COMMENTARY

Anatomy Factoids Do Not Create Great Physicians

Vinay Prasad, MD, MPH

Disclosures

June 29, 2020

Recently a medical student was shadowing me in clinic, and during an unusual period of downtime he studied from flashcards.

"Quiz me," I offered.

"What nerve innervates flexor digitorum superficialis?" he asked.

"Question time is over," I said, and returned to my note.

Around the same time, I was in the process of moving from the faculty of Oregon Health and Science University to the University of California, San Francisco, and had to do some serious downsizing. Each weekend, I was combing through my belongings, deciding what to keep, sell, or donate. This experience did not spark joy.

A gray wool scarf that I had not used in 5 years was a tough decision. It was true that I had not used the scarf, but that didn't mean that it might not be useful someday. I agonized about which pile to place it in.

In a moment of insight, I saw these seemingly disparate experiences as connected. They sum up the current state of medical education: It is a house full of things that might be useful someday. Over 150 years, we have accumulated biochemical pathways, anatomic structures, histopathologic findings, and clinical trial results; physiology, biochemistry, molecular biology, embryology, and more. And it has been very difficult to say, "Okay, it's time to get rid of this."

Instead, our house is overflowing.

Knowing Facts but Failing to Understand Evidence

That is why my student was not only memorizing the innervation of flexor digitorum superficialis but was also committing the origin, insertion, function, and visual appearance to memory. He has to be able to recognize the muscle in a dissected, desiccated cadaver, with a pin sticking out of it, labeled #37, as he moved from table to table in an intense test of rote memorization.

Later, as an experiment, I quizzed five of my medical school classmates, now more than a decade away from anatomy lab, on the same question my student had recently asked me. Four failed to answer the question correctly. Only one, a savant, gave the right answer. Even then, it's possible that he guessed. One classmate added that it was useless for all students to know this; only a few specialties need to know the muscles, nerves, and tendons of the hand at this level of detail.

Flexor digitorum superficialis remains in the medical school curriculum for the same reason I still have that gray scarf: because no one wanted to throw it out. Knowing the Latin name, origin, insertion, innervation, and appearance of this muscle could theoretically come in handy someday. At the same time, this fact takes up precious real estate in the brain. And we have more and more competition for that real estate. We have more and more to teach students.

Tools to keep up with the literature and critically appraise articles have never been more relevant in our profession. Consider the importance of these topics to the practice of medicine: evidence-based medicine and diagnostic reasoning; statistical interpretation and epidemiology; empathy and shared decision-making; handling uncertainty gracefully. Unfortunately, there is simply not enough time to do them justice the way we are currently teaching medical students.

Just like a cluttered home, memorizing low-value factoids prevents one from focusing on what matters. In my house, my bookshelf was stacked with novels two deep. There were so many volumes that I could not see what I might have actually wanted to read.

Similarly, each year when I teach my fourth-year elective course on critically appraising the medical literature, I am impressed by what students know and what they don't. This year, while discussing a paper on antiarrhythmics, one student could place all of the drugs into the appropriate Vaughan Williams classification. It was amazing, given that this information probably would not interest many doctors outside of electrophysiologists. At the same time, these same students struggled to tell me how to interpret a noninferiority trial. Was the observed result indeed noninferior?

This is just one example; I have accumulated many others. Students know facts that quite frankly have limited clinical relevance, yet they have been entirely deprived of foundational concepts used to understand evidence and make decisions, which are paramount in the career of a modern doctor.

Is This Essential?

As I decluttered my house during my move, it became obvious that the wrong question to ask was "Could this be useful someday?" Instead, I needed to ask, "Is this essential?"

Similarly, the wrong question for medical education is "Could this be useful someday?" A better question would be "Is this essential to the average physician?"

I say "average physician" because that is who we have forgotten as we go about developing our curricula. Medical school isn't meant to prepare you to be a novelist or a CEO or a Nobel Prize winner. Those may be things you can do with the degree, but they are not the most common outcome. Medical school is meant to train doctors, pure and simple. And frankly we could do a better job of that.

In the same way that I have a scarf I never wear and a shelf of unread books, not only do we struggle to throw things out, but we also have a compulsion to buy things we don't need. Some in medical education advocate that all doctors be taught business management, pedagogy, and even improv comedy. I'd argue that we refocus on teaching every graduate the tools needed to be an outstanding physician.

I have previously detailed my own proposals for reforming medical education, but I can easily summarize them as having the same core approach: Start with what a doctor needs to know and work outward from there. And by this I mean a doctor who predominantly takes care of patients — the most common outcome after medical school. It looks something like this: more clinical reasoning, critical appraisal, statistical interpretation, and decision-making and less Krebs cycle, isoforms of RNA polymerase, and flexor digitorum superficialis.

Medical education is overrun with clutter. It's time to clean it up.

Vinay Prasad, MD, MPH, is a practicing hematologist-oncologist and associate professor of medicine at the University of California San Francisco. He studies cancer drugs, health policy, and evidence-based medicine. He is the co-author (with Adam Cifu, MD) of Ending Medical Reversal: Improving Outcomes, Saving Lives and author of Malignant: How Bad Policy and Bad Evidence Harm People with Cancer. When not working, he enjoys cycling, reading, and binge-watching television.

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