Stan Goldfarb
Subject: Returning Science Education to Medical Schools
Bio: Former Dean at UPenn Medical School
Transcript:
Larry Bernstein:
Welcome to What Happens Next. My name is Larry Bernstein. What Happens Next is a podcast that covers economics, politics, and history. Today’s episode is Returning Science Education to Medical Schools.
This podcast was taped at a conference where I hosted several Penn Professors on various topics.
The audience included my friends who will join me in asking questions. Our speaker is Stan Goldfarb who was previously the Dean at UPenn responsible for the medical school curriculum.
Stan, can you please begin with six minutes of opening remarks.
Stan Goldfarb:
Before COVID when a new Vice Dean for Education came to Penn suggested that our curriculum was way out of date and that we needed to focus on social justice. That led me to write an op-ed in the Wall Street Journal entitled Take Two Aspirins and Call Me by My Pronouns that led to a tremendous reaction in the medical establishment. I wrote a book and then started this organization, Do No Harm, of which Jay Greene is the director of research. The idea is that medical education and medicine should be only dominated by a meritocracy and not by political ideology. Identity politics should be out the door. The problem has been not just the push for diversity but pushing for diversity to bring in more minority students.
The rationale for it in medicine has been two things. One is the reparations argument. People were denied something years ago and we need to make it up now. The other argument is that you need diversity to have better medical care for the public, particularly for the black community that they need more black physicians to have better health outcomes. There’s a great disparity in health outcomes for the black community, and this is the way to fix it.
What that’s led to is a dilution of the quality of medical education. The first thing you have to do is make sure that everybody gets through, because if you’re going to start taking people into medical schools and you then flunk them out, that’s not going to satisfy the diversity requirements.
In law school and nursing school, they tend to throw them out. Medical school, everybody graduates. The rate of graduation from medical school is like 98.5%. When I went to medical school, it was around a 9% attrition rate. Some schools had it as high as 15%. They used to give you a lecture on first day, look left and look right. One of them isn’t going to be here when you graduate. And that’s no longer the case.
Once you say, “everybody’s going to graduate,” now you have a problem because you have to create a curriculum that allows everybody to graduate. And the way that’s been done is twofold. One is to make it easier to pass exams. The other thing medical school education needs to be shortened and simplified.
What’s happened? If you went to Duke Medical School 40 years ago, you spent two years in the classroom, and then you were introduced to clinical medicine, and then the last year, you went on electives and maybe did some research.
Duke Medical School now has one year of classroom teaching, and then one year research, and then one year clinical medicine, and then the last year in all medical schools is a big waste of time, and have a good time, parties, and not much goes on there.
It’s led to a sense that we need not be serious about the scientific nature of medical education. Zeke Emanuel is at Penn made the statement that we shouldn’t be bothering to teach the Krebs cycle. The Krebs cycle for the non-biology people here is the basic way that energy is produced in cells. And when you understand the Krebs cycle, you understand something about energy metabolism.
It becomes really important in cancer research because cancer cells use the Krebs cycle in interesting and different ways, and that has become an important therapeutic point. Zeke who’s an oncologist thought nobody needs to understand the Krebs cycle. And it’s an analog of nobody needs to learn basic science in medical school. We’re going to train technicians.
Here’s the problem with just training technicians. When clinical research is done, the recommendations are for the average. So, if there’s a thousand people in a clinical trial, the results are going to be summarized as what’s the average response has been. The two edges of the distribution of the responses that patients are ignored for what will happen to the middle of the distribution.
A really good clinician is smart enough to understand the variation. Ralph Horowitz, who was a former Chairman of Medicine at Yale and at Stanford has written extensively on this, we need to understand not the average, but the distribution. A good clinical scientist who reads a medical research paper ought to understand the variation. They need to understand the statistical modeling that goes on here. Biostatistics in most medical schools now at Penn, it’s a one-week course.
Larry Bernstein:
Oh, come on.
