The challenge for basic science education in problem-based medical curricula.

There has been intense debate about medical curriculum reform since the early 1950s. The last 25 years have seen a steady shift ward problem-based learning curriculum design in schools of medicine and allied health sciences. This trend has been less challenging for clinical departments than for departments of basic science, where it has often evoked anxiety, antipathy, lack of cooperation, and general mistrust. This appears paradoxical, as problem-based learning (PBL) is promoted as an improved method of integrating scientific concepts, and the advances that drive much of modern medical practice are advances in the basic sciences. While proponents of PBL argue that the approach promotes better integration and use of scientific concepts, the evidence, such as it is, is against this. As well, other evidence suggests that clinicians do not use basic science concepts extensively in their practice. This then questions the utility of scientific knowledge in a medical curriculum. This article examines this notion of utility (the quality or state of being useful), to establish some ground rules for what does, and does not, possess utility, and to present strategies to develop specific objectives from general statements concerning utility. Understanding of biologic and pathologic processes becomes of central importance and arguably possesses utility. If it is both required and evaluated, such understanding necessitates mastery of basic science concepts. Previously, the presentation of the basic sciences in medical curricula has emphasized the acquisition of knowledge rather than its use. Such learning has been perceived to lack utility; strategies to enhance the value of studying basic science concepts are suggested. If the importance of objectives in the basic medical sciences is accepted, these objectives should be achieved early in training, maintained at exit from medical school, and revisited in continuing medical education. The process of change in medical education initiated by Abraham Flexner early in this century remains incomplete. One reason why curricular changes have proved frustrating to basic scientists is that much of clinical medicine remains unnecessarily unscientific. Until clinical medicine itself changes, the utility of science in the training of a physician will remain difficult to demonstrate.