The case for basicsciences in theundergraduatecurriculumKatherine Smith, Fourth-Year Medical Student, Imperial College, London

SUMMARYBackground: The importance ofbasic sciences in the training ofdoctors has been recognised forcenturies, and their position wasacknowledged and strengthenedby the recommendations of theGeneral Medical Council and theFlexner report.Context: Challenges to theircentral role have, however,arisen from many directions:

these include perceived lack ofrelevance to clinical medicine,and pressures on the curriculumfrom social sciences and thehumanities. Nevertheless, thejustifications for studying basicsciences remain strong, andinclude contextualisation,understanding of patho-physiology, training in the pro-cess of learning, an ability toexplain diseases to patients,

intellectual satisfaction,appreciation of uncertaintiesin science and therefore inpatients, and research leadingto advances in medicalcare.Implications: Innovativeapproaches to medical educationmay improve the teaching andlearning of basic sciences, andbuild on their inherentimportance.

Justificationsfor studyingbasic sciencesremain strong

Curriculum

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INTRODUCTION

Since the time of the AncientGreeks, medical studentshave been expected to learn

basic sciences as part of theirtraining. However, even as late asthe second half of the nineteenthcentury, debate continued abouttheir value versus the ability tolearn the art of medicine. Theirimportance in the UK curriculumwas nevertheless confirmed by theGeneral Medical Council (GMC).This body was established in1858, and in 1867 it producedrecommendations detailing thebasic science education requiredbefore proceeding to clinicalmedicine. Despite such guidance,teaching of the basic sciences wasa ‘hit-and-miss’ affair, for whichcurricula were devised accordingto the timetables, interests andpreoccupations of whoever waswilling and available to instructthe students.1

The importance of basic sci-ences was strengthened by theinfluential American educatorAbraham Flexner. Having studiednew approaches to medical edu-cation in Europe, in 1910 heproduced a highly critical reportabout the US system. Flexnerrecommended that medical edu-cation should begin ‘with astrong foundation in the basicsciences, followed by the studyof clinical medicine in an atmo-sphere of critical thinking withadequate time and facilities forresearch’.2 The impact of thisreport was felt even in the UK,with Flexner appearing before aRoyal Commission to explain hisconclusions. The commissionreported in 1913, endorsing thenewer approaches and recom-mending university medicalschools with strong basic sciencedepartments. By the middle ofthe twentieth century thecurriculum in most British medi-cal schools was similar. Two yearswere dedicated to learninganatomy, physiology, biochemis-try and other sciences, and

the remaining three years werespent in clinical training.

Despite these developments,the importance of the basic sci-ences has continued to be chal-lenged. Is it really necessary tothoroughly teach basic sciencesto undergraduates? Some wouldargue that it is unnecessary, evenimpossible, to achieve this goal.

In the seventeenth century,the eminent physician ThomasSydenham was vociferous in hisbelief that medicine could only belearned at the bedside, and eversince, similar opinions have beenrepeated. A second concern hasbeen the dissociation of thescientific basis of medicine fromclinical practice. At an extreme,students have felt that their pre-clinical years have been wasted,and that the subjects have hadlittle relevance in the treatmentof patients. Weatherall has sug-gested that basic science teachershave sensed their students’ lack ofinterest, and consequently havetended to present their subjectsin an ‘over-simplified and didacticway’.2 This has left the studentspoorly prepared for the complex-ities and uncertainties that willbe encountered when dealingwith patients.

Thirdly, there has been anexplosion in knowledge relevantto medicine. Even in 1867, theBritish Medical Journal expressed

concerns that students would beoverburdened. Today, more thanever, students cannot possiblyfamiliarise themselves compre-hensively with the sciencesrelevant to medicine.

Fourthly, and finally, the‘socio-political environment andpublic expectations have shif-ted…the GMC and the professionhave been forced to adapt to newsocial stresses and strains’.3 Therehas been more emphasis on com-munication skills, ethics, socialsciences and the humanities,inevitably at the expense of basicsciences. At an extreme, the needfor a broad education thatincludes the basic sciences hasbeen questioned – ‘surely aperfectly adequate, if slightlybarefooted, doctor could beproduced in a much shorter timeand still be able to meet theneeds of the community?’2

Against these onslaughts, is itappropriate to defend the role ofthe basic sciences, and if so, howcan this be achieved? In reality,there are many interrelatedreasons to justify the need tostudy these subjects.

Of prime importance is theissue of context. Basic sciencesprovide a ‘cognitive framework’,4

and therefore aid the retentionand recall of clinical knowledge.Conversely, if information isdecontextualised, it is acquired

Students cannotpossibly

familiarisethemselvescomprehen-

sively with thesciences

relevant tomedicine

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rather than understood, and isless likely to be retained. Someauthors have, however, suggestedthat clinicians rarely use basicsciences in routine diagnosis, andothers have even claimed thatstudents would be more able atdiagnosing if they used mathe-matical probabilities, but this is anotion disproved by Woods et al.5

An understanding of basicsciences, and thus of normalfunction, also permits the subse-quent understanding of the path-ophysiology of disease. Normanet al.6 accept that experienceddoctors employ simple ‘rule-of-thumb’ strategies for commonproblems, but point out thatthese may fail in complicatedsituations. If diagnoses or treat-ments are not immediately obvi-ous, doctors will then have to relyon basic principles to guide them.