Stan Goldfarb:
It’s a one-week course. I fought against it, but the students hated the course because they came to medical school to play doctor. They came to medical school to get into the clinic on day one. They’re going to have fun.
We’re going to give you an experiential education as opposed to ask you to read a textbook on cardiology. There are no textbooks in medical school. The Medical School had a bookstore at Penn. It closed. What you get is lecture notes. It’s little stuff at the bottom of each slide, and the exam is on that material. You’re told at the end of the course, “This is what we’re going to test you on, go home and study it and then they all pass the exam. And the exams are pass/fail, so it doesn’t matter how hard you study.
I was running the curriculum. I’m obviously guilty of some of this, but I fought like hell to keep us having grades. Grades were gone. In the clinical years, everybody gets honors. At Harvard Medical School, 92% of the students one year got honors in medicine. Well, obviously it doesn’t mean anything if 92% of the people get honors.
There are faculty that do research and do a little teaching. Medical faculty taking care of patients. They don’t pay that much attention to medical education. And then there’s the faculty that’s the administrative leaders of medical school. They’re the course director. They sit in every lecture for one or two months. They get a stipend for that. They’re not going to make noise, frankly, because it’s going to put their leadership at risk.
Larry Bernstein:
I have a question for Randy Kamien. Randy’s my high school friend who is a Professor of Physics at Penn. What are you doing in the classroom?
Randy Kamien:
One of the virtues of academic departments is that they’re always expanding the field they’re studying. It’s always growing. The curriculum that I had to learn when I was in graduate school doesn’t serve our students anymore because the field’s grown in the last 30 years.
We all are doing different things. Students want to learn computer science, pure mathematics, and neuroscience. We have a large group studying neuroscience in the physics department. Do those graduate students need to know of the Krebs cycle probably in neuroscience. Do the people studying astrophysics need to know the Krebs cycle? I don’t know. So over time, we’ve become much more generous about what we think the curriculum ought to be.
Larry Bernstein:
You didn’t move towards social justice discussions. You moved into more abstract concepts of science.
Randy Kamien:
Social justice discussions do not come up in graduate education in physics.
Larry Bernstein:
It does in medicine.
Stan Goldfarb:
It’s a fair criticism that medicine has grown rapidly. There’s so much new information available that you have to be flexible. This idea that you need to understand the basic science that underlies the therapies that have been developed. The lack of effort to teach students that information is going to lead to students that are going to focus on if I’m going to give someone this drug for leukemia that’s the latest thing. And understanding how that might interact with response to the drug and the disease.
Patients bring so much variability as opposed to the hard sciences where it’s a very different phenomenon. This is about the variability in human biology. Students need to be able to deal with the basic information to understand that variability. And that basic information is being reduced all the time.
The other part of it is their ability to read medical literature and understand the complexities of the studies has also been reduced because statistical modeling has gotten much more complicated. Many more studies based on analysis of databases as opposed to a single human experiment. And medical students are going to have to follow these guidelines without much understanding. And that’s where we’re really going to end up.
Will artificial intelligence and medical imaging make up for all this? Maybe, but there’s still going to be such variability in what patients bring to each individual encounter that a student that’s not strongly grounded in the sciences is not going to be able to be very effective. When you add on top of that, the willingness to bring in students that are not terribly talented, which is what’s really going on in most medical schools, you have the opportunity for this rather dim picture that I’ve tried to paint, which I think is really the case of what’s coming in medicine, particularly in this country.
In the Netherlands, if you want to go to medical school, it’s a lottery. You take an exam, and then there are too many people that still want to go to medical school, and there’s a lottery. I propose that for United States medicine as well that it be based on academic achievement and intellectual capability. Yes, you should be an ethical person, but that we should try to get the best and the brightest. There are 55,000 students that apply to medical school in the United States. 23,000 are accepted. There’s plenty of brain power to fill all the medical school classes, and yet that’s not what’s happening.
Moira McDermott:
You talked about wanting to return to a meritocracy, how do you think that should be done? Is the MCAT predictive of success in medical school?
