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Brush Up Your Shakespeare! Democratization of Medical Knowledge for the 21st Century

2015; Elsevier BV; Volume: 128; Issue: 7 Linguagem: Inglês

10.1016/j.amjmed.2015.01.041

1555-7162

John B. Weinstein, Ronald S. Weinstein,

Health Sciences Research and Education

In Shakespeare's time, health information, such as it was, was readily available and disseminated to the general public. Shakespeare's 37 plays include many sophisticated references to health-related information. If an American playwright today were to reference medical knowledge at the level relevant to the lives of the viewers, half of them would leave the theater bewildered. A decade ago it was estimated that nearly half of American adults lacked the health literacy needed for choices fundamental to their lives.1Neilsen-Bohlman L. Panzer A.M. Kindig D.A. Health Literacy: A Prescription to End Confusion. National Academy of Sciences Press, Washington, DC2004: 1-18Google Scholar In contrast to other literacies, health literacy does not correlate strongly with overall education level or household income. The American educational system largely delays medical science education until the latest years in the system, and the more elite the education, the more pronounced the delay. The general absence of medical science from college curricula has little to do with college students' skill at comprehending the nature of disease. Instead, a range of structural forces intersect. One is the continuing impact of Flexner's innovations from a century ago.2Flexner A. Medical Education in the United States and Canada. Carnegie Foundation for the Advancement of Teaching, New York1910: 20-27Google Scholar In 1910 Flexner recommended a novel framework for medical education that is still used in the United States today—2 or more years of college incorporating core “premedical” courses in biology, inorganic and organic chemistry, physics, and mathematics, followed by a 4-year medical school curriculum consisting of 2 basic science years and 2 years of clinical rotations. Flexner's justification for this particular set of so-called premedical courses is outdated. None of these courses are essential for the subsequent mastery of medical school subjects. Flexner prerequisites are not the sole source of medical science's absence from college campuses, for even the 10 undergraduate courses prescribed by Flexner would account for less than one-third of the course requirements for a bachelor's degree. University politics come into play. The separate academic silos within a university keep most PhDs within the faculty of arts and sciences, whereas faculties with various professional degrees are housed separately, with MDs in the medical schools, JDs in the law school, and so on. These groups each stand guard over their own fields, making any sort of medical or law course at the college level suspect. It is not a “real” course, and certainly a professional school would make a student who has taken such an offering take it again. They do not have the equivalent of Advanced Placement courses for medical school subjects. A different interdisciplinary science highlights the impact of this separation of professional schools from arts and sciences faculties. Environmental science is not one of Flexner's big 4—biology, inorganic and organic chemistry, and physics—and given his era, Flexner likely gave little thought to such a possibility. However, environmental science has gained great popularity on college campuses, as both an undergraduate major and a means of satisfying the science requirement that many colleges require. The popularity of environmental science among both the scientifically oriented students and their more science-averse classmates is hardly surprising, for environmental issues are prevalent in the media; but so are healthcare issues. If undergraduates are capable of understanding environmental disease, which requires the comprehension of material related to both biology and chemistry, there is no intellectual reason why they cannot fathom human disease. The difference is what follows, or the lack thereof. Separate professional schools in environmental science are not staples on university campuses, and there is no particular environmental degree beyond the masters and doctoral degrees already offered by arts and sciences faculties. Simply put, there is no separate silo with an interest in saving the study of the environment for later. To say that all undergraduates are deprived of courses in medicine, law, and business is an overstatement. This deprivation is, in fact, the sole property of those colleges in the most elite undergraduate institutions. The Ivy League institutions, which function as relatively large liberal arts colleges within their larger universities, together with their smaller liberal arts brethren, are the places most likely to eschew any course with an air of professional school within them. Many other institutions, including the public universities, offer BAs in business, criminal justice, or nursing, all of which offer more “professional” courses. If an aspiring doctor wants to study the nature of disease while still in college, he or she would have been better off enrolling at a nursing school. However, aspiring doctors tend not to do that, and even those who do not attend the most elite—and costly—undergraduate