Opinion: The decline of physiology

Medical schools in the UK are teaching physiology courses primarily focused on clinical applications with much curtailed practical laboratory training to the detriment of medical education

[Published 19th April 2011 12:39 PM GMT]

Physiology has been taught in British medical schools for a century and a half, but since about 1990, physiology teaching for medical students has been cut by more than fifty percent (see table). During this time, medical student numbers have doubled. Currently 8,000 new students enroll in UK medical schools each year. This bloating in numbers has outgrown the capacity of staff and space available to teach and accommodate them appropriately. Consequently, practical physiology training has been virtually eliminated.

A vivisection of a Common Sand Frog
Image: Wikimedia commons, Muhammad Mahdi Karim

Physiology studies the relationships between living states at all levels of biological organization, from molecules to organ systems. It is the key to understanding organ function and dysfunction. A good understanding of the subject is necessary for the proper training of the next generation of doctors under the UK's General Medical Council guidelines.

Some view physiology as an old-fashioned and mechanical approach to science -- rooted in a philosophy antagonistic to the statistical methodologies adopted by clinical science, such as epidemiology and human population genetics. But in fact this view is baseless; physiology has long since rejected its historical distrust of statistical evidence and enthusiastically embraces new methods, particularly molecular genetics, that shed light on biological processes.

Others take issue with the experiments performed in traditional physiology courses as a result of largely successful propaganda campaigns by anti-vivisectionists. Human and animal experimentation were first introduced into medical physiology teaching in Breslaw (Wroclaw) University 1842 by Jan Purkinje because it was believed that this form of active learning experience was better imprinted than any acquired by passive textual learning. Practical experimentation stresses the need for precision in preparation, observation, recording, collation, analysis and interpreting data, all of which are vital to the needs of all clinicians and scientists. Although animal experimentation is currently viewed with disfavour by a large section of the general public, government officials, and even some medical students, students lacking any such experience are relegated to being passive followers of conventional wisdom, wholly reliant on secondhand opinions for their own. Inadequate grounding in basic practical skills in biological experimentation will lead to wasted time, money and in some cases life in the laboratory or clinic.

*PBL plenary lectures on physiological topics
Thanks to Glasgow University Registry and Steve Franey for retrieving this information and for useful discussions with CAR Boyd, O Hutter and Michael Lucas.

Besides rising student numbers, several other factors have contributed to physiology's lamentable decline. Problem Based Learning (PBL), imported from North America was widely adopted in various guises throughout the UK medical schools during the 1990s. It avowedly aims to encourage self-directed learning and to erase the artificial barriers between the -ologies by promoting an integrated or "holistic" approach to medicine. It was also seen as a means of shifting the increased teaching load away from active researchers to non-specialist "facilitating" staff. But its adoption has meant a comprehensive loss of autonomy of the biological scientists who have participated in this venture. Clinicians now take a leading role in pre-clinical teaching, largely displacing pre-clinical scientists who are more in touch with basic physiological processes. Scientific content taught in the context of clinical problems omits much basic science, which is regarded as inessential digression from the clinical problems upon which the course is centred.

PBL is much more appropriately suited to medical teaching in North America, where every medical student has studied biological sciences at college level prior to entering medical school. Undergraduate British medical students only rarely have equivalent experience, so realistically can only be expected to integrate knowledge and solve problems once they have acquired a firm understanding of basic sciences.

Another factor contributing to the decline of physiology courses has been the loss of physiology departments as a result of their merging with schools of biological, life, health, or medical sciences. Only one or two discrete academic physiology departments remain in the United Kingdom. Resource allocation within the preclinical schools, formerly controlled by academics working at the pre-clinical faculty or departmental level, is now centralized and controlled by senior administrators and clinicians. The financial and man power resources are redirected towards the more highly prioritized needs of the medical school rather than to science departments.

Although the "old fashioned approach" of incorporating extensive laboratory courses in physiology into medical and medical science courses is costly in time, labor and space, their omission may prove to be even more costly. Eventually British graduates will lose out to their competitors trained in Continental Europe, where universities mostly still devote serious attention to teaching practical skills to medical and science undergraduates.

R.J. Naftalin is Emeritus Professor of Physiology, King's College London and a F1000 Member since 2006. He was trained in medicine at Glasgow University and in biochemistry London University.

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Replies to Some Critical Comments.

by Richard Naftalin

[Comment posted 2011-04-27 07:11:55]

Louise Lubetkin and the others offended by frog dissection and its display.

