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September 15th, 2019
A Former Medical School Dean Invents a False Dichotomy in Curriculum Content, and Advises Physicians to Stay in Their Lane
Aristotle, who famously said this.
Over on the editorial pages of the Wall Street Journal, a piece appeared last week with the following provocative title and subtitle:
Take Two Aspirin and Call Me by My Pronouns
At ‘woke’ medical schools, curricula are increasingly focused on social justice rather than treating illness.
Dr. Stanley Goldfarb, former associate dean of curriculum at the University of Pennsylvania, argues that current medical schools focus so much on advocacy, social justice, and various (left-leaning) causes that students don’t have time to learn how to care for patients.
And what are some of the distractions these medical students must endure as they try to master the craft of medicine?
Cultural diversity, gun control, climate change, health disparities. Teaching about these topics “comes at the expense of rigorous training in medical science.”
He cites no actual data that this is true, of course, which means it’s his opinion — an opinion I strongly suspect he harbors based on how he feels about these topics himself.
Regardless of how we feel about them, however, most will recognize the “back in my day we studied real medicine” tone. This one turns up frequently when many of us old-timers weigh in on the state of medical education today, be it in medical school or residency. You know, “back in the days of the Giants”, bringing to mind the “OLD MAN YELLS AT CLOUD” internet meme.
But back to the topic of his piece — is it really a new phenomenon that medical schools include a societal (as well as individual) view of medicine, and that students show interest in these topics?
Absolutely not — back when I went to medical school a million years ago (ok, in the early 1980s), we were urged always to consider our patients in the context of their community, and also to think broadly about what we could do as doctors to improve not just individual, but also community health. While patient care was a the core of our efforts, my classmates ended up choosing a huge range of different passions to pursue.
A quick list: Basic science research. Clinical research. Public health and epidemiology. Health disparities, both here and globally. Domestic healthcare policies. Healthcare finance. Teaching. The medico-legal interface. Investment banking and consulting. One even started her own footwear company!
In short, one of the great things about medical training is that it’s adaptable to a wide range of health-related pursuits. Since what we include in a medical school curriculum cannot possibly cover everything — more true today than ever — why not include topics that are important from a societal level too? Don’t these influence patient outcomes?
Of course they do — sometimes powerfully so, something most University of Pennsylvania doctors readily acknowledge, citing the vast economic disparities evident right there in Philadelphia.
I respectfully disagree with Dr. Goldfarb's arguments. @PennMedicine's students are required to rotate in our West Philadelphia EDs. Traditional curriculums do not prepare them to address the barriers (violence, poor housing, addiction etc) that impede good clinical outcomes
— M. Kit Delgado, MD, MS (@kit_delgadoMD) September 13, 2019
And it appears the University of Pennsylvania agrees, as evidenced by the letter they have sent to students and faculty:
Please know that the views expressed by Dr. Goldfarb in this column reflect his personal opinions and do not reflect the values of the Perelman School of Medicine. We deeply value inclusion and diversity as fundamental to effective health care delivery, creativity, discovery, and life-long learning. We are committed to ensuring a rigorous and comprehensive medical education that includes examination of the many social and cultural issues that influence health, from violence within communities to changes in the environment around us.
Additional Penn faculty quickly weighed in on the editorial, noting that “social and health policies have always determined who gets sick and who gets care, and where, and how.” Unlike in the Wall Street Journal piece, these authors include some clear examples — the Flint Water Crisis, urban gun violence, underdiagnosis of cardiovascular disease in women and depression in African Americans — on how poverty, race, and bias influence individual and public health.
As for Dr. Goldfarb’s opening salvo:
The American College of Physicians says its mission is to promote the “quality and effectiveness of health care,” but it’s stepped out of its lane recently with sweeping statements on gun control.
