As a second year medical student at an institution that has recently introduced a new curriculum, I have become fascinated with the question of what ought to be taught in medical school. With the roll out of this new curriculum, which focuses on a systems-based approach to learning as well as integrating clinical experiences early on in education, the whole medical school has been abuzz with the enthusiasm of change. As a result of this new atmosphere, it has become acceptable for the faculty and even the students to question just about everything. When is the best time to hold a test? Is it better to stagger tests so you are tested over ‘A’ even as you have just begun to learn about ‘B’, or should you compartmentalize? What is the role of case-based learning, and how is it best implemented? But above all the question that is most pervasive is how best to allocate time.
I have got into the habit of asking a simple question to any clinician I meet; “What do you wish was taught in medical school?” The answers vary significantly depending on who I ask, but strangely in many cases, glycolysis comes out as the example of something to cut in order to fit in their pet project or interest. “If they cut out an hour of glycolysis you could easily teach the basics of weight loss,” or, “If they spent less time on glycolysis they would be able to fit in more time on substance use.” Pain management, sex trafficking, social determents of health, Spanish, CBT, resiliency training, suturing, nutrition, research skills, financial management, community service—the suggestions were as varied as the people I asked, but in almost every case they shared a strange commonality. Why does everyone hate glycolysis?
Now more than ever it has become apparent that the administration at medical schools seeks to find a balance between preparing their students for the USMLE as well as for the real world. One might expect this to be relatively easy, but in my interactions with physicians it has become clear that these are very distinct entities. As one of my mentors put it, the USMLE only tests about zebras. There is an old adage used throughout clinical medicine, “When you hear hoof beats, think horses not zebras.” This is solid advice. Common things are common, so that is what you are likely to encounter, but s one of my mentors put it, the USMLE has a zebra fetish. It has almost become comical the amount of times that our instructors have said, “You will never see this in practice, but the boards like to ask about it.” And I now believe, that this divide is no better exemplified than with glycolysis.
Clinicians hate glycolysis because it represents something to them that is mostly theoretical and therefore is wasting time that could otherwise be allocated to something more practical. Though they are rare, disorders of glycolysis certainly exist and cause diseases that are vital to understand and treat. But I think it is often held up as an example of the folly of medical education 1) because it is perhaps the one area of biochemistry that everyone remembers, and 2) because disorders of glycolysis are the ultimate zebra. This is not to say that learning about glycolysis is unimportant—because it certainly is—the point is that everything is important and in the end the time allotted to medical education creates a bit of a zero sum game. Into this game step the clinicians, each with their unique agenda but their common enemy.
The next few years will be an exciting time to be involved in medical education. The changes that have brought this to the forefront have been building for years and in this unique environment of change, not only in my institution, but around the country, people are beginning to ask fundamental questions about what we ought to learn. There are no easy answers, and I expect there will be no final resolutions, but either way this debate reaches to the core of what it means to be a doctor in our society and the final result will tell us a lot about what we value.