I regret that this has caused offence. Clearly inhumane treatment of animals is unacceptable and in UK, as in USA it is illegal. Animal experimentation should be humanely done and in all teaching and research laboratories in UK is carried out in an ethical and humane manner. This is safeguarded in UK by being strictly licensed and supervised by Home Office inspectors. Frogs used for teaching and experimental purposes are first sedated then decerebrated, hence made insentient, prior to any form of experimentation. Mammals are fully anesthetised prior to experimentation.

Animal experimentation is a necessity for testing physiological hypotheses, or drug action and safety. Anti-vivisectionists propagandize the view that all animal research is inhumane and therefore unacceptable. This is a point of view with which I disagree. Domestication of animals either for pleasure, as with pet animals, or for legitimate trade, including humane slaughter is integral to human civilization. To single out vivisection from the other lawful uses to which animals are put for human benefit is mischievous.

Bob Lust. I take issue with the suggestion that medical professionals can do without personal experience of experimentation whilst scientists need this more. My contention is that medical students will learn better to think for themselves if have this background, rather than being satisfied with hand me down views. If laboratory experience is sauce for educators/scientists, then why not for educator/clinicians?

Raphael Gruener. It is difficult to quantify what lack of experience in experimental labs has done to medical graduates in US. However one way might be to count the number of post docs from overseas filling posts in US medical research labs now and compare that with how it was twenty or thirty years ago. My impression is that the number of overseas post-docs has risen. If this is the case, can you think of a plausible explanation?

Remembering live animal dissection

by Louise Lubetkin

[Comment posted 2011-04-25 09:54:23]

Prof Naftalin is absolutely right that live animal dissection "imprints itself" better than any textual learning. In the decades since I was obliged to take part in physiology labs as a student in the 1970s I have been continually haunted by the memory of the terrified cries of cats who were about to be deliberately bled to death in order to demonstrate the physiology of hemorrhage. I remember, too, the live frogs who were "pithed" with the spike of a dart before being pinioned to a board and dissected, alive. It seemed to me then, and still does, that the gratuitous sacrifice of animal life that I witnessed during my student days in dental school was a thinly disguised apprenticeship ritual, designed, through the shedding of blood, to initiate a bunch of novices into the medical fraternity. It was not, as Prof. Naftalin asserts, the "propaganda campaigns" of anti-vivisectionists which caused me to take issue with experimentation on live animals, but the insistent cries of my own conscience. Louise Lubetkin, Senior Research Associate, PETA

Another Use for Physiology Animal Experiments

by PAUL STEIN

[Comment posted 2011-04-21 12:06:40]

As a physiology graduate student in the U.S. back in the day of basic sciences education where several live canine experiments were performed for the medical physiology curriculum, I utilized a totally different purpose of these exercises: as a control of ego. Here in the U.S., as is probably the case everywhere, there are a few medical students per class who truly believe that they are God's gift to humanity, and act that way on every possible occasion. They were so full of themselves as to be insufferable.

I felt that if they were to going to take care of me or my parents some time off into the future, to focus on us as patients rather than themselves, their self-image seriously needed to be taken down a notch or five. After my colleagues and I would anesthetize, transport, and secure the animals in the laboratory, the students would file in, six to a table. I would quickly scour the room, to seek out the most egotistical, and be that table's teaching assistant. As that student, as usual, would be blathering about something, making himself the center of attention, I would seize the moment.

I would state that in the cardiovascular laboratory exercise the first thing to do was to cannulate the femoral artery and vein...and I would hand the scalpel to Mr. Perfect and say, "Here, you're the surgeon." I can honestly state that the next two seconds were completely life-changing; going from in control of the world to barely in control of one's bowels.

Of course, each student would protest vehemently, but I would stand firm, and carefully guide him successfully though the process. I can confidently state that an extreme personality change, for the better, was noted for the rest of the year in each and every person.

Not only wet labs, but also hours are reduced..

by ARAM MEGIGHIAN

[Comment posted 2011-04-21 02:00:25]

@ Dr. RAPHAEL GRUENER

As you wrote (only one time, mainly focussing your observations on wet labs..) and as it was claimed in the beautiful article, also the total number of hours dedicated to physiology courses were reduced.
You ask Dr Naftalin to produce data certifying an effective reduction of medical doctors clinical scores and medical practice.
I should say you that this is quite easy: the total number of unuseful exams is extremely increased in our Hospitals leading to a boost of health expenses. Many of those exams could easily be spared with a more accurate physiopathological approach, which, naturally, relies on a deep knowledge of human body physiology, let's say system physiology.

