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Teach the Doctors Well
by Michael Balchunas

The patient, a 50-year-old smoker, had already lost two-thirds of his left lung to cancer, and six months later a tumor appeared in his brain. Deciding against more surgery, he instead underwent full-brain radiation. Within three months, clusters of tumors clogged both lungs.

Young medical students now study his case intently--but not to chart the progression of his disease. What they study is a poem the patient wrote about the moment when the doctor delivered the news of his rapidly approaching death. The poem, "What the Doctor Said," by Raymond Carver, ends with the lines:

I just looked at him
for a minute and he looked back it was then
I jumped up and shook hands with this man who'd just given me
something no one else on earth had ever given me
I may even have thanked him habit being so strong

"It's a very short poem, but it's very powerful in terms of how physicians give bad news, what the patient can hear, what kind of communication is really taking place," says Pamela Schaff '76, director of the Introduction to Clinical Medicine program at the University of Southern California's Keck School of Medicine.

Its use in the training of future physicians is also illustrative of changes in the way medicine is taught today. Advances in science and technology have brought great promise, but also disappointment, as their limitations become apparent. The skillful practice of medicine as an art as well as a science is being increasingly emphasized. The changes have an important bearing on the preparation of future physicians, both at large universities and at small liberal arts colleges such as Pomona.

A surprise for many parents of prospective students inquiring about Pomona's premed program is that there isn't one, at least not in the form many expect.

"There is a sense among parents that there's a program of study that prepares you for medical school, and it's really not that way at all," says Richard Lewis, professor of neuroscience, who recently completed his first year as chair of the College's Medical Sciences Committee. First-year students with an interest in medicine and allied fields--about one-fourth of a typical incoming class at Pomona--are advised from the start to broaden their views.

"The first thing we tell the student is, major in what's most interesting to you," says Lewis. "If you look at the statistics, you will see that there's no advantage to any particular major. For a lot of people, that is the first clue, to see that there is no advantage to majoring in biology, and in fact, that there could be some advantages to majoring in art history."

The acceptance rate at medical schools for Pomona graduates is about twice the national average. But premed advisers prefer not to cite numbers because different institutions measure acceptance rates in different ways, making direct comparisons difficult and misleading.

The Medical Sciences Committee, which has operated continuously since 1951, advises students and assists them with medical school applications. Premed students need not avail themselves of its services, although almost all of them do. Pomona's small size means that most premed students are well-known to the committee members. Also, there has been considerable stability on the committee over the years: Long-serving members, all of them past chairs of the committee, have included Alvin Beilby, professor of chemistry emeritus; Yost Amrein, professor of biology emeritus; the late Larry Oglesby, professor of biology emeritus; and Martha Andresen, professor of English.

"They were the premed program at Pomona," says Andresen, referring to the longtime professors who preceded her as chair. "It was a labor of love." For most of the past 50 years, committee members would spend untold hours crafting lengthy, highly personalized composite letters of evaluation for an average of 40 to 50 medical school applicants from each graduating class. The process has now been streamlined at Pomona, and at other colleges and universities, because it became too cumbersome and too great an imposition on faculty members. The committee, with administrative support from Paula Goldsmid, coordinator of medical sciences and graduate fellowships, now helps students gather individual letters of evaluation, and the chair prepares a summary that is shorter than the previous composite letters. Some larger universities no longer send composite letters or summaries, and some charge students for sending any materials at all.

Lewis, Beilby, Andresen and others say there are other, more significant, differences between premed studies at a small liberal arts college such as Pomona and a large university. "Why come to Pomona as a science major or premed student rather than go to a large university? It's the chance for that personal contact," says Beilby.

Lewis says that what's most important is the match between the student and the institution. "The nature of the classroom, what goes on in the classroom, is very different here from what it is at Berkeley, for example," he says. "We can do certain things in the classroom that they can't. There is going to be a more personal connection between students and faculty. A large university, on the other hand, can offer a greater range of research seminars and exposure to big-lab science. But the advantage of science at a small place like Pomona is being able to work directly with faculty on research. We look for faculty with research programs that can be done at a place like this."

Science is important, says Mary Ann Reynolds '56, a retired physician who majored in zoology and chemistry at Pomona, but during the undergraduate years, she believes, educational breadth is even more critical. "I firmly believe that the liberal arts education is far more important than the science background that you take with you," says Reynolds. "Knowing how to learn, how to evaluate, how to conduct research into literature, were far more important to me than the actual information. Most medical schools start all over with a good part of the science anyway. Yes, it might help you to have had a lot of extra biochemistry or something, but you should take the time to study other things. You can't relate very well to people and their problems if you haven't read about them or thought about them." Besides caring for patients in her general practice, she and her husband, a surgeon and a graduate of Claremont Men's College (now Claremont McKenna College), for many years provided medical care to people in need in Haiti, the Marshall Islands, Mexico and elsewhere.

Jenny Kim '95, a chemistry major at Pomona, recently completed her first year of medical school at USC. "Some of my classmates went to places like Berkeley, where they had 500 or 600 people in a class," she says. "I liked being in a smaller environment." One of the courses Kim took at USC was taught by Schaff, who personifies some of the changes occurring in medical education today.

