Atractivo

JGIM
POINT-COUNTERPOINT

Basic Biomedical Sciences and the Future of Medical Education:
Implications for Internal Medicine
Eric P. Brass, MD, PhD
Department of Medicine, Harbor-UCLA Medical Center and the David Geffen School of Medicine at UCLA, Torrance, CA, USA.

The academic model of medical education in the United
States is facing substantial challenges. Apprenticeship
experienceswith clinical faculty are increasingly important in most medical schools and residency programs.
This trend threatens to separate clinical education from
the scientific foundations of medical practice. Paradoxically, this devaluation of biomedical science is occurring as the ability to use new discoveries to rationalize
clinical decision making is rapidly expanding. Understanding the scientificfoundations of medical practice
and the ability to apply them in the care of patients
separates the physician from other health care professionals. The de-emphasis of biomedical science in
medical education poses particular dangers for the
future of internal medicine as the satisfaction derived
from the application of science to the solving of a clinical
problem has been a central attractionof the specialty.
Internists should be engaged in the ongoing discussions
of medical education reform and provide a strong voice in
support of rigorous scientific training for the profession.
KEY WORDS: biomedial sciences; medical education; internal medicine;
apprenticeship.
J Gen Intern Med 24(11):1251–4
DOI: 10.1007/s11606-009-0998-5
© Society of General Internal Medicine 2009

heCarnegie Foundation’s Report on Medical Education in
the United States and Canada, commonly referred to as
the Flexner Report1, noted in 1910 that “Society reaps at this
moment but a small fraction of the advantage which current
knowledge has the power to confer”. The report also emphasized
that “modern medicine…is…more than mere empiricism”.
These assessments hold true today as ourunderstanding of
human biology and disease has reached a depth and richness
unimaginable a few decades ago. Yet, contemporary trends
threaten to undermine the fundamental tenets of medical
education that have been widely embraced throughout most of
the 20th Century.
The Flexner Report emphasized an academic training model
in favor of the less well standardized apprenticeship model
which dominated100 years ago in the United States1,2. This
academic model links the scientific principles underlying
human biology and disease to the clinical decision making

T

Received September 30, 2008
Revised February 25, 2009
Accepted April 1, 2009

that is central to effective medical practice. The academic
clinician who is able to apply fundamental scientific principles
to sound clinicalreasoning is central to this model. This
educational model is implicitly based on the unproven hypothesis that medical decision making based on an understanding
of the underlying biomedical sciences results in improved
clinical care. However, no alternatives to the current model
have been shown superior, the core model has served society
well, and the principles are inherently reasonable.
Therapid expansion of the science that can support
improved rational medical decision making is one of many
stressors on the medical education system in the United
States. However, it is difficult to escape the conclusion that
medical education and the practice of medicine are distancing
themselves from rigorous training in the biomedical sciences
and the skill sets necessary to apply this scienceclinically in a
rational manner. Medical schools are challenged to incorporate
new biomedical knowledge into limited curricula time using an
ever-increasing number of faculty for whom medical education
is not the highest priority. Important additional competencies3
relevant to the practice of medicine are competing with the
teaching of core scientific knowledge for student time. In US...