Stan Goldfarb:
The data for the vast majority of studies show that MCATs predict performance in medical school. Now there are a couple of large studies, one of internal medicine trainees, one of emergency medicine trainees that show that minority groups, which tend to have MCAT scores a standard deviation lower than Asian students, for example, that when they get into residency programs, the faculty judges them as being less effective trainees.
There was a paper that came out in The Journal of the Association of American Medical Colleges, which looked at like seven good internal medicine training programs. The faculty judged the minority students substantially lower on preparation for practice, medical knowledge, even professionalism. The authors of the article said the reason for this was that the schools and the faculty were biased against them and the school didn’t make it a welcoming place for minority students. And finally, that the tools that they use were racist and that’s why they judged them poorly. And I wrote, maybe they weren’t so good at being residents, and then all hell broke loose over that.
So, you can show that they’re doing less well. And finally, there are data that show that those who do less well on their board certifying exams, their patient outcomes are less good in terms of mortality and readmissions to the hospital, which was tested in a group of hospitals. That’s the data we have. We also know that there’s a higher dropout rate by minority students when it comes to training programs. Something like a third of the male minority trainees drop out before they complete their surgical training, even though there’s a great desire to recruit these people into surgical training programs.
Larry Bernstein:
How will AI change medical education and the practice of medicine?
Stan Goldfarb:
Imaging has been a huge issue in medicine. That’s so profoundly changed diagnosis. One example is appendicitis, very common disease. People used to come in with abdominal pain and the question is, do they have appendicitis? And we’d go through this elaborate set of physical diagnostic tools. We’d do blood tests. We’d think about it hard. And even then, we’d miss patients. They would send them home thinking they were fine. They’d come in 12 hours later, sick as hell, fever and having perforated. Nowadays, you come into the emergency room, you have abdominal pain, you go right to get a CAT scan. CAT scans are extraordinarily effective at picking up appendicitis. A good emergency room will do that, and that’s the end of the problem. All that learning about the physical diagnosis goes out the window.
They’ve had an appendectomy but they’re still febrile. Now imaging is gone as the issue. Now we need a clinician that understands possibilities. What will AI do? I think it will make a great difference. It will give them possibilities. The question is this variability that I’m talking about. AI is going to read the literature. The literature talks about the middle of the study, the average patient in the study. It doesn’t talk about the extremes, and it doesn’t talk about the variability that now this patient with appendicitis is also 87 years old, has a history of multiple sclerosis, has been on corticosteroids for a long period of time for another condition. And all the variability that that patient brings, will AI be able to capture that?
At the end of the day, there needs to be someone to talk to the family and how it’s going to all play out. Now, maybe an AI printout will be used for that. In my foundation that I’m on, we’re getting proposals from medical schools all the time about training students in AI and we’re funding those because it’s important and we’ll see where it all goes.
I don’t know that this is a good rationale for taking in less qualified students to be physicians. Since our job is to take care of patients and not to make students happy and not to solve the world’s social problems and not to get rid of any inequality that may have existed a hundred years ago, our job is to make sure patients get the best outcomes. I still think that that’s where our organization needs to focus in making sure the best and the brightest get a chance to be physicians.
Larry Bernstein:
I want to follow up with the appendicitis example. I had some lower right quadrant pain. I went to visit my doctor, and he said you need to get a CAT scan and it turns out that the radiologist on call was Renee Yap who went to Penn and my high school, and she invited me in the back to look at my scans with her. The first thing she said is, “Do you eat vegetables at all? “ I said a little bit.
She said, “I don’t think you’re having an attack. It’s over and you can go home.” So, I went home and then the following Monday she called me and she said, “We had our weekly radiology conference, and I threw your appendix up on the screen and we took a vote on whether or not we should remove your appendix.” And it was even, it was eight / eight. I said, “What do you think I should do? She said, ”It’s really your call.”
I said, “Well, what basis do I have an opinion. I don’t know anything. I didn’t take a week of biostatistics. These are professionals.”