institutions end up mimicking the curricular choices of those who do, in the pursuit of Flexner's ideal premedical education. Instead of meeting each other in Health Sciences 101 as college first-years, doctors and nurses are separated before they could ever enter such a course. The nursing students begin their nursing school studies with medical science materials, whereas future medical doctors are purposely kept away from such topics. They are also kept away from the nursing students, whom they will not encounter until they reach their clinical rotations years later. The seeds of interprofessional understanding that might have been sown, not just between doctors and nurses but with future pharmacists, social workers, and additional allied health professionals, are cast aside for curricular reasons that might have made sense once but certainly do not now. If students began together in an undergraduate medical science course, they could make more informed decisions about which track in the health professions to choose, even if that track is not in a health field at all. The medical field loses too many bright prospects simply because those students faltered in organic chemistry. Medical education is hardly the only element of the American educational system to elude substantial change even as the world around it transforms. The basic K-12 framework for education, which is as lacking in medical science curricula as its collegiate counterpart, has also not changed since Flexner's day. Although American youth have little in common with their peers from 1910, whether in their exposure to the world beyond or even the pacing of their biological clocks, they still attend high school in largely the same way, for the same 4 years. For the brightest students the last 2 years of high school and the first 2 years of college have significant curricular overlap—in other words, they repeat each other. The proliferation of Advanced Placement courses attest to that; strong high school students are regularly ready for college-level studies by the time they reach their junior years. In the early 1960s Elizabeth Blodgett Hall identified this phenomenon and decided to break the mold. Mrs. Hall was the longtime headmistress of Concord Academy, a highly regarded independent school for girls in Massachusetts. She felt that many of her students were ready for college work but were held back by the need to complete high school. She founded Simon's Rock in 1966, initially labeling it as neither a high school nor a college, because it was hard to say exactly what it was in that moment. During its early decades it evolved fully into a college, becoming the first institution in what is now known as early college.3Sharpe P. Early College: What and Why?.in: Yanoshak N. Educating Outside the Lines. Bard College at Simon's Rock on a “New Pedagogy” for the Twenty-First Century. Peter Lang Publishing, New York2011: 223-237Google Scholar Now named “Bard College at Simon's Rock” and part of the Bard College system, the school remains the only early college in the nation to offer a BA degree, although numerous AA-granting early colleges are now in operation, including Bard High School Early College campuses in Newark, NJ and 4 other Bard locations. Early college is gaining traction nationwide, with more and more students concluding their high school studies early to begin college-level work at an age when they are intellectually ready to do so. If college can transform into early college, might there be early medical school? Flexner apparently flirted with that idea himself.2Flexner A. Medical Education in the United States and Canada. Carnegie Foundation for the Advancement of Teaching, New York1910: 20-27Google Scholar A new pathway to the medical profession could begin by transforming the current 4-year blocks (eg, 4 years each of high school, college, and medical school) into a new sequence of 2-year elements. A student will begin with 2 years of high school, during which time strong students can complete most of the necessary prerequisite material for college admission. A 2-year early college AA program will follow, leaping students to college-level thinking, not through Advanced Placement courses or some other collegiate proxy but through true college courses. During this time all students would be exposed to at least 1 course in the medical sciences, which serves both the liberal arts ideal as knowledge an educated citizen should possess and also the preprofessional desire to explore future career paths. In that course, both those interested and not interested (or think they are not interested) in healthcare professions will explore health issues together. For the next 2 years, the BA years, students would begin to diverge from one another, in accordance with their interests. However, those pursuing medical science areas will remain together, completing an undergraduate degree in medical sciences that includes the scientific and societal knowledge essential for all health professions.4Schmitt M.H. Gilbert J.H.V. Brandt B.F. Weinstein R.S. The coming of age for interprofessional education and practice.Am J Med. 2013; 126: 284-288Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar At this point, future doctors, nurses, and pharmacists will all be working together as one—as they will again at the end of their respective profession-specific education paths.