30 Responses to “A Former Medical School Dean Invents a False Dichotomy in Curriculum Content, and Advises Physicians to Stay in Their Lane”
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
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Absolutely agree. I am sure you are right about Dr. Goldfarb’s political orientation. Physicians have a responsibility to society at large, and that responsibility includes the very subjects he dislikes. My medical school time was the late 1960s, even more ancient than yours, Paul. Campus ferment around us and fellow students provided more education on these subjects than the medical school. Far better for medicine as a whole if emerging physicians understand they must advocate for social justice (not just view medical training as a route to entrepreneurship).
In my experience,”Stay in your lane” invariably comes from someone who is taking up two lanes, and should not be driving any more…..
The sad performance of some physicians in our congress about items of health, reveals a deficit in their medical education and lack of knowledge about social, legal, policy, and poor open discussion during contacts with faculty and peers during their years of med school.
Well stated. I am a family physician and in the past few years have been seeing more and more people for mental health issues. Psychiatric problems (as well as physical problems) do not arise in a vacuum. We as physicians have to look at our patients in the context of their lives and culture.
And don’t get ME started on transgender issues and use of correct pronouns.
From the faculty opinion piece published in the Philadelphia Inquirer: “Social and health policies have always determined who gets sick and who gets care, and where, and how. Understanding the social drivers of health and illness is not peripheral or tangential to health. It is key to diagnosing and meeting a patient’s fundamental needs, and to restoring health.” Indeed! Dr. Goldfarb is certainly entitled to his opinion and to write what he thinks. It is unfortunate that that opinion is now associated with the University of Pennsylvania, an institution that teaches students to think deeply about social justice and to take action to address inequalities and disparities.
As a Penn Nursing school alumnus (GrNU 99),I agree with Penn SOM on our moral mandate to look human suffering and its causes directly in the eyes and and act accordingly. To do otherwise implies a concocted self-superiority to those whom we care for and called upon to serve. Let them eat cake has never fed the hungry and bind eyes cannot see what our better angels reveal to us. Your humble nursing correspondent and ally in compassion.
I think the former Dean is right. There is plenty of time to focus on social justice and whatever is your heart’s content is in the 22 years leading up to medical school and the rest of the physician’s life there after. Medical School should focus on pathology and developing your differential diagnosis
Assumptions that may or may not be true:
1) Primary health care (PHC) is dying. There are lists of dying professions in the media that list PHC. There are examples given of American PHC doctors immigrating to Canada in order to survive.
2) Goals of varying priority in a medical curriculum can be (a) to develop a technical expert, (b) to develop an academic expert (c) develop an health expert who is the flag carrier of medical ethics (seeing all the horrific genetic developments in medicine), (d) develop a student with the financial and business acumen to survive (e) develop a student that develops a consciousness that sociological processes outside the influence of the doctor determines doctor-patient interaction and health outcomes.
3) The PHC physician or the specialist or the public health specialist or the legal fraternity can be the gatekeepers. I as physician do not believe that health management are good gatekeepers. Without good gatekeepers medicine is going to lose all credibility in the near future.
I think the solution lies partly in the Covey model. Phase 1 the phase of dependence (first 4 years or first 6 years). Very technical training.
Phase 2 The phase of independence (year 4 to 7 or year 7+). The student starts developing the skill of putting theory into practice.
Phase 3 The phase of interdependence ( Year 1 to 6 … or year 7 + or postgrad).
All students go during their careers through all 3 these phases. The question is on whether they should academically get a crash course on “life” compressing aĺl the exploration in a standardised 6 year package.
I think it is exciting to qualify as a technical expert and not to have had in-depth training about the external environment. In depth training of the sociology, demography and alike can be part of a life-long learning program designed by the students themselves doing Public health coursework.
Seeing the medical curriculums are of such long duration I feel that students should have the option of exiting the medical curriculum and have the option to complete some degree in a paramedical field…. maybe via a public health school or department.
Science of Medicine stays the core of learning and social context influences the clinical acumen to give the best to the patient. Medicine is an art and science. Social and health policies refine the art of medicine and not the science of Medicine.
