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Evolutionary Biology in the Medical School Curriculum. Bioscience 53 Education Evolutionary Biology in the Medical School Curriculum RANDOLPH M. NESSE AND JOSHUA D. SCHIFFMAN The principles of evolution are finding new applications in medicine,but little is known about the role of evolutionary biology in medical curric- ula. To determine which aspects of evolutionary biology are included in medical curricula and the factors that influence this, a questionnaire was sent to all deans at North American medical schools who are responsible for curricula.The questionnaire asked about content areas in the curricu- lum,their perceived importance, and the factors that influence the amount of coverage given to those areas. Forty-eight percent of the deans who responded considered evolutionary biology important knowledge for physicians. Only 32 percent of the respondents reported that their schools covered at least 8 of 16 core topics in evolutionary biology,and only 16 percent of the schools reported having any faculty with a PhD in evolution- ary biology.Lack of time in the curriculum and lack of faculty expertise are the main perceived impediments to increased teaching of evolution. We conclude that the role of evolutionary biology as a basic medical science should be carefully considered by a distinguished group of biologists and medical educators.In the meanwhile,undergraduate educators need to recognize that, for now at least, most future physicians must learn evolutionary biology as undergraduates if they are to learn it at all. Keywords: Darwinian medicine,evolutionary biology,medical education,curriculum fforts to bring the principles of evolutionary aspects ofthe immune system, thus perhaps accounting for Ebiologyto bear on the problems ofmedicine have grown rapidly rising rates ofallergic and autoimmune disorders rapidly in recent years (Williams and Nesse 1991, Ewald (Rook and Stanford 1998, Bach 2002). Although natural se- 1994,Nesse and Williams 1995, Stearns 1998, Trevathan et al. lection does not shape diseases themselves, it is responsible for 1999, Greaves 2001). In the area ofinfectious disease, for in- many aspects ofbodily design that leave us vulnerable to stance, long-standing recognition ofantibiotic resistance has diseases. Major tasks for Darwinian medicine include ex- been augmented by new,sophisticated models ofhow selec- plaining why these vulnerabilities remain,despite the force of tion shapes increases,as well as decreases,in levels ofvirulence, natural selection,and how this knowledge can assist medicine according to their benefits for pathogens (Ebert 1998, Levin and promote public health. et al. 1999). Also,defenses against infection,such as fever The benefits ofusing evolutionary ideas to understand and immune responses, are now interpreted as the products disease are becoming widely recognized both in research, ofan evolutionary arms race in which stasis is likely to be where thousands ofrelevant reports have appeared,and in the fatal and effective defenses are likely to be costly and causes many new undergraduate courses on Darwinian medicine.In ofdisease in their own right (Ewald 1995). The maintenance the curricula ofmedical schools, however, the role ofevolu- ofsexual reproduction despite the huge fitness costs ofhalv- tionary biology remains uncertain.A briefquestionnaire ing the proportion ofan individual’s genes in each offspring study conducted in the United Kingdom in 1997 reported re- (as compared with asexual reproduction) may be explained sponses from 20 ofthe 30 medical schools surveyed (Short by the benefits ofvarying the targets that pathogens attack 1994). The question “Is evolutionary theory regarded as rel- (Hamilton and Zuk 1982,Wilkinson et al.1998). In genetics, evant for the training ofdoctors?” was answered in the affir- old models ofmutation– selection balance are being aug- mative by 75 percent.Eleven UK schools reported having mented by systematic analysis ofthe selection forces that “teaching sessions in animal/human evolution included in the may maintain the presence ofalleles that increase vulnerability medical curriculum,”and 18 included population genetics. to disease, whether by heterozygote advantage or other means. No comparable data are available for North American More broadly yet,physicians are now seeking not only prox- medical schools. To begin to fill this gap, we sent a one-page imate explanations for why some individuals get sick and letter and questionnaire to each medical school dean in North others do not but also complementary evolutionary expla- America listed by the Association ofAmerican Medical nations for why we all have bodies that are vulnerable to so Colleges as responsible for the medical curriculum ofhis or many diseases.For instance,many diseases result from the