“90 percent of what you will learn over the next four years will be wrong in a couple of decades from now.”
Speaking to a lecture hall of 120 first-year medical students, our professor’s prophecy seemed to fall on deaf ears. Looking around, I saw no concerned students, no diminishment of our collective enthusiasm. For me, however, his words of caution struck a chord on that first day of medical school.
As a newly matriculated MD-PhD student, brimming with newfound excitement at the prospect of completing a closely interwoven clinical and research-based dual degree program, I arrived at medical school open to many possible career paths — but certain that I would seek truth in whichever specialty that would be.
I believed that the underlying purpose of the natural sciences was to make sense of human beings and the human condition. What better way to seek human truth than to simultaneously conduct research at the frontier of the biomedical sciences, learn physiology and pathology from esteemed clinicians, and apply these findings to heal patients?
But as I dissected my way through anatomy lab, learning about the sympathetic nervous system through Grant’s Dissector and Netter’s Atlas, I found centuries of thought overturned. While my Atlas said that the sacral nervous system was parasympathetic, researchers boldly declared that the sacral system was, in fact, sympathetic. Sifting through my immunology lecture notes, I found no references to the recent discoveries that lungs are greater producers of platelets than bone marrow or that macrophages are just as essential as cardiomyocytes for the beating of one’s heart.
For much of the knowledge we’re taught, we assume it as fact and take it at face value. However, taking a critical eye to assumptions, even ones that have been accepted as fact for a century or longer, appeared to be a continual source of novel findings and insights. While I had honed this critical eye during my previous years of research, I found little use for these skills in the medical curriculum. In scientific research, we act on the vanguard of known human knowledge in highly specialized fields and niches, often contributing incrementally and hopefully in leaps and bounds. Yet in medicine, we learn an extensive array of physiology and medical knowledge that, even upon specializing, would be viewed as broad by any scientific researcher. How could I reconcile these two types of thinking in my dual path as a medical practitioner and biological researcher?
It was during my rheumatology longitudinal clerkship that I began to understand what mattered.
As I followed my preceptor through her private practice, I noticed that she preferred prescribing etanercept over adalimumab for rheumatoid arthritis. I asked her why she had this preference, as my understanding suggested that they acted similarly through TNF-alpha blockade. I anticipated being imparted some wisdom on comparative effectiveness, that one of the drugs showed greater rates of response or remission. Instead, she pointed to her patients in the waiting room who were surprisingly jovial as they waited for their care. Many were conversing with each other, familiar with one another from their many past appointments. One played cheerfully with her service dog. She explained that etanercept’s side-effect profile was generally more favorable, resulting in increased quality of life. Looking out into the waiting room, it was plain to see.
I never learned which of the TNF-alpha inhibitors proved more clinically effective. In the end, it didn’t really matter. To the patient who regained an ability to play the piano without a shroud of pain, it certainly did not. To a patient with thrombocytopenia, does it matter whether the underlying cause may be partially pulmonary in nature? And does it matter whether the nomenclature of a nerve changes if the drugs blocking the neuropathic pain work?
Despite ongoing changes in our understanding of the underlying biology that occurs, what we currently learn in medical school is taught because they are reliable. They work to generate clinical benefits in patients, even if sometimes we don’t always understand all the physiological facets behind them. It doesn’t mean there isn’t room for improvement — rather, it means that physicians and scientists must continue to collaborate in determining how physiological discoveries can transfer from the bench to the bedside and back again.
This is and has been the basis for novel therapeutics, diagnostics, medical devices, and care processes that have transformed almost all facets of medicine.
While the pace of change in clinical care is slower than that of the exponential speed with which scientific discoveries are being produced, change is slower not because of recalcitrance, but because the lives and livelihoods of patients — people who are our friends, neighbors, and family members — are at stake. With this in mind, “be quick but don’t hurry” takes a whole new meaning.
Now in the research component of my training, I think back to a second quote that same professor shared with us almost exactly a year ago, one by Dr. Francis Peabody. “One of the essential qualities of the clinician is an interest in humanity, for the secret of the care of the patient is in caring for the patient.” Medicine as an art doesn’t necessarily change whether we know the latest research in the top tier journals or are aware of the newest technological advances.
Just as a more expensive paintbrush doesn’t make a painter a master-painter or a Stradivarius make a violinist a concertmaster, a fancier stethoscope doesn’t make a better doctor. It is this art, the sincere care that doctors provide, that medical school not only teaches but also instills within us that constitute the most important lessons.
While 90 percent of what we learn may be wrong, I now realize that’s not the answer to the question that matters. In medical school, the question need not be, “Is what we are learning correct?” but rather, “Will what we learn help our patients?” I have found, undoubtedly, that the answer to that question is “Yes.”
Joshua Y. Yang is a medical student.
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