Hype does not lead to hope

by n dev

[Comment posted 2011-04-21 00:05:41]

Dr.Naftalin has done a commendable job by exposing the current status of physiology. The slow demise (or rather deliberate poisoning) of classical physiology, although partly caused by the anti-vivisectionists and those who equated ill-conceived animal welfare to go hand-in-hand with the anti-vivisection movement, and to a major extent by the full (either intentionally or influenced by corrupt peddlers in the hallway and corridor of Capitol Hill)support by the research funding agencies to facilitate and encourage scientific reductionism and scientific monism, and describe life fully in the context of whatever response one obtains from the color-mixture in the test tube, and importance of classical physiology and its teaching is being relgated to the land of nowhere- a fundamental element to understand not only how the parts act together, but the most perplexed and unsolved question of Ecclesian trialism, which only (integrative and system) physiology may have a handle.
Although I agree with Professor Cannell's view in this forum, I do not view the depiction of frog surgery lamentable. It may not (and is not) the tell-all story of physiology, but utterly unavoidable to elucidate the basic foundation of neuro and reflex-physiology (the votta experiment). Without that basic framework, even doyen of physiology, Professors Sherrington and Adrian probably had to have taken some other work to persue. That simple volta experiment did have century's of consequential clinical relevance. The fairy queen's foot-web capillary network is also a living example of reaction of series and parallel-resistance to activating drugs. Basic system physiological experimentations are vital to study input-output relationship, and a dynamic process and of direct clinical relevance to patient and animal welfare. we need co-habitation of 'old-fashioned' physiology (which is better understood with a grasp of physics, and is a part of biological physics, It is a fallacy to understand life without contribution from integrative basic physiology. In recent past and at present, terminology hype, such as, Translational biology has occupied most of the pages of biology textbook and scientific papers, as if translation of basic laboratory findings has never occured in clinical medicine. This is a disservice to the goal of science. Translational biology existed from the dawn of greek and egyptian civilization, but it was never hyped as in present time. For ultimate humankind and to understand our homo-sapiens status, co-habitation requires knowledge participation of physiology, physics, and molecular biology too, and not demise of one or the other.

Decline of Physiology Another Symptom of Managed Care?

by anonymous poster

[Comment posted 2011-04-20 15:34:46]

I applaud Dr.Naftalin for raising awareness about the decline of Physiology. I think that this is the result of both reductionist molecular biology as the scientific basis for eradicating Physiology, and the medical practice of Managed Care. The molecular biologists would have us believe that biology is antiquated, yet they can't make sense of their data without it. And Managed Care, which practices medicine (unlicensed) from the 'bottom line' uses the molecular biologist's perspective to reduce people to test values, and in cahoots with Big Pharma, pushes pills that make the symptoms go away, but doesn't address the underlying cause of the disease. Many of my research colleagues are puzzled that I still think we can find medical cures, rather than being content with the Managed Care cop out of living with cancer, diabetes, heart disease, etc, by taking pills.

Physiology decline?

by Bob Lust ﾠﾠ[Not You?
[Comment posted 2011-04-20 14:42:48]

I read with interest the article by Dr. Naftalin and the ensuing comments.

Relevancy, and the desire to remain so is a central desire of any person in any discipline. I completely agree that a picture of a dissected frog does a great disservice to what we would most advocate for in physiology teaching.

It is also true that teaching anything differently (less or more) is not in itself bettter or worse, just different. Dr. Greuner's assertions that we should follow the data to decide "better or worse" is spot on.

It is also well-founded in the educational literature that retention is greatest when learning has an active component, whether that is participating in a laboratory, active note taking (as opposed to "electronic handouts"), annotations of electronic files, etc.

I trained in "dog labs", and learned quite a lot, but I have also found that there are new laboratory experiences that are quite helpful, and can be very instructional. For example, we use cardiac ultrasound to expose the students to how a heart can be visualized, but we also use it to re-inforce the physical principles of sound, material densities etc. While the color doppler is a beautiful image and has a great ooh-aah factor, it is also an opportunity to reinforce velocity area relationships, the relationship between anatomy and physiology, and to ask how velocity gradients across a stenosis might correlate to pressure gradients, and how the ultrasound was validated. Seeing the dual movements of the mitral valve in real time does more to re-inforce the physiology of active and passive ventricular filling than any number of hours memorizing a cardiac cycle diagram. We do the same things with pulmonary function testing. In each case the students are the experimental subjects for each other.

