Premedical Ethical Education
By Jonathan B. Hoover
Thesis: In order to better ensure that future physicians develop into responsible medical professionals, a premedical ethics course should be required..
A. Broad Overview of the Issue
B. Importance
II.The Current Premedical Curriculum
A. Weakness
B. Strengths
C. Back to Weakness
III.Professionalism, the Larger Problem
A. What is professionalism?
B. Lacking in medical education and therefore medical practice
C. Unconscious professional development
D. Gearing towards more professionalism in medicine=> start with premedical ethical education
A. Educators and physicians as a whole do not feel that technical training should be altered
B. Large consensus that there are issues related to the lack of ethics in medicine today
C. Many feel that more focus should be greater ethical education
A. Summary of previous points described in the introduction with an affirmation of the original thesis.
VI.References
The American Association of Medical Colleges (AAMC, 2006) mandates that students wishing to enter medical school complete one year each of general chemistry, organic chemistry, general biology and physics. For the past several decades, these requirements have remained constant. Current issues relating to medical ethics and professionalism raise to the question, should alteration of these core requirements be considered? One extreme opinion is that changes shouldn’t only be considered, but that they should be immediately and drastically implemented. The majority of the medical community, however, expresses little concern with changing premedical education and tends to focus more on medical education itself (Enarson & Burg, 1992; Whitcomb, M. E., 2006; Bloom, S.W., 1988). Ethical education in medical schools varies from school to school and there is currently no requirement for ethical education prior to medical school (Emanuel, 2006 ; Makoul, 2003). In order to better ensure that future physicians develop into responsible medical professionals, a premedical ethics course should be required. This could work as a starting point for a move towards more efficient and effective ethical education in medicine
Since the quality of medicine depends on the education and training of its providers, discussion on the validity of these topics is relevant. Medical care as a whole is imperfect due to the fact that it’s largely a human enterprise and should thus be open to constant critique and improvement. By critiquing the very process that produces physicians, large-scale impact may possibly be achieved.
The Current Premedical Curriculum
In an article entitled Changing Premed Requirements and the Medical Curriculum, Ezekiel J. Emanuel (2006), MD, PhD, describes in detail his perceived flaws with premedical education. He believes that the premedical curriculum grossly over-exaggerates science education:
Does knowing how to integrate sin θ have anything to do with caring for a patient or elucidating the role of TERC in aplastic anemia? Do any physicians, even researchers, have to know about Diels-Alder adducts? Is calculating the angular momentum of a spinning top relevant to any medical practice? Most of what is contained in 1 year of college calculus, organic chemistry, and physics is irrelevant to medical practitioners, researchers and administrators. Researchers who need such information do not rely on their college courses.
He feels that the purpose of a strong science education as a prerequisite for medical school is to primarily weed students out, and that courses more relevant to medicine should be required instead. By calling on the AAMC to eliminate physics, organic chemistry, and calculus from the Medical College Admission Test (MCAT) in order to encourage a change (Emanuel, 2006), he exposes weakness in several of his views.
First of all, the creators and implementers of the MCAT point out that, “an understanding of calculus is not required in order to solve the problems on the MCAT science sections” (Association of American Medical Colleges, 2005, p.5). Calculus is a prerequisite for studying physics and not to mention training in graphical interpretation, just like organic chemistry is a prerequisite for studying biochemistry. A deep understanding of the biochemical aspects of human physiology is essential, as Dr. Emanuel points out. However, “a few weeks” (p.1129) spent studying molecular nomenclature and structure prior to taking a course in biochemistry will not suffice.
The course requirements established by the AAMC allow students to study a broad range of established science thus permitting them to move through the medical education process and specialize as they wish. The objective aspects of medicine are rooted in science and that is why medical schools want students trained in the sciences. Dr. Emanuel suggests that students should essentially take genetics, molecular biology and biochemistry classes while at college, because this is more relevant to medicine (Emanuel, 2006). Currently, the majority of students taking these classes prior to medical school are presumably science majors. Statistics show that science majors do no better than non-science majors while in medical school; they show that MCAT scores, which require a thorough understanding of the basic sciences, are better predictors of success (Colliver et. Al., 1989; Huff and Fang, 1999).
Due to their inherent complexities, studying the basic sciences can be challenging and much effort is often required to succeed. Medical school offers yet an even greater challenge. Therefore, it is primarily for two reasons that the AAMC requires extensive study in the basic sciences: medicine is entirely rooted in these sciences and studying them will prepare students for the rigors of medical school.
By citing the Hippocratic Oath, which points out that medical practice is riddled with ethical challenges, Dr. Emanuel (2006) stresses that premedical requirements do not include an ethics course. For the most part, no serious considerations are given to ethical education in the core requirements established by the AAMC. The inclusion of ethical content and discussion is entirely dependent on the individual colleges and universities themselves. On the other hand, formal education in medical ethics at medical schools has been steadily increasing over the last several decades and is now commonplace in medical training (Veatch, 1976; American Association of Medical Colleges, 2005).
Current issues pertaining to professionalism highlight the need for a higher level of ethical awareness among physicians. Professionalism in medicine is built upon ethical principles. Every medical field requires professionalism from its physicians in order to ensure the integrity of medical care as a whole. However, some claim that a widespread deprofessionalizationof medicine is occurring due to physicians focusing less and less on the interests of the patient, while being influenced by businesses and markets (Pellegrino, 2000; Wynia et. Al., 1999).