Stan Goldfarb:
I’m so opposed. This patient autonomy is fine, but my job as a doctor is to tell patients what my best opinion of what they should do. And my line was always, “Look, if you were my mother, this is what I would advise you to do.” And to me, physicians that say, “Look, here are the options you pick.” It’s insane. And it’s been taught as if that’s a valid thing. Patient autonomy means you can’t force people to do things. It doesn’t mean that you should let them without background decide what’s best for them. It’s truly insane.
Larry Bernstein:
To follow up on that. I later got a second appendicitis attack and they say, “You should get a second or third opinion.” So, you meet the second great guy, tremendous pedigree. And the first doctor says, A, the second doctor says B, the third doctor says C. And now you must decide where there’s inconsistent medical evaluations. How is that patient who’s the same idiot as before, supposed to decide between three excellent physicians how they’re supposed to make a life determining decision?
Randy Kamien:
You’re supposed to look at their grades.
Stan Goldfarb:
Well, actually, that’s not facetious.
Randy Kamien:
That’s ridiculous.
Stan Goldfarb:
But here’s what I tell patients. If you have a complex problem, you should go to an academic medical center. The people will talk about your problem. They’ll think about it. They’ve generally been picked because of their performance in the past to have opportunities to be at a place like Penn. They’re not out at a small community hospital. You should stick with their opinion. You should not go around shopping opinions because if the situation is that complex, there’s not going to be an absolute answer that somebody can give you a probability. At some point you have to bite the bullet, and make a judgment. And that’s to me the best advice because you’re talking about biological variation.
Fritz Breithaupt:
50% of patients do not take the medicine as prescribed. This is true also for life-threatening things like cancer medicine. We know that patients are more likely to comply if they sense that their doctor has empathy, cares for them. Is that something that should be part of the medical training?
Stan Goldfarb:
Yeah. Everybody agrees with that, that if you can’t convince your patient to take your medicine, then you’re not going to be effective. When you look at healthcare disparities, the issue of what the patient brings in terms of adherence is never measured. It’s never questioned. We have no idea when you see disparities, how much of it is due to patient factors as opposed to the healthcare system or the physician’s judgment.
At Penn, for years, there was a very effective and useful activity called doctoring, where we had actors who portrayed patients so students would learn how to convince them to take their meds, how to deliver bad news, how to deal with family issues that may arise. Patient/doctor communication is critical.
I don’t think that we need a separate curriculum on social justice issues. I thought that instead of having a one year of basic information, that it should be expanded back to the two years and included in the two years ought to be a course in psychology, because that’s what we’re talking about. I was taught in medical school why patients were making decisions, but I don’t see that as learning cultural competence. I see that as learning human psychology and understanding what patients are bringing to the encounter.
And that can be taught, that should be taught, but it’s quite different from teaching that’s going on the idea that patients that poor outcomes are due to medical racism and we need to teach you all about your biases. That’s not the issue. The issue is understanding human psychology so that you can be an effective practitioner and communicator to your patients.
Jeff Shell:
I did a little Claude research before this, so I’m sure I’m wrong, but medical outcomes are determined by a lot of studies to be worse for women, black people in the United States than white males and Asians. Seems to be widespread and there’s been a lot of studies on that. And so I’m not sure this movement towards more diversity in medical schools is for only the reason of reparations or justice, but it’s to try to make sure when you walk into a hospital or a doctor’s office, regardless of your gender or race, you have the same chance of a good outcome.
How do we get better outcomes for people who have different skin color, different genders, if it’s not provided more doctors that look like them?
Larry Bernstein:
Jay Greene you work with Stan as Director of Research at Do No Harm. Can you add to the conversation.