Medical knowledge is expand-ing dramatically, and it is beyondthe ability of any individual to beomniscient. New scientificdomains that promise paradigmshifts in clinical thinking havebeen emerging. Conversely, muchof what is taught today may soonbe superseded or irrelevant.Against this background, thepredominant focus for medicalstudents must be on the processof learning. Undergraduates mustknow how to find and interpretmedical information as much as,if not more than, memorising it,and they must be able ‘to incor-porate new knowledge into theirpractices over the course of theirprofessional careers’.7 Teaching ofscientific principles such asresearching the literature, rigor-ous evaluation of data, etc., cannurture these skills, and provide alifelong critical approach tomedical advances and theirapplications.2

In contemporary society,where information and communi-cation are of paramount impor-tance, it is crucial that cliniciansare able to explain concepts in

health and disease to patients.Basic science training providesdoctors with the skills to interpretdata so that they are then able todo so for the benefit of patients.Sweeney even suggests that basicscience concepts should be used‘as an antidote to irrationalthinking about health anddisease, which currently supportsa growing interest in alternativemedicine’.8

A further justification for theteaching of basic sciences is thatthe true understanding of medi-cine that follows is intellectuallysatisfying. At its best, the teach-ing of basic sciences can ‘stimu-late and provoke curiosity…imbue students with a sense ofwonder at new ideas…[and]…challenge and inspire them’.1

MacLeod describes a thoroughunderstanding of basic sciencesas being ‘at the heart of ourability to grasp the deeper satis-factions of medical practice andto function at a professionalrather than utilitarian level’.9

Weatherall highlights a differ-ent facet of studying basicsciences: he describes how recent‘study of disease at the cellularand molecular level has emphas-ised the quite remarkable indi-viduality of our genetic make-upand hence our responses to ourenvironment’.2 Sick people areone example of the ‘multi-layeredcomplexity’ of all living things. Heargues that if students couldappreciate such uncertaintiesearly in their careers, it wouldresult in much greater ‘humility intheir approach to sick people and,pari passu, reduce the degree ofself-certain pomposity that hascharacterised the medicalprofession over many centuries’.

A further benefit of basicsciences is that some of thestudents will progress to becomemedical scientists. Basic sciencedepartments in medical schoolshave undoubtedly contributedenormously to the development of

medicine: many of the advancesin medical care have followed on‘from curiosity driven science thatwas not directed at particularclinical goals’.10 Training in thebasic sciences will also have abeneficial role for those studentswhose research is clinicallybased. Thus, adequate knowledgeof the basic sciences is acknowl-edged as being essential ifmedical practice ‘is to continue toevolve as a scientifically basedendeavour’.7

This robust defence of thevalue of basic sciences does notnecessarily imply that older mod-els of medical education shouldbe perpetuated indefinitely.Innovative approaches to learninghave been developed. Intuitivelyat least, basic sciences learned inthe context of clinical scenarioswill be better understood andmore easily applied than basicsciences learned in isolation. TheCase Western Reserve MedicalSchool introduced a system-basedcurriculum in 1952. This com-bined the teaching of basic sci-ences and clinical medicine, withpatient contact occurring fromthe beginning of the course.Similarly, problem-based learningwas pioneered by McMasterUniversity in 1969, wherein self-directed learning is employed tostudy a series of problems thatdefine both the basic science andthe clinical curricula. While suchapproaches have ‘released stu-dents from the shackles of rotelearning and didactic styles oflearning…it remains to be deter-mined whether modern educationmodels will produce doctorsbetter equipped for the challengesand uncertainties of the post-modern world than previouseducational strategies did’.3

In summary, the importance ofbasic sciences to medical educa-tion has long been recognised. Therole of basic sciences has bothbeen acknowledged and ques-tioned, but they remain crucial forseveral reasons. Debate continues

Adequateknowledge ofthe basicsciences isacknowledgedas beingessential

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on how they can be best taught,but there can be no doubt thatmedical undergraduates need tostudy basic sciences.

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Smith EKM. Cognitive differences in

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7. Association of American Medical

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8. Sweeney G. The challenge for basic

science education in problem-based

medical curricula. Clinical and

Investigative Medicine 1999;22:15–

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9. MacLeod SM. Basic science in medical

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Corresponding author’s contact details: Katherine M Smith, 36 College Court, Hammersmith, London, W69 DZ, UK. E-mail: schull@btinternet.com

Funding: None.

Conflict of interest: None.

Ethical approval: This paper does not describe research on human subjects, and therefore ethical approval was not necessary.

There can be nodoubt that

medicalundergraduates

need to studybasic sciences

214 � Blackwell Publishing Ltd 2010. THE CLINICAL TEACHER 2010; 7: 211–214