I think the “overarching” issue here is that medical schools are being turned in progressive bastions, as are our public schools. I’d love to see what would happen if a conservative idea was taught at a medical school….that professor would be tarred and feathered. When all of the professors and teachers are liberal, there is no longer room for discussion as to what is appropriate. You either buy in to the progressive ideals, or you are a horrible person. Please let someone chime in who isn’t a democrat to disagree with me. I’ll probably be waiting a long time.
There are several academicians the world over expressing anguish at the declining standards of clinical skills, and carry an apprehension at the ‘demise of clinical medicine ‘. With advancing technology delivering quickest results , but some with the note ‐‐- correlate clinically , there are occasions where neither the laboratory nor the imaging helps the diagnosis ‘final and complete’. Thus core of matter for the medical graduate is ‘sound clinical acumen ‘. The medical curriculum is ever expanding and clinical diagnosis by itself will not be adequate in a vacuum, where social , financial , legal , ethical , aspects are ignored. Thus information , exposure and awareness of these factors is vital ; the issue is if ‘balance and perspective ‘. The pendulum of the core and the coating should not be allowed to swing too far in the interest of the student , the patient and the profession. Concerns expressed may evoke strong reactions , but every coin (issue) has two sides and the right balance has to struck. Prof ME Yeolekar , Mumbai ( Former Dean)
Liberal progressive teaching has absolutely no place in a professional curriculum such as medical school. Med students have already had ample exposure to this kind of indoctrination in college, whether they wanted it or not. Today’s academia is totally ruled by the PC crowd. Any faculty who dares to speak out against this does this at his or her peril. And that is despite the fact that “inclusiveness” is one of the buzz words of that crowd (see the university’s official rebuttal of Dr. Goldfarb’s article!). But their “inclusiveness” does not allow for dissension. What a sham. And what a shame.
I have treated thousands of patients compassionately and competently, and saved numerous lives in my medical career, without taking any such PC courses. Those were most assuredly not part of our curriculum then. Medical School should be exactly that: Going to school to become the best medical provider possible, without burdening the student with politically correct humbug.
When I get sick, I want a doc who spent his time in med school studying diagnosis and treatment, not social justice.
Alan J. Zimmerman, M.D,
“No man steps in the same river twice…”
Dr Goldfarb,
First, I must challenge your assumption that the American College of Physicians “stepped out of its lane in its sweeping statements on gun control”. For the past 25 years I have worked at your institution as an Emergency Medicine doctor and sadly, I am well-versed in managing victims of gun violence. While I can wield the algorithms of ATLS (Advanced Trauma Life Support) in my sleep, after so many years resuscitating 17year olds dying from gunshot wounds, I have arrived at the conclusion that I must not be silent and content with waiting for the next victim to come crashing through the doors to apply my skills. My goal as a physician is to make communities and individuals healthy and sometimes that requires a willingness to leave my comfort zone and step up as a physician to lead and advocate in thought and action. To simply ignore the myriad of socio-economic variables that lead to the trauma that I see on a daily basis is absurd and steeped in the elitist notion that your op ed piece embraces. It is essentially a justification for “burying my head in the sand” and dodging responsibility.
And that brings me to that famous American model for medical education and health care that is emulated the world over. I was in Nicaragua in the early 90’s at the USAID headquarters in Managua listening to our government rationalizing the privatization of health care services under the mantle of neo-liberalism. I was a young faculty member working in the emergency department at the interface of academic medicine and the real world and my eyes were wide open with respect to the successes and failures of modern medicine. So I had to ask the hard “emperors clothes” question to the USAID representatives…”Why would we export a model for health care that fails to meet the needs of 40 million Americans; and one that spends more per capita per individual and yet was ranked 36th in the word in health care outcomes?” Nearly 25 years later this question becomes increasingly relevant when the issue of health disparities in our nation is raised.
The pre-Socratic philosopher Heraclitus stated “no man steps in the same river twice, for its not the same river and he’s not the same man”. He was talking about the concept of “flux”, the notion that little escapes the forces of change.
