Basic Science

As an undergraduate and then a first and second year medical student, we spend much of our time learning the basic science, principles, mechanisms, and theory behind clinical medicine. Whether physics, chemistry, physiology, or pharmacology, we labor over the memorization of pathways and proteins, equations and formulas. But when we reach the clinical years of medical school and then postgraduate training, we leave all of that basic science behind. We focus on our doctoring skills and on the practical applications of what we know. In the busy days of rotations, if something isn't clinically relevant, it isn't relevant. If the basic mechanisms behind something are too complicated, then we hand-wave about it. For example, in hyperkalemia, calcium gluconate is given to "stabilize cardiac membranes." What does that mean, I wonder. Does it change the Nernst potential or activate ion gated channels? I used to think about that, but now on clinical rotations, "stabilizing cardiac membranes" is a sufficient explanation.

Nevertheless, basic science is fundamental in the education of an effective independently-thinking physician. We could easily just teach clinical medicine. In hyperkalemia, give calcium gluconate, insulin, glucose, bicarbonate, albuterol, kayexelate. In an anion gap acidosis, we memorize MUDPILERS as the etiology. We can teach this way, and often on the wards, we find ourselves using such shortcuts. But this is the way to train technicians, not physicians. I greatly appreciate technicians, and they are essential for many tasks, but doctors aren't technicians and training them in that fashion is a mistake. Like other professional schools, medical education is focused on teaching students to think. We want doctors who can reason, adapt, innovate, and create. By teaching the basic science, we make the intellectual connections that force the material to transcend dull memorization and take on a life of their own. In hyperkalemia, I think about how insulin and glucose work to shift potassium into cells; in anion gap acidosis, I think about why those etiologies increase the unmeasured anions. But beyond that, we don't want doctors who are dependent on textbooks, who cannot teach themselves, who cannot determine what research questions need to be asked, who cannot reason out how to approach a disease they've never seen.

Many people complain about the basic sciences, and I understand why. We entered the field to take care of people, not memorize equations and names of genes and proteins. And indeed, much of that fades in the clinical years and we look them up when we need them. But I firmly believe that the act of learning the basic sciences, drawing connections, struggling with problems, and finally integrating that knowledge sets a foundation for the rest of one's medical career.