Learning about science is still important

Art is meant to disturb, science reassures. Georges Braque, 1952 Since ancient times, medical students have been expected to learn the basic sciences – anatomy, physiology and pharmacology, for example – as part of their preparation for practising as accredited clinicians. Over time, and as knowledge of the basic sciences grew, biochemistry, bacteriology, epidemiology and others were added to the rapidly increasing list of required subjects. Spending hours assimilating lists of facts out of enormous textbooks still figures large in the public imagination as one of the principal activities for which medical students are renowned. Before Flexner wrote his famous report1 in 1910, the teaching and learning of the basic sciences was a hit-and-miss affair, for which curricula were devised according to the timetables, interests and preoccupations of whoever was willing and available to instruct the students. The wholly desirable result of the reforms that took place in medical schools across the world after the publication of the Flexner report was that medical schools became increasingly affiliated with universities. The education of medical students became the concern not just of busy practitioners, but also of laboratory teachers working in the basic sciences. The effect was to codify the curriculum into 2 parts, with the preclinical (usually the first 2 years) followed by the clinical (usually a further 2- or 3-year period). Academic scientists and researchers took responsibility for the preclinical years and clinicians guided students through the realities of clinical practice. This approach was successful for many years, and there is no doubt that its introduction led to improvements in standards. However, in recent years, medical educators have begun to question the manner in which the curriculum has been divided into these 2 parts and are looking for ways in which science learning can progress in parallel with clinical learning, rather than preceding it in what is sometimes a remote and disinterested fashion. We know that making the transition from preclinical to clinical studies is often difficult for students,2 but we can alleviate this by striking effective partnerships between the basic sciences and clinical practice to ensure a learning environment that is a coherent and relevant whole. Although this will not be an easy process, it is an important one, because learning about science is still a crucial part of the medical curriculum. And as Rudland and Rennie3 report in this issue, clinicians and research scientists do not always see eye to eye about the relevance to clinical practice of some of what is taught in the preclinical years, and medical students are caught in the resulting crossfire. However, before we can begin to tackle the issue of what science medical students ought to learn, we need to remind ourselves of the purpose of learning basic science. As I see it, this is fourfold. Application Students need to be able to apply their basic sciences knowledge in order to identify and understand the phenomena underlying clinical problems. In addition, they need to be able to make specific application of contemporary science knowledge to particular problems. This is quite a challenge and involves not only knowledge of key concepts and facts in a wide range of the natural and human sciences, but also an awareness of up-to-date ideas and innovations. The days of teaching science as a dry set of facts are long gone. Although teaching methods such as lecturing, seminars, lab sessions and dissection persevere, they do serve a purpose when used selectively and appropriately within an active and integrated curriculum of learning. Integration Patients and their problems do not fall neatly into physical, psychological or social categories and many, of course, have complex problems incorporating more or less of each category. In dealing with a patient, effective clinicians have to consider not just the underlying physical science but must also integrate their knowledge of the human and population sciences in order to understand a patient's beliefs, ideas and concerns about his or her problems, and to understand the patient as an individual within a broader society. Interpretation All clinicians deal with patients, and one of the things that patients require is an explanation of their problems and the bewildering, strange and unique world they enter as they embark on a course of clinical treatment. It is part of the clinician's job, as an inhabitant of this strange land, to assist and guide patients as they discover more about the unfamiliar landscape, language and customs of clinical care. This is particularly true at a time when patients are less inclined than ever to accept whatever service is provided without comment, while at the same time they are overwhelmed by large amounts of incomplete and unfocussed information gained from a wide variety of sources, including television and the Internet. Clinicians can no longer rely on their undergraduate experiences to carry them through a lifetime of caring for patients; they need to have the skills to interpret these data for themselves so that they are able do it for the benefit of others. It isn't only the family doctor to whom Heath's challenge applies: ‘The meanings of illness, the threat, the fear, the suffering and the endurance can only be interpreted, ordered and contained if both doctors and patients can find and agree on the right words.’4 (p 37) Imagination As Marcus Aurelius4 wrote, ‘Nothing is so productive of elevation of mind as to be able to examine methodically and truly every object which is presented to thee in life, and always to look at things so as to see at the same time what kind of universe this is.’ Scientific study is a foundation and bedrock for life – it isn't just the introduction to clinical learning that many preclinical courses make it. Not all medical students will progress to medical and scientific research, but some will go on to explore, to add to our existing knowledge and to create new understanding. Whenever possible, the teaching of science should be stimulating and provoke curiosity amongst students. At its best, science teaching should imbue students with a sense of wonder at new ideas; good science teaching should always challenge and inspire them. Medical students need to learn the basic sciences, now more than ever. But they need to learn the right science for the right reasons, in the right place and at the right time. It should hardly need repeating that the purpose of medical education is to produce competent, professional practitioners of the art and science of medicine. Junior medical students cannot be expected to be able to judge what it is relevant or necessary for them to know in order to prepare themselves for a lifetime of clinical practice, and basic sciences teachers can no longer respond: ‘Why, everything we ourselves know, of course.’ This may have been a realistic aim at a time when information exchange was slower and the entire body of scientific knowledge could be physically contained within a few select libraries. In those faraway days one could learn first and practise afterwards. Nowadays, we must teach tomorrow's doctors both to practise and to keep on learning. The editor wishes to thank Julie Brice for her assistance in the preparation of this editorial.