After thirty years in academic medicine, one of my observations and criticisms of the medical model that you feel is so threatened with change rests on the simple fact that at it’s core, it remains essentially the same model that has been handed down as the gospel for generations of past and present medical students, ignoring the reality of a changing society and its needs. With its roots deeply seated in the sixties, when nearly 90% of our population was white non-Hispanic, and with a strong emphasis on specialization and technology, defaulting to this model runs the danger of perpetuating an elite, status quo eduction for the next generation of providers that essentially creates them in our own image, which by default is that of our forefathers.
As medical educators we must critically ask ourselves, “What is the world going to look like 10-15 years from now, when the students we teach today have completed their training and enter the workforce?” Embracing Heraclitus’s notion of flux, a lot of change can happen in 15 years, and a word of caution about hawking a static outdated model for medical education… we are doing our students a disservice, and ultimately the communities they are entrusted to serve.
Limiting ourselves in our vision has consequences. Take for example, in 2010 the AAMC published the Flexner Centenary Report on the status and future of medical education. In the same year, the IOM in partnership with the RWJ Foundation published a report entitled “The Future of Nursing: Leading Change and Advancing Health”, highlighting the critical role of nursing on the front lines of patient care. And yet, in the AAMC report there are no articles about nursing or the essential role it plays in the health and wellness of our society. Nearly 10 years later, one needs only to ask “how many medical schools have moved beyond their siloed models of training to embrace an integrated multi-disciplinary approach to the training of its nursing and medical students?”…which many would argue is the future of healthcare in our country.
I think of the lesson from George Washington, who as the “father” of the newly founded United States of America, chose not to be crowned a King. He looked critically at the future of the nation and saw that the country would grow beyond 13 colonies, and that more people and land would be added and that new ideas and responses would be needed to meet the demands of an ever-changing society. To that end, medical education might be better served if rather than allowing “long in the tooth” senior leadership to perpetuate the outdated terms for the education of their charges, it truly encouraged and supported faculty with “fresher eyes” on the challenges and needs of our society to bring much needed innovation and creativity to the forefront.
Sincerely,
Steve Larson MD
Executive Director Puentes de Salud
Associate Professor of Emergency Medicine
Perelman School of Medicine
University of Pennsylvania
What exactly is my lane and who is the traffic cop to keep me in it? Just wondering.
I agree with Dr. Goldfarb. Physicians should only focus on medicine in medical school. Social justice, gun control, etc. are not the reasons why people go into medical school. If you want to focus on these issues, you can go into Public Health/ Global Health. You don’t have to be a doctor to be an expert in those areas.
Other “lanes” that medical schools should take: tax evasion and funding of political campaigns by corporations and the wealthy. 2 subjects closely interwoven with fiscal difficulties in funding public health. Call it “FC” for fiscal correctness
Think about: right = individual, left = government.
What an amazing oversimplification. I feel bad for your patients.
My lane is wherever my patients take me in the journey to help them. The more we understand their lives, their challenges and their preferences, the better we can help the overcome their health issues. My job is to inform, guide and suggest. Empathy is how I gather that information effectively and interpret it. For those of us who became doctors to help people, we need to first understand what help they want and are able to take. Having worked with underserved and underinsured communities my whole life, knowing their social context defines how I can help. As someone else said, medicine is art and science. how exactly does it hurt to learn to be better at both? And why is it so offensive to others if we teach about public health issues that will affect our careers and our decision making for patients? When did more exposure and education become a bad thing? Not to mention, there is scientific evidence that social variables affect health and outcomes…
The American College of Physician’s recent position paper on gun violence falls far short of the mark. Handguns and rifles in the home are far safer than hot tubs, swimming pools, snow blowers, and of course the car. If you want to save lives, perhaps it would be more effective to spend a doctor’s precious time recommending that we all drive SUVs. An SUV is five times safer than driving a small car. We could save about 500,000 lives a year if we all switched to driving large SUVs, but of course, saving lives is not the real reason for the ACPs position paper. No, the ACP just wants to join needlessly in politics. If they wanted to save lives, there are lots of measures that could save lives like focusing on smoke and CO detectors in homes.
