It offers a sturdy integrative framework one on which

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Unformatted text preview: evolution provides the unifying framework for interpreting biological phenomena that otherwise can often seem unrelated and perhaps unintelligible” (56). It offers a sturdy integrative framework, one on which myriad facts can be hung in retrievable locations. Bilirubin metabolic pathways become much more memorable when integrated with the evolutionary reasons for those pathways. The role of cholera toxin in the small bowel makes more sense when considered in light of factors shaping virulence. The tendency of certain strains of Streptococcus to cause rheumatic fever makes more sense when integrated with the arms races that shaped the vulnerability. Proximate mechanisms that explain our vulnerability to obesity and substance abuse make more sense when framed in terms of the environments that shaped those mechanisms. Beyond a framework for organizing medical knowledge, a deep evolutionary understanding also helps to correct the prevalent dependency on the metaphor of the body as a designed machine (47). Of course, the body is a system of interlocking mechanisms, with levers, pulleys, and chemicals and feedback regulation at all levels. It is not, however, a machine built from blueprints created by an engineer. Instead, it is a jury-rigged system that generally works, despite serious “design” aws such as the inside-out eye and the double curve in the spine (57). Its complexity goes far beyond complexity we can readily describe, because it emerged from layer on layer of systems built from tiny variations over hundreds of millions of years. Many wish it was easy to map modules in the brain to speci c functions, but we are nding functions distributed among various areas in ways that defy common sense and any ability to come up with a clear description (58). We strive to characterize the function of a gene, only to discover that most do more than one thing, and some have very different functions depending on the tissue and the phase of development. Thus, as Childs et al. (47) pointed out so well, the body is not a designed machine; it is a soma shaped by selection, and that is something very different. As students become increasingly able to understand the limits of the designed machine metaphor, and as they grasp the body as a PNAS | January 26, 2010 | vol. 107 | suppl. 1 | 1805 product of natural selection, they will have a deeper understanding of the body and why it is vulnerable to disease. will require careful research designs to measure the knowledge and performance of students who have and have not received teaching about evolutionary applications in medicine. In addition to measuring knowledge about evolution and its medical applications, we suggest measuring changes in their ability to explain diseases to patients, their ability to evaluate evolutionary hypotheses critically, their ability to integrate knowledge from diverse sources, and the degree to which they attain a “feeling for the organism,” that informs their intuition about conditions they have not speci cally studied. Implementation could be accelerated by the simple and overdue action of including questions about evolutionary biology on medical certi cation examinations at all levels. The Medical College Admission Test will soon include questions about evolutionary biology. Step 1 of the U.S. medical licensing examination includes questions from each of the traditional basic sciences for medicine, but does not cover content related to evolutionary biology. Students know they need to learn details about anatomy, physiology, and biochemistry to become certied. No such questions ensure that physicians understand the principles of evolutionary biology. We recommend adding such questions. Implementation At the Sackler Colloquium, leaders from Harvard, Yale, and Johns Hopkins discussed plans to incorporate evolutionary biology into their medical curricula. Other institutions are making similar efforts. Some countries, such as Norway, seem to be ahead (59), while the United Kingdom faces different challenges (60). Variations among such plans will soon reveal what works better and not so well, and curricula will evolve. As is the case for a rare bene cial allele, however, the initial spread is the risky part. We offer several suggestions to ensure that the current momentum continues, and some thoughts about how to get initial efforts going in healthy directions. First, additional formal investigations into the role of evolutionary biology in medical and public health curricula are needed. Our opinions, however considered, are no substitute for the conclusions of diverse groups of experts convened to address these issues. We hope the AAMC, perhaps in conjunction with the HHMI, the Institute of Medicine (IOM), and a major scienti c society of evolutionary biologists, will convene groups to address this issue. Second, new teaching materials are needed for premedical and medical curricula. Some are newly available (27, 28, 61), but it is important to...
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This document was uploaded on 01/31/2014.

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