In search of medicine’s shifting frontier

Herbert S. Chase Jr., M.D., believes in bringing medicine to what he calls “the edge,” the constantly expanding outer limit of medical knowledge or “the most detailed explanation [of a given topic] that we have right now.” It is to the edge that doctors must now turn in treating their patients, says the new deputy dean for education. And as the edge of knowledge advances with each new discovery, medical students must learn how to find and evaluate it.

It was “the edge” that brought Chase to Yale. Last April he came to the Cushing/Whitney Library to talk about the Internet as a research tool in medicine. In the audience were at least two members of the search committee for the deputy dean’s position. At the time Chase had no plans to leave Columbia University College of Physicians and Surgeons, where he has spent 22 “absolutely fabulous years” and received high honors for his teaching, including the university’s Presidential Teaching Award. The lure of spreading his vision for education across a broader canvas proved too great to resist, however. On July 1, he will formally begin his Yale duties. Until then Chase plans to visit New Haven once a week to meet with faculty and students. Chase will continue to live in New York City, where his wife is a lawyer and one of his sons is still in high school. He has another son in college.

Medical education, Chase says, has become all consuming. He used to dabble in photography and play classical guitar, bassoon and clarinet. He still goes to the opera but has little time for activities outside his work and family.

Staff Writer John Curtis visited Chase at Columbia recently. An edited transcript of their conversation follows.

What are the challenges facing medical education, around the country and at Yale?
The problem with medical school in general is that there is a language of between 15,000 and 20,000 new words that must be learned by students before they can converse with their colleagues about patients. Because of the time pressure to learn that language during the first two years of medical studies, it’s hard to weave a meaningful clinical experience early on. But clinical studies can be put into those first two years. And after that there is no reason we can’t have a more fluid integration between clinical and basic science during the third and fourth years.

One of the challenges of medical education is teaching the content at the right time. We have a pretty good view of what we need to teach. The problem is finding the right spot. We often teach genetics concepts in the first year, which is appropriate. Then we teach abnormal genetic makeup in the second year, and that is more suitable to the third and fourth year. A good deal of the basic science would be much more interesting to the student in the third or fourth year.

Most medical schools are behind electronically. Say you’re a patient and I’m your doctor. I have core knowledge, which allows me to figure out what you’ve got. It also allows me to find information in the library. Now my role is not to look into my brain and see what’s up there. That’s ludicrous. That’s likely to reveal old information. I go to electronic search engines right here at my fingertips. Finding the edge is a skill. Assessing the edge is a skill. Medical students must be provided adequate computing facilities. The curriculum must demand that they use computers.

At Columbia, you directed interdisciplinary basic science courses for first-year students. Do you plan to encourage similar courses at Yale?
It’s definitely on the table at many places. The basic principle—that basic science activities are confined to the first couple of years and clinical activities are confined to the third and fourth years—all emanated from the Flexner Report [of 1910]. I think that paradigm is no longer valid. There’s nothing preventing us from having a much more fluid curriculum, where we have basic science and clinical science interwoven throughout the four years.

For a long time, the national boards were given in June of the second year. There was no compelling reason to have the students start the clinical years in March, April or May because their minds would not be on the task. That’s all changed. You can hook up online and make a date to take the boards in January. That alone, as absurd as it may sound, may be the linchpin of the whole reorganization nationwide in terms of fully integrating medical education—starting the clerkships earlier, starting the clinical material earlier and then bringing basic science into the clinical years.

Traditionally, departments have determined course content. How do you secure departmental cooperation in integrating courses?
Departments have a legitimate stake in the pedagogical process in terms of imprinting their vision of biology on the student. That is a very powerful vision. It should not be lost. An integrated course does not minimize that vision. In fact, it strengthens that vision. The individual disciplines maintain their identity by providing an essential piece to the mosaic which creates a vision of the patient as a whole entity. Departmental identity is also established and reinforced in problem-solving sessions that are central to an integrated presentation of human biology.

The departments also play a critical role in helping the student develop medical decision-making skills. Why do we teach basic science? We obviously teach basic science so we know the molecules of the body and how they work. But there’s a much more important lesson from basic science, one that is long-lasting. We teach basic science so that the student learns the scientific method and how to apply the scientific method at the bedside. Yale has a leg up on everyone because it has the thesis. This, in spades, gets the student up to speed in terms of analyzing and assessing data.

We need to divide the curriculum into two equally important units. One is content. You cannot proceed in medicine without a core of knowledge. A second, equally important goal is to provide process, to find ways for the student to master the scientific method.

How can technology help us gain access to the latest knowledge derived from advances in research at the molecular level and the mapping of the human genome?
We will reach a state where we will know every molecule in the human body. It is likely that we will know from a drop of blood that a patient has 14 of 19 genes for high blood pressure and we have 172 drugs that will interact with that. Only a computer will be able to organize this information. This, of course, poses a difficult challenge. The physician must be skilled at complex decision-making. The doctor’s role will now be one of judgment, where we look up the information on the patient, who is alive and breathing next to us, and we make an appropriate decision. Technology is creating the need for a rigorous medical decision-making curriculum. That does not exist in any medical school curriculum and Yale can lead this effort.

How do you educate physicians to become more than technicians, and how do you ensure that they treat the patient, not just the disease?
The medical school curriculum in general—and this is true nationwide—is one of deconstruction. The patient comes in and we look at the biochemistry, we look at molecules, we look at the organs. We have little pieces of the patient that we pull apart so we can study them. Then a process of reconstruction has to occur. That is what I think is lacking in medical schools.

Graduates leave medical school feeling comfortable with part of the patient rather than the whole patient. If you come to me with heart disease, am I more likely to give you a medicine than send you for an operation because I am an internist? If you go to a surgeon are you more likely to be operated on than receive medicine? Activities that focus on the whole patient need to be built into the curriculum. Yale has this fantastic new elective called “Women’s Health.” It’s very successful. The focus is on the person. Yale could devise a number of short, meaningful whole-patient views of medicine.

Integration of the basic sciences reinforces the whole-patient view as well. If one studies only the physiology of the system or the cell biology of the system, we are deconstructing. We could reconstruct these disciplines into a functional view of the whole patient as we rotate through the body.

How can you instill in the faculty the notion that teaching, as well as clinical or research excellence, is a path to recognition and advancement?
Teaching needs to be rewarded. There has to be daily recognition from the University that you are doing a great job. Those of us who are deeply committed do it for the satisfaction we get. At our level of teaching, yes, it is very important to serve as a role model to excite the students about what we do. That is the real skill of the charismatic teacher. Nevertheless, the University must recognize and encourage outstanding teaching.

We need to define the career path for teachers. Who will lead the educational programs when we all retire? Faculty development of great educators is as important as the development of great scientists and clinicians. Yale has created a clinician-educator track and that is a major step forward. This will guarantee that Yale remains one of the great medical universities in the world. YM