It shouldn't begin in the clinic, and that's all right

I can't count how many times I have heard applicants, accepted students, or first year students talk about how "jazzed" they are that the curriculum at a given medical school starts off with "clinical" coursework from "the first day of classes." It's all the rage these days. Why start with your nose in the books when you can begin by actually seeing and treating patients? After all, that's what doctors do, right?

In a quest to meet these expectations, medical schools do everything to be "clinical" from the start: patient interactions begin on day one, medical history-taking is taught before any principles of cardiovascular or pulmonary physiology are explored, every opportunity is taken to emphasize the "clinical" relevance in all aspects of medical education, and small groups are formed ("Problem-Based Learning" [PBL]) to discuss "clinical" cases.

Must. Have. Clinical. Only. Always.

Relax, people.

Let's not kid ourselves. Simply discussing how a topic (say, for instance, the molecular development of a certain type of cancer) relates to a clinical diagnosis (say, a diagnosis of melanoma) does not mean that the curriculum is "clinical." It means it's putting basic scientific curriculum into the proper context. Contextual learning is not clinical learning, and nor should it be. If one were to start Day One of medical school learning the clinical aspects of melanoma, it would mean learning treatment algorithms, the principles of managing Il-2 patients, and the best practices for detecting and treating recurrent lesions. That approach of course wouldn't work if someone has no idea about skin physiology and anatomy, to say nothing of basic cancer biology.

My point is not to dismiss all clinical learning from the beginning. I think that the way in which doctoring/clinical skills are introduced in the first and second years of medical school are hugely beneficial. To be thinking about how a history is taken is a huge asset to how students learn the material.

To dismiss the first two years' physiology, anatomy, pathology, and so on -- in favor of watered down, "clinically-oriented" curriculum -- is to do a disservice both the medical students and the medical school as an institution. There is no substitute for having an understanding of the basic science of medicine. To whatever extent that material can be integrated with clinical examples is both instructive and beneficial. However, when it is replaced or challenged by students, faculty, and administrative powers-that-be with comments to the effect of "we want only the clinical 'high yield' info," core elements of the medical school experience are eliminated. And then everyone loses.

So please, let's refrain from obsessing over whether it's clinical and focus instead on whether the information is integrated, useful and necessary. I would bet all that "basic" science -- anatomy, physiology, histology, pathology, molecular biology -- is crucial to the education of the doctors of the future. The algorithms and protocols can wait. The basics need their place in education, too.