Schaff was an English major as an undergraduate at Pomona. "I was the only person I knew in my class who wasn't a science major," she says. "In subsequent years that changed, because there was recognition by medical school administrators and admissions committees that people who had interests in other areas brought another perspective to medical school. I felt at a disadvantage for my first semester at medical school, because I just thought, oh my God, these people have had all the science and I didn't. It was a huge amount of overwhelming information, and so until I learned how to just do it, I felt insecure and scared." She went on to finish first in her class at Mount Sinai School of Medicine in New York City and became a pediatrician with a practice in Los Angeles.

Students in Schaff's course, unlike earlier generations of medical students, have contact with patients almost from the outset. "Twice a week you go into the hospital and talk to patients," says Kim. "For first-years, the goal is to learn how to do a complete patient interview, to take their medical history. For second-year students, the goal is a complete physical."

Schaff's students crack open literary books as well as science texts. She may have them reading William Carlos Williams, Raymond Carver, the noted child psychologist Robert Coles, or Rachel Naomi Remen, a physician known for advocating a relationship-centered approach to healing. "We've read fiction and poetry and essays, and I've had them writing narrative reflections and keeping a journal as they went through this course of learning about taking medical histories and learning their physical exam skills," she says. "I really believe that it helps them to think narratively and to understand the issues of their patients much better than when they're coming from a strictly logical, scientific perspective." Schaff herself is pursuing a Ph.D. in literature at USC.

"What I have begun to see," she says, "is that my love of English and what literature means to me, and my relationship to being a physician, really converge at a certain point, and it's about getting to the heart of the human condition. I think what I adore about teaching and about patient care is that I have a chance to hear the stories of patients, to understand what it is they've experienced, and to help them along that path to healing."

Pomona, Schaff says, "always has had an incredible reputation for doing well by its premedical students. The science foundation is still first-rate. What students might lose is the access to Nobel laureates doing research right there on campus, but frankly, that's not what they need in undergraduate education. What we had all the time when I was there was people who loved teaching who were there in the classroom, not off in their labs."

One of them is Andresen, who teaches Shakespeare and Milton, and who served as chair of the Medical Sciences Committee before Lewis took on the position of general premedical adviser. It may be unusual for someone with Andresen's specialty to be advising premed students, but, as she says, "that's the virtue of a small liberal arts school, where someone from a field that seems not directly relevant to the process is brought in, in a significant way." But it was not as much of a stretch as it may seem: Andresen was a premed student for a time as an undergraduate herself, and her father was a family doctor in Minnesota. "He would put in a full day at the office and he was always on call, the phone was ringing all the time at our home; in Minnesota blizzards he would make house calls day and night," Andresen says. "He gave his patients time in a way that physicians are not allowed to now because of the constraints of medicine as a business. He treated whole families, and he was so involved with them that he had a distinct sense of what was hurting them and what might help them and heal them."

She laments the loss of that kind of personal health care, but says she was impressed by the students she got to know as chair of the committee. "I think our insistence on liberal arts, our PAC requirements, our distribution requirements, give a student, as they do at other small liberal arts colleges, not just a breadth of knowledge, but an opportunity to develop gifts of critical and creative thought, research and expression, that are absolutely invaluable," she says. "These students are able to use critical and creative gifts across a range of disciplines, and therefore I think they indeed have a more holistic approach: to disease, to the body, to suffering, to the politics of medicine. They have a capacity to think about problems beyond a technology-driven medical field."

Andresen believes there is one area in which more attention perhaps should be paid to the preparation of prospective medical students. A shortcoming of Pomona's writing- and research-intensive curriculum is that students applying to medical school often are not as skilled as they could be at oral presentations, she says. The value of that ability, not just in medical school admission interviews but in the practice of medicine, is but one of the lessons to be found in Shakespeare, in Andresen's view.

"I have all of my students not just study and master a given number of plays, but I have them perform," she says. "For my premeds, I want my Shakespeare class to be an exercise in empathic imagination. Shakespeare allows them to 'take another's part': not just to perform that part, but to interpret and experience reality through a character very different from themselves--a different gender, perhaps, or race or class, in a different time. I want my students to experience that uniqueness of character, to master a new idiom and action, which is the magic of the stage. I want them to keep a finger on the pulse of the human: the really timeless, big problems of choice and consequence, suffering and insight, good and evil, the uses and abuses of power. It's all there. And the artists I love--Shakespeare and Milton--display what I would want my students to cultivate: superb intellect and enormous compassion."

John Walters, assistant dean for student affairs at Washington University in St. Louis School of Medicine, one of the nation's leading medical schools, says that "Although Shakespeare is not viewed by many premeds as appropriate or necessary study, those that do take the challenge may be just the kind of student we are looking for at Washington." Choosing the right kind of person to train as a physician, he says, is itself an art.

"Medicine is a very personal profession," says Walters. "It's easy to pick good students, but it's much more difficult to pick good people--the kind of doctor you and I would want to see when we're sick as can be."