Med School: It’s Not What You Think It Is

I am so tired of seeing statements like these:

– Nutrition is not taught in medical school.
– Pain management is not taught in medical school.
– Practice management is not taught in medical school.

All three of those statements, and the vast majority of others bemoaning the shortcomings of medical education just because “XYZ isn’t taught in medical school” are right, but oh so wrong.

“Nutrition” is not taught in medical school. What we learn is biochemistry, metabolism, gastrointestinal and endocrine anatomy and physiology. We may not learn “nutrition” per se, but we learn what we need to know to understand nutrition in a more fundamental and comprehensive way than can be gleaned from any course in “nutrition”. This also means we understand nutrition differently — and more completely — than anyone without that same level of medical education can, however much they’ve read about nutrition.

“Pain management” is not taught in medical school. What we learn is neuroanatomy, pharmacology, behavioral psychology, and neurophysiology, so that we have the basic knowledge to understand pain management. Narcotics dosing, epidural steroid injection techniques, rehab protocols and so on are learned in residency. I agree that pain is often not well managed, but not because “it’s not taught in medical school.”

Practice management is not taught in medical school. Why should it? Not every doctor is going to have to manage a practice. Many of them are going to become employees. Should everyone leave medical school knowing how to read an employment contract? Well, yes, but is medical school really the right place to learn that? How about the basics of money management and investing? You should have learned that around the kitchen table from your parents before you started high school. That’s not what medical school is for.

Medical school is where you learn the basics about the human body, its structure and function in health and disease, and the disease processes that afflict it. You learn about the microorganisms that make people ill and the drugs that make them well. And that’s just the first two years. The second two years is when you put those basics to work at the bedside, discovering what all those things you learned the first two years look like in real life. Hopefully by the time you’ve gone through those four years, you’ve decided what kind of physician you want to be, so you can move on to postgraduate (residency) training, where you learn how to do what you need to do. Almost all of the knowledge and skills physicians use in day-to-day practice are learned in residency, not medical school. That’s where a surgeon learns to surge, where OBGs learn to deliver, and where family docs learn everything. Even after training is completed, there’s Continuing Medical Education to help us keep up to date. (There’a also UpToDate.)

Family doctors, internists, pediatricians and all other primary care doctors need training in nutrition. Surgeons, hospitalists, oncologists, and all doctors who take care of sick people need training in pain management. Everyone needs to understand the basics of running a business, including the underlying principle of receiving payment for providing professional services. But medical school is not where these things need to be taught.

Doctors also need to know how to respect others, how to manage their time, even how to wash their hands. Ideally they should know these things long before medical school. If not, they shouldn’t be accepted in the first place.

Most of the hue and cry about alleged med school deficiencies is really a set of straw man arguments made by non-physicians trying to demean medical education because “doctors aren’t taught about this,” whatever it is they’re selling. Don’t but it. By the time you see a doctor, he knows what he needs to know in order to figure out what’s wrong with you and what to do about it. If not, any deficiencies are not because of things “not taught in medical school”.

10 replies »

  1. “We may not learn “nutrition” per se, but we learn what we need to know to understand nutrition in a more fundamental and comprehensive way than can be gleaned from any course in “nutrition”. This also means we understand nutrition differently — and more completely — than anyone without that same level of medical education can, however much they’ve read about nutrition.”
    If this is true, why are 1 in 3 Americans diabetic?

  2. I couldn’t agree more! It’s embarrassing that doctors are not the first source to turn to when it comes to getting heathy and taking ownership of self inflicted disease. We should all be preaching the prevention message. Obviously, that isn’t taught in med school. There isn’t job security in that idea.

  3. I’m currently a medical student myself, finishing my third year and have several comments.

    1) Nutrition as a field is NOT taught in med school. I’ve had, to date, 2 lectures that brought up the topic of nutrition, the main one ending with the concept that it all comes down to intake vs output and as long as intake is equal to output, you’re fine from a medical standpoint. I couldn’t disagree more.

    2) Brings us to the point of whether these classes even belong in med school or not? Well, primarily nutrition education is done in the hospital and clinic largely by staff, dietitians, nutritionists- but I think it is as important for those doling out meds to understand nutrition as it’s own science, and not just “biochem and physiology”. Nutrition has such a large role in human health- how can we purport to understand health on a micro level and be okay with not knowing about it on a macro level when that is the way we deal with patients?

    I find shame in the fact that I walk through the hospital as a new member of the medical team and see diabetic patients with high glycemic index items on their trays like boiled carrots, mashed potatoes, rice, and pie. I see children being fed mac and cheese, enriched white flour bagels, and fries. It makes me feel like we are undoing the physical well-being we are attempting to give these people as we “treat” them in the hospital. Can we all really just ignore this?

  4. I practice primary care and unfortunately, there isn’t enough time to teach patients about nutrition. I rely on ancillary staff and clinics to do more education. I am disappointed in the lack of whole food diets in diabetic education and etc. I will say that I don’t think medical school is capable of teaching all the details of nutrition. But, after practicing a year or so, it becomes obvious that disease is caused by what we eat.

  5. Graduate degrees in nutrition?

    There is no (repeat NO) good randomized trial data in nutrition, at least in medical/critically ill patients.