Although ethics is now a routine part of American medical education, the widespread deprofessionalization described by Pellegrino et al. illustrates that current medical education is not sufficient. Dr. Emanuel (2006) writes that the extent to which ethics is taught in medical school isn’t sufficient. In medical school, ethics courses are often taught by unqualified individuals; there is much variation on what is taught from school to school; little conceptual framework is provided to guide students in their learning; and the education is not continuous, as it should be.
Professionalism, the Larger Problem
Wynia et. Al (1999) describe medical professionalism in detail. They outline three core elements: devotion to medical service, public profession of values, and negotiation regarding professional values and other social values. Each of these core elements is part of the integrated whole that is medical professionalism.
Their first element, devotion to medical service, is based on the idea that “professionalism requires a moral commitment to the ethic of medical service (p.1613).” Physicians should place the goal of public health above all other goals and should influence those around them to do the same. They should even go as far to “criticize and police” one another (p.1613). The standard of medical care they provide should not change from patient to patient. The net effect will be to maintain the trust between physician and patient and the integrity of patient care (Wynia, et. Al, 1999).
Since the Latin meaning of the word “profession” is “speaking forth,” public profession of values means that physicians should make the public aware of where they stand. By doing so, they make the standards known to everyone, forcing them to be accountable. This public profession, however, should not be one-sided (Wynia, et. Al, 1999).
The third element, negotiation regarding professional values and other social values, implies that physicians need to negotiate their medical values with the societal values and generate a social contract between physician and public. Negotiation makes it clear for both parties what is expected in the health care. The challenge is to maintain accountability to the public while maintaining basic health care values (Wynia, et. Al, 1999).
Failure to maintain these elements as equally important and integral parts can have negative consequences. Physicians who do not remain devoted to the ethical aspects of medical care may behave in self-protecting ways, leading to ignorance of patient needs. If values are not professed to society and negotiated, uninformed decisions detrimental to medical practice could be put in place by society (Wynia, et. Al, 1999).
Due to the widespread variability of ethical education in medical schools (Makoul, 2003), it is unclear to what extent these concepts of medical professionalism are being taught in medical school. In the book, Educating for Professionalism: Creating a Culture of Humanism in Medical Education, the authors describe how the surrounding dominant culture is influencing medical students’ professional development rather than their curriculum. The authors suggest that professionalism is something to be constantly considered and continuously developed (Wear and Bickel, 2000).
Medical professionalism is rooted in proper ethical behavior and is somewhat lacking in medical practice today. Some suggest that continuous education is the answer (Emanuel, 2006; Wear and Bickel, 2002). If an ethics requirement in premedical education were mandated, then students would benefit from a more thorough, continuous ethical education. This is already the case with science: early on students are exposed to the basic sciences and go on to develop concrete logic in dealing with related problems. Ethics should to be treated equally along with the basic sciences.
By teaching ethics early on—during the premedical years—in an organized and uniform manner, it may be possible to curb the current deprofessionalization and have large-scale positive effects on the medical institution. If the AAMC could reach an understanding on what basic ethical concepts should be studied and understood during the premedical years, just as they have done with the sciences, then premedical and medical education alike could then move towards unity in the ethics material they teach, possibly creating a national standard and thereby changing our current direction.
In addition to his ideas for revamping premedical education, Dr. Emanuel suggests some changes for medical education. Being a bioethicist, he believes that courses like communications, bioethics, statistics, health care financing, health law, and management are more important than those such as pathology, cytology, and pharmacology. He admits that each professor has their own opinion on what is important and there is no widespread agreement on what, if anything should be excluded (Emanuel, 2006). Due to lack of consensus regarding the exclusionof material, nothing should be excluded. The same applies for premedical education. As discussed above, a variety of literature exists expressing the need for a greater concern towards issues like professionalism and ethics. Thus, the focus shouldn’t be on what to exclude, but rather what to include. A one semester course taught by a qualified individual, such as someone who has received a degree in ethical studies, could be a starting point.
In reference to screening medical school applicants, AAMC president, Jordan Cohen (2001), said,
Leave the GPAs and MCAT scores 'til later. Rather than looking first for reasons to reject an applicant -- like evidence of a lackluster start in college, or a bad semester, or a C in an organic chemistry, or a "7" on an MCAT subtest -- why not look first for reasons to accept an applicant - like evidence of deep-seated social awareness, of having triumphed over adversity, of personal sacrifice for the benefit others - and only then consider the statistical predictors of mastering our challenging curriculum (Bowmen, 2001).
This came from the man who essentially represents all 142 accredited medical schools in the United States and Canada. His statement highlights the growing need for students who are ethically aware—yet doesn’t discount current scientific education—and will be capable of developing into competent medical professionals. A small change in the premedical curriculum to include ethical issues along with a concomitant move in medical education to create a more uniform system of educating medical students is therefore necessary if we are to over-come the current deprofessionalization of medicine.
Dr. Ezekiel J. Emanuel’s (2006) ideas about altering premedical and medical education requirements for physicians were used to examine the strengths and weaknesses of current premedical education. He highlighted the need and importance of ethical education and pointed out that it was essentially absent from the premedical curriculum. The writings of Wynia et. Al. (1999) were used to illustrate the relationship of ethics to medical professionalism. A brief and general consensus of physicians and medical educators illustrates the desire for ethically aware students. The current deprofessionalizationdescribed by Pellegrino (2000) suggests that something needs to be done in order to improve the integrity of medicine. Therefore, a good start to remedying current problems would be to include an ethical education requirement in the premedical curriculum.
References
14. Wynia, M. K., Latham, S. R., Kao, A. C., Berg, J. W., Emanuel, L. L. (1999). Medical Professionalism in Society. The New England Journal of Medicine, 341(21), 1612-16.