How on earth could SUV’s save 500,000 lives per year if there are only 37,000 and change traffic fatalities per year in the US?? and gun deaths in the US (39,000+) now exceed traffic fatalities ?
Just trying to understand your math.
“An SUV is five times safer than driving a small car. We could save about 500,000 lives a year if we all switched to driving large SUVs”
[citation needed]
Medicine has been politicized for better or worse; Dr.s Goldfarb and Saxe as well as most of the preceding comments reflect this. There are numerous consequences but one of the more disturbing relates to the polarization effect on caring for individuals (harder all the time for physicians and patients of diverging political views to appropriately focus on care). It also appears in public health issues such as vaccines and gun violence. Medicine has lost credibility, the moral ‘high ground’ with fairly good ‘chunks’ of the population secondary to various views of ‘political agendas’. At least part of this is the consequence of ‘advocacy’.
The pursuit of social issues should be left to those who have been given the luxury of time and reflection. For practitioners, such pursuits represent distractions from patient care and a retreat from our mission.
Doctors, in my perhaps elitist opinion, already as a cohort enter medical school knowing too little science. I question whether training a generation of amateur sociologists will produce practitioners with the technical skills necessary to be truly outstanding contributors to medicine.
What is my lane ?
Should I stay on a lane determined by the gun lobby, the for profit medicine corporations, the pharmaceutical companies that jack up the prices of medicines to answer the expectations of their stockholders, the medical schools that are mortgaging our profession, those who deny that health care is a human right, or the ones who consider contraception too expensive and Viagra a birth right ?
Are we to remain silent while the water supply is polluted, the air we breath too dangerous, the epidemics spread by global warming more lethal ?
I am not going to be silenced by anybody, my lane is what I chose it to be.
Thank you very much.
Good, I recognize the US again. Grab every opportunity to promote gas guzzlers, even when there is a climate conference in the US. Moreover if a small car is hit by a guzzler those in the small car are less likely to survive which makes SUV-drivers more careless in my experience (when cycling peacefully on my errands inhaling exhaust, I am often threatened in my “lane” by a too near SUV in a hurry). Can somebody please do a study about type of car including brand and hitting cyclists? If we burn more fossil fuels mostly people in remote countries are the victims.This attitude more or less proves colleague Paul E. Sax, point.
Douwe Verkuyl, PhD, FRCOG. The Netherlands
training at penn in the mid 60s ,part of our medical training involved going out into the community with the public health nurses and going into the homes of their patients. this rotation gave us a first hand,living picture of the social condition that the clinic patients lived. changing that condition was beyond our capabilities and goals but the stark recognition of the social condition made us more tolerant and compassionate physicians. diagnosing and treatment of disease that arise is the aim of medical school. recognition of the social background is important in diagnosing and treating those problems arising in the social environment but totally changing that environment is the goal and job of public health officials and government influence. those involved may be doctors trained in public health but that training should not be a significant part of medical training.
Having looked as far as I know how into Dr. Goldfarb’s bioprofile, I see no evidence that he is a paid shill of the NRA or the gun lobby. I think he deserves to be listened to. So how can the medical establishment deal with social issues and still “stay in lane?”
Certainly it’s in a position to describe the prevalence of socially and environmentally-caused medical conditions and the associated pain and suffering. Doing that for black lung disease, for example, can help provide impetus for change. But can a doctor tell us how to generate power? Can he tell a coal miner whether or not he can have a job?
A doctor can describe the trauma of a gunshot wound. But can he predict that eliminating every gun as if it were a germ won’t increase the incidence slashing and blunt force trauma? He can tell you us that the mortality rate of such injuries will be lower, but can he tell us that the victim’s mother won’t be traumatized just as much? Should he be able to tell someone at risk that he is not entitled to the most effective means of self defense?
“Ne ultra crepidam judicaret,” “Schuster bleib bei deinem Leisten” and “Cobbler, stick to your last” all mean the same in every language and applies to physicians and well as shoemakers.