    Reductionistic investigative approaches (i.e., giving omega 3 fats does this, a high carb diet does that, this tube feed formulation does the other) has always failed to yield useful or conclusive data, because human metabolism is interdependent and so complex as to be beyond the point of current human understanding.

    Most people posing as nutrition experts on the hospital ward have a pseudoscientific training, but aren’t aware of that — they think it’s scientific. That’s the source of the snubbing and looking down our noses by MDs. We respect evidence, and in nutrition, there isn’t any that’s good enough to hang your hat on and defend it strongly in making clinical decisions for patients.

  6. I have been a practicing chiropractor for about 16 yrs and although we have a solid class-room education with 4 yrs post secondary (just like the MD’s and DO’s). I can not go a week without hearing about how inferior my profession is to the other health care practitioners. I get really tired of it. It is complete ignorance. I am not in a position to comment on MD education– I didn’t go to MD school. I have some basic understanding of what the core curriculum is. But how the actual lectures are presented? No idea. Similarly, MD’s should stop bad-mouthing the DC education (unless that MD also has a DC degree).

    I certainly do bad-mouth the wackos in my profession who leave their science, evidence-based training at the door and start doing crazy, non-science modalities. I shake my head and hide in shame just thinking that some DC is going to sell a foot-bath-body-detoxifier (for 4 payments of $99). But I am bad-mouthing their loss of clinical judgement, not their education and training.

  7. Bobby G you took off on a tangent however you are correct about certain items. Schools do approach nutrition in different ways so generalizing is not a good measure of what happens. Left out is the additional time in training during residency years. There should be a clear definable core of knowledge in the curriculum to be certain nutritional education is coalesced from training in basic sciences. Perhaps a nutrition text or recommended reading should be added to these other courses. M uch of this information could be integrated into the courses on preventive medicine.

  8. “…A core justification for the enormous time and expense of physician training, and for the legal monopoly and high compensation conferred on physicians, is their scientific training. Presumably that training enables physicians to apply medical science to patient needs with scientific rigor. Yet, one of the leading medical schools in the world here describes itself as failing to provide adequate experience in the elements of clinical medicine, failing to provide good learning conditions in either hospital and ambulatory settings, failing to provide uniformity of content, failing to enforce educational rigor, failing to reliably evaluate students’ core competency and failing to integrate basic science and clinical medicine.

    Failure to integrate the two is predictable, given what happens in the medical school curriculum. At the beginning, faculties overload students with abstract knowledge—textbook answers to questions they never asked about observations they never made. Learning of this kind is the antithesis of scientific inquiry. Students who undergo this process can easily become doctors who “quote what is in the book and deny what is in the bed.” A number of studies, for example, have documented the phenomenon of students who unconsciously “fabricate” findings in patient examinations, perhaps because the findings “are consistent with their understanding of the disease believed to exist or because they are consistent with the ‘classic presentation’ of the disease felt to be most likely.”

    After the beginning curriculum, medical students are thrust into clinical settings with the hope that they will somehow learn to apply their abstract knowledge to real patients effectively while mastering a broad range of manual skills. Yet, absent are the optimal conditions for learning—manageable scope, an individualized program, the opportunity for single-minded attention, careful progression from simple to complex tasks, close feedback. Learning tends to happen on a “sink or swim” basis, with students often left to their own devices, receiving less structure and less organized feedback than in their formal education. The environments in which students are placed do not assure mastery of essential skills. Nor do these environments foster the disciplined behaviors that medical decision making demands. Indeed, the medical school environment violates a basic educational principle stated by John Dewey: “We never educate directly, but indirectly by means of the environment. Whether we permit chance environments to do the work, or whether we design environments for the purpose makes a great difference.”

    Teaching skills and behaviors is not emphasized in medical education. Rather, its “traditional emphasis is on teaching a core of knowledge, much of it focused on the basic mechanisms of disease and pathophysiological principles.”242 But no definable core of knowledge is actually transmitted to or used by practitioners in patient care with any kind of uniformity. Whatever core of knowledge medical schools attempt to teach varies from one institution to another, students do not learn all they are taught, they retain only part of what they do learn, that residue varies with each individual, and some of that residue quickly becomes obsolete.

    Weed MD & Weed JD, “Medicine in Denial,” pp 199 – 200.

  9. I have to agree with Tim about nutrition. The real question is, should we HAVE to know about nutrition – or should that be left to mid-level practitioners who can convey that information to patients much more cheaply.
    I also disagree about one more thing – in today’s world, medical students MUST learn about the science behind patient safety, efficient delivery of care and working in teams. The ‘craft’ of medicine, as so eloquently stated by Dr. Brent James at Intermountain, is the real dinosaur. Let us check our egos at the door and humbly learn how not to kill people with human error – in medical school, where that skill firmly belongs.

  10. “We may not learn “nutrition” per se, but we learn what we need to know to understand nutrition in a more fundamental and comprehensive way than can be gleaned from any course in “nutrition”.”

    No, that won’t do. This is an assertion without evidence. In fact, it sounds obscurantist. Lots of people with graduate degrees in nutrition think your profession is ignorant and smug about it.