Briefly: two things, either one of which I could expand into an essay.
First: trainee workload. DS2 - very much a MiniMe, the poor man - is currently doing his internal medicine residency thirty-five years after I did mine.
Much of it is the same, but what is most instructive to me are the differences.
First is the sensible work hour restrictions. The formula is complex (how many days in a row; how many hours per day; some other stuff wrt purely instructional hours e.g. practice board tests). Those are unequivocally better than my era, when no restrictions existed. Internship for me averaged 110 hours/week over the 52 weeks, easing only slightly in the ensuing two years. My personal most-ridiculous schedule: 24 hours on/24 hours off for a full month, working (with culpably little supervision) the emergency room of an inner city university hospital of a major metropolitan era. At only 84 hours/week (on paper, in reality more like 90+), it seemed great for the first few days…but then the physiologic reality of being up all night, every other night started to kick in. I did five months of this in three years.
Yes, it was dumb. And dangerous. And it was the era that brought the Libby Zion case, where an overwhelmed intern and his supervising resident caused the unnecessary death of a young woman in a major NYC teaching hospital. Once again, medicine couldn’t/wouldn’t police itself, so the justice system and multimillion-dollar lawsuits were needed to get the policy-makers’ attention.
I’m less than fully enthusiastic about the work limits now set on even senior trainees, because that’s not how the world works. Barring the few fields where there are few truly urgent cases (think: dermatology), in cardiology, oncology, nephrology, ob/gyn, emergency, critical care, etc etc etc there are just going to be random days where the load is two standard deviations above average. While a third-year medical student just starting on the wards is best capped at 2-3 patients at a time, and newly minted interns probably shouldn’t have more than, oh, 5-6 existing patients plus 2-3 admissions per shift - the senior trainees should have real-life exposure to those full moons when the wheels fall off, the cavalry isn’t coming, and triaging, time efficiency and a sleepless night are critical to getting the job done.
But overall: DS2 experience much more appropriate in 2022 than was mine during the Reagan administration.
My second thesis: I actually have a pretty good idea what in a perfect world, driven by logic, should supplant organic chemistry as the default undergraduate weed-out.
(Parenthetically: I did a brief internet search and it looks like around fifty US medical schools no longer require O-chem, or around 25%. I mean, if you’re an undergrad and make the decision to get in the high-stakes poker game where everyone else is playing from a 52-card deck while yours has 39, then God be with you. Complicating this is that many of these are state schools which just don’t take out-of-state applicants. If you’re a resident of the great state of WX, and the Univ of WX Med school requires O-chem, then)
OK, out of time. Very briefly: my O-chem replacement concept. The necessity is that of a complex, highly technical set of closely interrelated subjects which lends itself to testable hypotheses…but is necessary for the intelligent practice of 21st century medicine, which O-chem is not (and truly ever was. Biochem should have supplanted O-chem as a premed weeding course around 1980).
And I’m not in favor of eliminating organic chemistry entirely. As I wrote somewhere above, ten instructional hours or so should be plenty for an MD
My proposed replacement thesis statement: “The Wacky World That Nucleic Acids Have Wrought”, or (more sophisticated): “A Comprehensive Survey of Information Transfer in Biologic Systems”
You start with Mendelian genetics and Punnett squares. That takes a day. Then you quickly move on to translation, transcription; up- and -down-regulation; gene transfer. A moderate survey of different organisms (viruses, fungi, prions, even intuitively common things like corn) are instructive as to what is essential to life, and why different trees ‘chose’ differing strategies.
You move on to the modeling of 3D protein structures (which in the final analysis are dictated by physical chemistry meeting a certain nucleic acid sequence) and implications for drug design - necessarily including some pathologic variants (e.g., oncogenes)
Yes, it’s hard science - and the computer modeling is just beginning. It may not lend itself to a lab section as O-chem, but, uh, so?
The course has room for enormous breadth, and could be as complex as the university chose to make it. But the graduate would be facile with, well, Life.
My hypothetical course finishes with memes - the original Dawkins variety, where the whole purpose of life becomes the transmission of information across generations.
I’d rather my doc - or any well-educated biologic scientist - be capable of handling and be well-versed in the methods, vagaries, adaptations, errors than in Kekule’s snake or the Grignard reaction.
/rant