Learning is also best when there is relevancy and context. It is reasonable to expect that medical students (or any other student) will want to learn more if they see "context". We shouldn't be threatened by "encroaching" clinical presence in the "physiology time"... we should be advocating for more physiology in the "clinical time" where the patient experiences again provide the context for learning, and where we can address the physiological basis for why certain things look the way they do.

In the last 30 years I've taught in systems-based, discipline based, PBL, hybrid, and just about any other system. I've taught undergraduate students, nursing students, medical students, OT, PA, and PT students. We are about to begin teaching dental students, because the one thing the dental faculty are least comfortable teaching, and which they feel the students most need to know, is physiology.

There is a reason that all those medically-related disciplines want physiology to be taught to their students, more so than just about any other discipline. I am increasingly convinced that it has less to do with the actual facts of any particular science or system, but that Physiology as a discipline also is a way of thinking, and those trained in physiology are absolutely the best trained for teaching how to think analytically and integratedly across systems.

No matter what instructional system is used, there are always "boundaries", and those trained in physiology seem to have the best capacity to teach the students how to reason their way through problems that "span boundaries" (or represents the "atypical" clinical presentation). I am concerned that the students, in an increasingly algorithm-driven world, lose the ability to "work the problem".

I am much less worried about the education of medical or other health professionals. I am most worried that we preserve training programs in which the process of thinking in physiological terms is taught to the next generation of educators/scientists, and the funding to support research programs based in that approach to experimental sciences maintains its vitality.

Respectfully,

Bob Lust, Professor and Chairman, Physiology
Brody School of Medicine
East Carolina University

Decline in physiology parallels the decline in all basic sciences
by Barbara Pierscionek

[Comment posted 2011-04-20 11:05:02]
Bravo Professor Naftalin for this splendid article,
The physiological principles that I was taught decades ago are no longer considered important and neither is the appreciation that physiology is the physics of the body. Just as physics has been replaced with 'stamp collecting' exercises, so physiology in medical courses has been squeezed out to make room for softer social subjects with an ever increasing emphasis on 'communication skills' and pleasing the patient. We have lost and continue to lose knowledge of the basic sciences, and we may not recover this if there is not a paradigm shift in our approach to teaching medicine as well as other basic science subjects.

The decline of physiology
by Viktor Belousov

[Comment posted 2011-04-20 08:19:48]
The author of article has truly defined problems of physiology. The problem that motivation define, how prompting to action, actually motivation reduces prompting to action. As consequence of this mistake - have united a cell and the whole organism in the general doctrine.

Experiments with Volunteers?
by Rainer Nobiling

[Comment posted 2011-04-20 08:11:35]
Teaching physiology since 30 years, I oberved the successful transition to experiments using human volunteers, recuited from the respective course students. There are many clinical methods that are useful for typical physiological experimentation. In addition, students motivation has been improved, because of a better visibility of clinical relevance of physiological experiments.
Clearly, a dissected frog is perhaps the worst example you can give for "succesful practical experience in physiology": this is contrary to our intentions to teach with practical and medical relevance.
Use of powerlab - simulations on the other hand is more an extended type of theory rather than practical experimentation.

Practical physiology is still necessary
by Jose M. Lopez-Novoa

[Comment posted 2011-04-20 05:47:31]
I agree with the comment that teaching less Physiology is being impairing the formation of the Medical Doctors. Having been involved in Physiology teaching for medical students for more that 35 years, and subjected to the already commented increased number of students with simultaneous cut in money for laboratory practices, I have been also enthusiastic in the past about implementing new ways of learning physiology through computer simulations or Power Lab demonstrations. Even I have published our experience on this. My conclusion is that, although this type of teaching increases some kind of knowledge, for example integration of the function of several organs, and spare animals, it does not substitute to the classical laboratory experiments. Our solution with less money, less animals and more students is to organize cheaper but instructing experimental approaches. For instance we have prepared 4 laboratory practices on renal physiology for about 240 students using only 10 rats and about 100 Euros in materials and reagents.
Jose M. Lopez-Novoa
Professor of Human Physiology

Well said
by Joachim Payne

[Comment posted 2011-04-20 05:33:36]
Having been a product of early 1990s medical teaching and myself a "PBL facilitator" in the early 2000s I can only agree that much has been lost through the downgrading of Physiology tuition. When I compare the fascinating weekly practical classes we experienced (including electrocuting our fellow students) with the minimal hands-on work carried out today I sometimes despair. See also the loss of experienced Histologists in research today.