mis- match between our modern environment and the environ- ment in which we evolved (Eaton et al.2002). Examples Randolph M.Nesse ([email protected]) is a professor in the Psychiatry De- partment at the University of Michigan, Ann Arbor, MI 48104-2321. Joshua range from atherosclerosis to myopia. Recent evidence sug- D.Schiffman ([email protected]) is in the Department of gests that the benefits ofmodern hygiene have serious costs Pediatrics at Stanford University School of Medicine in California. © 2003 in lack ofexposure to infections that stimulate inhibitory American Institute of Biological Sciences. June 2003 / Vol. 53 No. 6 BioScience585 Education her institution. The survey, conducted under the auspices of scientific status ofevolutionary biology”and “concerns about the World Federation ofMedical Education, asked 30 ques- political controversy”were issues at only a few schools. Only tions that covered five areas: (1) medical school prerequisites, one item was cited by more than 5 percent ofthe schools as (2) topics in the required medical curriculum,(3) faculty a “major impediment”: “lack oftime in the curriculum,” resources, (4) deans’impressions regarding the importance which was cited by 31 percent. ofevolution education, and (5) reasons why increasing This study has several limitations.Although the sample was coverage ofevolutionary biology might be difficult.Responses incomplete,an inevitability because ofthe deans’busy sched- were received from 50 schools. ules,it was nonetheless large enough to convey an estimate Deans at 24 ofthese 50 schools (48 percent) answered ofthe amount ofevolutionary biology in the curricula of “yes”to the question “At your medical school,is evolution- North American medical schools and its perceived importance. ary biology regarded as important knowledge for physi- A more serious problem is the lack ofa method to determine cians?”However, only three schools require a course in whether respondents understood the questions; several noted evolutionary biology as a prerequisite for matriculation, and in the margins that they did not recognize some ofthe listed only two have “a distinct course or lecture sequence that pre- concepts, which, ofcourse, adds unreliability to the reports sents evolutionary biology as a basic medical science.”Among about the topics covered.The lack ofan accurate recognition the 30 complete responses to the question “Outside ofa spe- ofcertain topics may help explain the apparent discrepancy cific course on the topic, about how many lecture or contact between the high percentage ofschools that reported teach- hours are devoted to teaching [evolutionary biology]?”10 ing the somewhat technical topic oflevels ofselection (51 per- deans reported 0 hours; the median for the other 20 cent) and the very small percentage that reported covering responses was 4 hours. Only 8 (16 percent) schools reported elementary concepts such as kin selection (9 percent) and the having any medical school faculty with a primary specialty of distinction between proximate and ultimate explanations in evolutionary biology. (5 percent) (table 1). As shown in table 1, more than halfof the schools re- A more comprehensive study would require backing from ported covering core topics involving basic genetics and a major US medical education organization to increase the re- pathogen evolution.Evolutionary explanations for vulnera- sponse rate for a questionnaire that would require consider- bility to disease were covered in 10 to 25 percent ofschools, ably more time from respondents. The questionnaire would while fewer than 10 percent reported covering fundamental need to define the concepts in more detail, confirm respon- principles such as kin selection and the distinction between dents’understanding ofthem, and determine the coverage of proximate and ultimate explanations. each content area in each curriculum.An optimal study Table 2 summarizes responses to the question “Which of would go further and verify what is actually presented and the following factors would likely make it difficult for your what medical students actually learn.Such a definitive study medical school to incorporate or increase evolutionary biol- would be worthwhile. The information gathered here is suf- ogy teaching in the medical curriculum?”T wo reasons were ficient,however,to show that North American medical schools cited by more than halfof schools: “lack ofcurriculum time” do not teach evolutionary biology as a core basic science and and “lack offaculty expertise.”“Lack ofconfidence in the that their curricula fail to cover many fundamental evolu- tionary principles and concepts. The simplest explanation for Table 1.Percentage ofmedical schools reporting these shortcomings is that fewer than halfof the schools re- coverage oftopics
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