventions including education, lifestyle changes and, one hopes, diet and medication to avoid or ameliorate disease.

In the era of predictive medicine, we will gain a better understanding of who is likely to encounter a disease process and what might be done about it.

Finally, the American public will demand that medicine become increasingly participatory. The recipients of health care will view this participation as occurring on two levels.

First, they will expect that physicians will work in teams rather than as lone actors. We can expect to see a demand for teamwork amongst physicians, nurses, physical and occupational therapists, psychologists, nutritionists and the yet-to-be-well-defined notion of health-care coaches.

Second, there will be the demand for joint participation in health care decisions between physicians and their patients. An increasingly educated public, with access to an enormous amount of information from electronic databases, will want to play an active role in decision-making about what they will and will not accept in their health care. Young physicians who wish to lead in the coming molecular biology revolution must understand that you cannot expect the social and cultural environment to adapt to you. If you wish to lead, you must adapt to it.

As we approach this new era of medicine, some medical educators have suggested that the time has come for a redefinition of premedical education requirements in the United States. (2,3,4)

Among the two most common targets are: (a) the view expressed by some that "many premed requirements -- especially calculus, organic chemistry, and physics -- are simply a waste of time and effort"; (b) the requirement for a liberal arts education at the college level including English literature.

I take strong exception to the removal of English, history, calculus, organic chemistry and physics from our requirements for premedical preparation. While some assert they cannot see what calculus, organic chemistry or physics have to do with human medicine, I can. (5)

It is easy to derive a very long list of examples of the essential nature of these subjects as a preparation for the study of medicine.

Calculus and physics are crucial to an understanding of the interaction of ionizing radiation with human tissue, cardiac contractility and blood flow, the gas laws, biomechanics and the behavior of light in the human eye. Organic chemistry is essential to an understanding of how drugs are designed, absorbed, metabolized and excreted; neural impulse transmission; and metabolism and hormone activity. Mathematical reasoning and calculus are important prerequisites to understanding statistics; and statistics, as we are all coming to understand, is essential for the modern physician who wishes to analyze clinical research and practice evidence-based medicine.

Many of today's premedical students have exceptional training, as undergraduates, in the biomedical disciplines. We increasingly see students who have completed highly sophisticated scientific research projects and have published in the peer-reviewed letter medical literature. This is entirely to be commended. I cannot, however, countenance the fact that many students also lack a rudimentary familiarity with the history of western thought and culture.

Immersion in science, as an undergraduate, is a necessary part of premedical education. It must not, however, be at the expense of a general liberal arts education. "If we aim to prepare tomorrow's physicians to appreciate the challenges and privileges of practicing medicine (sacrificing the liberal arts) is a fool's bargain." (6)

A clear understanding of written and spoken English, and the ability to express oneself, underpins our ability to communicate with patients, communicate with other health-care providers and express ourselves in the medical chart and scientific literature.

There is simply no substitute for reading and discussing the greatest minds in the history of our civilization: in philosophy, Plato and Aristotle; in history, Thucydides and Gibbon; in literature, Cervantes and Shakespeare reading the great books offers an opportunity to understand what makes us human, including vital features that cannot be titrated in a beaker or imaged with x-rays. (6)

A similar point of view was expressed by Lewis Thomas, author, former dean of the medical schools of New York University and Yale, and president of Memorial Sloan-Kettering Cancer Center. Thomas argued that the premedical curriculum should include a sound footing in the liberal arts.

We could look forward to a generation of doctors who have learned as much as anyone can learn, in our colleges and universities, about how human beings have always lived their lives. Over the bedrock of knowledge about our civilization, the medical schools could then
construct as solid a structure of medical sciences as can be built, but the bedrock would always be there, holding everything else upright. (7)

A firm grounding is physics, organic chemistry, English and calculus have historically been, and will remain, crucial for science-based clinical medicine. We should not "redefine" premedical education into less-than-adequate preparation.

I have no intention of serving as dean of the University of Louisville School of Medicine to preside over the dilution of scientific-based medicine by a cheapening of our requirements for premedical preparation.

Edward C. Halperin, M.D., M.A.
Dean, School of Medicine

Citations:

1.) van Eschenback AC. Progress with a purpose: eliminating suffering and death due to a cancer. Oncology 2006; 20:1691-1696.

2.) Emanual EJ. How to redefine a medical education. Chronicle on Higher Education 10/12/06; B12-13.

3.) Emanual EJ. Changing premed requirements and the medical curriculum. JAMA 2006; 296:1128-1151.

4.) Ganguil I. Medical school on demand. Lancet Oncology 2006; 7: 900-901.

5.) Halperin EC. A continued need for premed courses. Chronicle on Higher Education; 12/8/06, p.B18.

6.) Gunderman RB, Lanzieri C. Opinion: the need for the liberal arts. Journal of the American College of Radiology 2006; 3: 904-906.

7.) Thomas L. The medusa and the snail. NY: Viking Press, 1979; 137-141.