How are we measuring the value of knowledge
by Haydn Allbutt

[Comment posted 2011-04-20 00:32:49]
Nice article. I personally hate it the way that the worth of all things these days seems to be measured by how necessary they are to the education of medical students. Since when is what a medical student knows the guiding principle upon which everything else should be centred. I agree with the observation that it is the merging of Physiology departments with various schools or other disciplines that have resulted in the loss of emphasis on the practical sciences. That is what has happened at our University too. I can understand that practical engagement with biological material is expensive in terms of time needed to set up and execute these classes as well as monetary cost and it is a modern trend to perform as little work on living tissue as possible, but even if you do consider the education of medical students the sole purpose of a University and its resources, sooner or later those medical students will have to navigate their way around an actual living, breathing human. Would any of us honestly want to be treated by a doctor who has only ever learnt about our anatomy and physiology from text books and facilitated discussions?!?

A general view is needed
by Vladimir Matveev

[Comment posted 2011-04-19 23:29:20]
In addition to studying an infinite number of parts and a details general view on physiology is needed. In cell physiology such a common sight offers Russian scientific school founded by D.N. Nasonov (unknown in the West). Interested parties can learn more about this school after reading my article 'Protoreaction of Protoplasm'.

Learning Alternatives in the Information Age
by MERVAN AGOVIC

[Comment posted 2011-04-19 18:47:55]
I fully agree that a good understanding of human Anatomy and Physiology is essential for future physicians and may contribute to reduction of medical errors. However, learning Physiology in classic wet labs might not be the most productive approach, though not the reason to wipe out the discipline from medical curriculum either. Most of the typically considered physiological processes crucial for maintenance of organismic homeostasis can now be effectively studied by interacting with computer simulators such as PowerLab. This provides a more time efficient and intuitive method for visualization, data acquisition and analysis; yet, it spares animals. Therefore, utilizing technology may require fewer hours spent in laboratories to better suite learning of modern-life-paced medical students.

Mervan Agovic, Ph.D.
Assistant Professor of Biology

Proof?
by Mark Cannell

[Comment posted 2011-04-19 16:54:05]
Prof. Gruener asks for proof that medical training has deteriorated, but exam passes cannot provide the required information when the exams only test what has been taught. I have taught medical students for more than 25 years and I know that we are teaching physiology in less depth (largely due to an approximate halving in contact hours). I always held that a good understanding of basic human physiology would allow the doctor to recognize and correctly diagnose illness symptoms (rather than rely on pattern recognition). More than a third of doctors say that they, or their family members, have experienced medical errors, with most leading to serious health consequences (New England Journal of Medicine). Perhaps we should wonder how many of these errors might involve a lack of understanding of physiology?

Lamentable indeed...
by Mark Cannell

[Comment posted 2011-04-19 16:14:02]
I frankly object to the inclusion of a photo of frog dissection as having anything to do with modern physiology.

Physiology
by Mike Waldrep

[Comment posted 2011-04-19 13:56:48]
Interesting!

Proof of Assertion: Decline of Physiology
by RAPHAEL GRUENER

[Comment posted 2011-04-19 13:35:57]
Professor Naftalin decries the 'decline' of physiology in UK medical schools based on the elimination of 'wet labs' and a slight reduction in contact hours (the reported difference between original physiology hours less laboratory hours). This has been a long time mantra also in the USA where wet labs have been eliminated for at least a decade and replaced with 'team led' applied physiology discussions.
I think it is disingenious to claim a 'decline' of the discipline without first defining the objectives and outcomes of teaching physiology to medical students. Absent research studies on the competency of the 'product' (namely, medical students and practicing physicians), Naftalin's assertion is empty and decries only the loss of self-worth of physiologists in their role of medical student teachers. I therefore challenge Prof. Naftalin's assertion and challenge him to document (as a scientist is expected to do)the deleterious effects on medical students performance in their clinical years, in their clinical scores (like the USA Board tests), and most importantly in the quality of their medical practice. Since the elimination of wet labs took place roughly 20 yrs ago, a sufficiently long time has passed to statistically evaluate such parameters.
sincerely,
Raphael Gruener, PhD; Professor Emeritus