This year marks the centennial anniversary of Abraham Flexner’s seminal report on medical education in the United States and Canada. It is remarkable that a report from an educator in Louisville, Kentucky could have such a dramatic and lasting impact on the field of medicine.
Another educator from Louisville has made a considerable contribution to medical education, Uldis Streips. While his reputation and impact will probably never reach that of Flexner, he has had a significant impact on his students and through them medicine. Further, he has been an active member of our association for many years, serving most recently as the editor of JIAMSE. Together with his team of Marshall Anderson as production editor and the rest of his editorial board, they have advanced the journal and promoted medical education. While Flexner identified a variety of issues and offered some argument for addressing these, Uldis, Marshall and the rest of the editorial team have been at the front lines making those things happen and sharing the ‘stories’ of others through the journal. We would like to take this opportunity to thank these dedicated individuals for their service to IAMSE by dedicating this special issue to them.
This issue of JIAMSE provides the culmination of a study conducted by IAMSE to examine one aspect of the issues raised by Flexner, that of the basic sciences. One of the greatest outcomes of Flexner’s report and the changes that occurred in medical education in the early 20th century was the grounding of medical education in the sciences. While this was not a phenomenon solely due to Flexner’s urging, as there were a number of initiatives already underway at the time, Flexner did bring the issue to wider attention.
The International Association of Medical Science Educators (IAMSE), having its origins in the focus of basic science in medical education, wanted to celebrate and recognize Flexner’s contributions by examining his findings for the basic sciences in the context of medical education for the 21st century. In 2006, IAMSE initiated the Flexner Revisited project to examine the role and value of the basic sciences. We brought together a study group representing a wide array of medical educators; the composition of the study group is listed at the end of this manuscript. The specific goals of the study were: (1) Define and describe the sciences that constitute the foundation of medicine, (2) Identify the role and value of the sciences and scientific thinking in medical education, and (3) Identify the best practices of when, where and how the foundational sciences should be incorporated into medical education. To meet these goals, we defined five questions we would ask multiple groups of medical educators to address. The questions were:
- What are the sciences that constitute the foundation for medical practice?
- What is the value and role of the foundational sciences in medical education?
- When and how should these foundational sciences be incorporated into the medical education curriculum?
- What sciences could/should be pre-requisite components of the undergraduate medical curriculum (i.e. be part of the pre-medical requirements)?
- What are examples of the best practices for incorporation of the foundational sciences in the medical education curriculum?
We posed these questions at a number of medical education gatherings including the IAMSE annual meetings, American Association of Colleges of Osteopathic Medicine, American Association of Medical Colleges and the Generalist in Medical Education. In addition, we asked for perspective papers from a number of individuals representing the various disciplines of medical education, including both the basic sciences as well as a clinical medical educator perspective. The papers in this special issue are their perspectives. The following is a summary of the findings of our study. An early report of this project was presented in the February issue of Academic Medicine.1
What are the sciences that constitute the foundation for medical practice of the future?
The traditional basic sciences (anatomy, physiology, biochemistry, microbiology/immunology, pathology and pharmacology) in addition to genetics, molecular biology, epidemiology and biostatistics and the behavioral sciences were considered the foundational sciences upon which a preparation for medical practice is based. The participants were unified in their sentiments that simply listing the science disciplines was not sufficient to capture the essence of the fundamental nature of these sciences to medical practice. The key is that the concepts must be relevant and applicable to medicine (human health and disease) to form the fundamental foundation for medical practice.
The breadth and depth of knowledge and understanding engendered considerable diversity of opinion. The collective consensus was that the goal should be to prepare medical students for entry into residency education.
What is the value and role of the foundational sciences in medical education?
The contribution of the basic sciences to the development of the medical practitioner goes beyond the factual information and serves to inform the critical thinking and decisional framework. The basic sciences were felt to be critical for clinical application and effective thinking skills. The application of the knowledge serves to provide a mechanism for the integrative approach to problem-solving. Those who have a deeper fund of basic science knowledge were better able to address uncommon and more complex clinical situations than those relying solely on a presentation and algorithm approach.2
Clinical medicine is based upon the recognition, classification and then treatment of abnormal physiology (pathophysiology). To appreciate the abnormal, the practitioner must first have a solid foundation in what is normal. The basic sciences define these parameters. The treatment is designed to modify these systems to return them towards the normal state.