Jay Greene:
There’s a thing called social determinants of health, which is people have adverse health outcomes because society is constructed in a way that contributes to that. There’s truth to that. And I don’t think that that’s the issue here. The issue is to what extent do you want medical training to be reoriented towards addressing that? I think what we want is for doctors to be involved in individual treatment of individual patients, that that is a personal relationship, and that the doctor is not fixing society, they’re fixing a patient. And it’s a political problem for political actors to worry about these other social forces, and they should attend to that, and they probably don’t want your doctor to do that in large part because your doctor has no tools for fixing it.
We want doctors to do what they’re well equipped to do, which is to treat the individual patients who are in front of them rather than fix society.
The race or the sex of the applicant for medical school, these qualities are very unlikely to be related to the merit of that person as a doctor, unless you believe in this claim of racial concordance that the race of the doctor on its own has an effect on the outcomes of the patients, either because of an empathy effect or some other factor that’s related to similarity of race, similarity of culture alters the health outcome.
The research on this is really not good. I know there’s the claim, people point to studies, but all you have to do is start diving into the studies and quickly figure out how it’s distorted and accepted because there’s such strong political demand to have that result. So, the Florida baby study. This is Greenwood et al. This was cited in the Students for Fair Admissions Supreme Court decision. And this was an analysis of every birth in Florida over a couple decades. And they found that Black babies were more likely to die if they had a doctor who was not black.
I know we have an aversion to discrimination, but it saved babies’ lives. You want dead babies or your principles about not discriminating, we have got to save babies. Except it wasn’t hard to figure out where they hid the ball. They controlled various factors about the baby’s health, but one thing that was obvious that they didn’t control was whether the baby was very low weight. They controlled whether the baby was low weight but not very low weight. And the information was the ones that died and very low weight babies get treated by neonatologists more often than a regular obstetrician or regular pediatrician and the neonatologist is very likely to be white because there are very few black neonatologists. It’s not that white doctors were killing black babies, it was that black babies who were going to die because they were very low weight were assigned to white doctors.
And sure enough, a Harvard economist got hold of the data, reanalyzed, introduced this control and the result goes away.
David Brail:
Every time I go to a hospital, the doctors that I have are the right pedigree. My mother lives in Central Florida. She’s been hospitalized repeatedly. All the local hospitals, every doctor she meets with it’s always an island or a foreign medical school. The big city teaching schools get the pedigree doctors and the provinces get doctors trained elsewhere. If there’s a capacity issue, why can’t we expand the number of seats in medical school? And then how do you view the relative capabilities of foreign and island trained doctors versus US trained doctors?
Larry Bernstein:
Jay Greene, you want to speak about this?
Jay Greene:
It’s true that we bring in 25% of our doctors each year from abroad, and that’s because the number of residencies far exceeds the number of MD graduates from US schools, and the gap that has to be made up by bringing in the others. Now, in the 1980s, it was under 10%, so it’s tripled in the last half century when we were cream skimming the very best from abroad. It was advantageous to us that they were paying for the training of people that we were then bringing in their very best. But as we get to a quarter, we begin to dip deeper down into the pool, and because we are not involved in the accreditation or oversight of their training, we don’t know about the quality of their training.
We need to ramp up US med schools. It’s not obvious to me that we’re making a smart trade off of saying, “Well, our clinical training isn’t good enough, but the clinical training for the med school in Ghana is A- okay.
We have to reduce our dependence on having to import doctors where the training is suspect and we can be a little bit more selective in the importation of doctors so we can return to maybe 10% from abroad as opposed to 25%.
Larry Bernstein:
Thanks to Stan for joining us.
If you missed our previous podcast, it was How Academics Shaped the CIA.
Our speaker was Peter Grace who has a recent book entitled The Intelligence Intellectuals: Social Scientists and the Making of the CIA. Peter discussed how just after World War 2 and at the height of the Cold War, American academics worked inside the CIA’s research and analysis department to forecast enemy activity, and how they set up methods and processes that have been applied by the CIA ever since.
You can find our previous episodes and transcripts on our website. Please follow us on Apple Podcasts or Spotify.
I am Larry Bernstein with the podcast What Happens Next.
Check out our previous episode, How Academics Shaped the CIA, here.