Flexner championed the role of the basic science in medical education.3 He posited that without a strong background and understanding of the scientific method and basic sciences, physicians would be no more than mere technicians, following a proscribed algorithm for diagnosis and management. The physicians who understood the underlying principles would be the ones to address the more complex issue and would be the leaders in developing new approaches.
When and how should these foundational sciences be incorporated into the medical education curriculum?
There was considerable interest in this question. Clearly, all respondents felt that the simple answer was early and often. In general, the consensus was that the science should be incorporated throughout the entire undergraduate medical curriculum and continued in the post-graduate experiences as well. The key elements were, however, that the sciences needed to be clinically relevant and that they should be presented in an incremental fashion. Rather than a ‘hard and fast’ approach, a more dispersed design was favored. This permitted the student the opportunity to distill the information, synthesize it with other knowledge and experiences and formulate new knowledge. The method of instruction impacts learning. With the sciences, as in learning itself, it is the process more than the content that is crucial. It was felt that an experiential instructional, thus learning, method would be superior to a simple didactic teaching style. Having the student actually experience the learning then the knowledge become ‘owned’ by the student rather than ‘borrowed’ from the instructor. Mimicry does not equal learning.
What sciences should be pre-requisite components of the undergraduate premedical curriculum?
To address the issue of pre-medical preparation opens the question of what we want as potential physicians. While a strong background in the sciences and a large core set of prerequisites would help to streamline the medical curricula, it would tend to narrow the diversity of the matriculate pool. A clear consensus of the respondents was that an undergraduate major in the science was not necessary for preparing a student to study medicine. Rather a well rounded education with a focus on the basic vocabulary and core concepts of science were essential. Pre-medical coursework promoting problem solving and thinking skills were considered of greatest importance.
The recently published HHMI/AAMC report, The Scientific Foundations for Future Physicians, well delineates the views of our respondents and sums nicely the issues of pre-medical foundations.4
What are examples of the best practices for incorporation of the foundational sciences in the medical education curriculum?
While Flexner used Johns Hopkins as his ideal model, identifying one or two exemplar programs was more problematic. Many quality programs were identified, and these are mentioned in the accompanying papers in this issue. Our respondent did identify characteristics of best practices that should be emulated. These included clinical context, incorporating clinical perspective in the ‘preclinical’ years and scientific perspective in the ‘clinical’ years and building upon principles of adult learning with the goal of knowledge application.
The papers in this special issue of JIAMSE address the topic of the basic sciences in medical education from the perspective of the various disciplines and provide a sense of what the basic sciences contribute to medical education. It is illuminating to compare the thoughts of Flexner from 1910 with those of our colleagues in 2010 and see the similarities.
In closing, we would like to acknowledge the effort of all those who comprised the IAMSE Flexner Revisited Study Group: Peter Anderson, Mark Andrews, Giulia Bonaminio, Robert Carroll, Sheila Chauvin, George Dunway, Aviad Haramati, Louis Pangaro, Gary Rosenfeld, Nehad El Sawi, Tom Schmidt, and Doug Wood.
- Finnerty, Edward P., Chauvin, Sheila, Bonaminio, Giulia, Andrews, Mark, Carroll, Robert G. and Pangaro, Louis N. Flexner Revisited: The Role and Value of the Basic Sciences in Medical Education. Academic Medicine 2010, 85:349-355, 2010.
- Woods, Nicole N., Neville, Alan J., Levinson, Anthony J., Howey, Elizabeth H.A., Oczkowski, Wieslaw J., Norman, Geoffrey R. The Value of Basic Science in Clinical Diagnosis. Academic Medicine 81: S124-127, 2006
- Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4. Boston: Updyke; 1910. Available at: http://www.carnegiefoundation.org//sites/default/files/ elibrary/Carnegie_Flexner_Report.pdf . Accessed October 29, 2009.
- Association of American Medical Colleges–Howard Hughes Medical Institute. Scientific Foundations for Future Physicians. Available at: https://services.aamc.org/publications/index.cfm?fuse action=Product.displayForm&prd_id=262&cfid=1&cf token=F9879A96-CFB4-D414¬35197D3ADBF868B2. Accessed October 29, 2009.