Why Organic Chemistry should always be taken (and passed) by pre-meds

Back when I was posting on “The Skeptical Chymist”, the editor (Stuart Cantrill), told me that noises were being made about dropping organic chemistry from the pre-med curriculum and asked me to comment. I didn’t because the idea seemed so ridiculous. There is no possibility of really understanding anything about cellular biology, drug action, molecular biology etc. etc. without a firm grounding in organic chemistry. You simply must have some idea what vitamins, proteins, DNA and RNA and the drugs you’ll be using look like and how they chemically interact — which is what organic chemistry gives you the background for. Not that you can stop there — but all medical schools teach biochemistry — which starts at organic chemistry and takes off from there. Organic certainly helped me follow molecular biology as it exploded starting in the 60s.

Cynics might say that docs don’t synthesize things or crystallize the drugs they use. Knowing what’s going on under the hood is just esthetic filigree. Just tell them what ‘best practice’ is, and let them follow it like robots. Who cares if they know the underlying science. People drive cars without really understanding what a carburator or a manifold does (myself included).

It wasn’t until I got about 400 pages into the magnificent textbook of Organic Chemistry by Clayden, Greeves, Warren and Wothers (only 1100 action packed pages to go !) that the real answer became apparent. The stuff is impossible to memorize. Only assimilating principles and applying them to novel situations will get you through — exactly like the practice of medicine.

Let us suppose you have an eidetic memory, and know the best treatment for every condition. You wouldn’t have to know any science at all, would you?

What’s wrong with this picture? First of all, there isn’t a best treatment known for every condition. Second, every doc will see conditions and problems that simply aren’t in the books. When I first started out, I was amazed at how much of this there was. I asked an excellent internist who’d been in practice for 30 years if he’d seen it all. He thought he saw something completely new each week. Third, conditions occur in combinations, and many patients (and nearly all the elderly) have many more than one problem. The conditions and treatments interact in a highly nonlinear fashion. The treatment for one problem might make another much worse (see below).

Here is a concrete example using a familiar person (Sonia Sotomayor) and a disorder which should be known to all (the new Swine Flu which swept America and the world this spring). Let’s say that you’re that lucky soul with the perfect memory who knows all the best treatments (well those that exist anyway) and as such you’ve been given the responsibility of taking care of her.

It is public knowledge (e.g. Wikipedia) that Justice Sotomayor has had diabetes since age 8, requiring insulin since that time. Pictures show, that like many diabetics, she is overweight — depending on how tall she is I’d guess by 25 – 45 pounds. Influenza is usually a disease of the fall and winter, and the new Swine Flu is now down in South America, but it’s likely to sweep back up here this fall. We know it’s extremely infectious, but so far fortunately rather benign. There is no guarantee that it will stay that way. Suppose that while down in S. A. it mutated and has become more virulent (a possibility that the CDC takes extremely seriously).

What if she gets the new Swine flu next month? At this point there is no ‘best treatment’ known. Diabetics don’t do well with infections — they get more of them, and have more complications when they do. Her diabetes is certainly going to get worse. What if some think the ‘best treatment’ is corticosteroids (which is often used for severe lung infections) — which will really raise hell with her diabetes? Should you give it? Recall that corticosteroid use during the Asian SARS epidemic (another serious lung infection) seemed to hurt rather than help (Journal of Infection, Volume 51, Issue 2, Pages 98-102). There is no data to help you here and you and your patient don’t have the luxury of waiting for it. Don’t forget that her father died at 42 of heart disease. That could be relevant to what you do. Suppose, like many overweight diabetics she has high blood pressure and elevated lipids as well. How will that affect her management?

Your perfect eidetic memory of medicine will not be enough to help you with her management — you are going to have to think, and think hard and apply every principle of medicine you know to a new and unfamiliar situation with very little data to help you.

Sounds like Organic Chemistry doesn’t it? Anyone without the particular type of mind that is able absorb and apply multiple and (often) conflicting principles doesn’t belong in medicine. A hardnosed mathematician I audited a course from a few years ago, said that people would come up to him saying that if they couldn’t pass Calculus, they wouldn’t get into medical school. He felt that if they couldn’t, he didn’t want them in medical school (I’m not sure he told them this — probably he did). The same thing holds in spades for Organic Chemistry.

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Comments

  • Wavefunction  On September 1, 2009 at 11:48 am

    I also remember flinging that particular article about dropping orgo aside with embarrassment. Of course this is a point which is totally lost on premeds; most of my sophomore pre-meds could care less if a ketone was more reactive toward nucleophiles than an aldehye. Among about a hundred students from three semesters, I remember three who were actually interested in organic chemistry and also good at it.

    The physicist David Deutsch (whose book I recommended to you) writes that medicine today is in the state architecture was four hundred years ago. One could build these wonderful cathedrals simply on the basis of experience and rules of thumb without knowing a thing about the basic mechanics and physics of materials. Medicine is in a slightly better state today, but as you indicated, the fact that every patient is different says volumes about how far we still need to go for a fundamental understanding.

  • luysii  On September 3, 2009 at 11:20 am

    Off label (and even anti-label) use by MDs can and has benefited patients. This is another example of where ‘best practice’ just won’t cut it.

    Two early examples. In the 60s the label for diazepam (Valium) said it was contraindicated for epileptic convulsions which did not stop (status epilepticus) because of respiratory arrest — probably due to the seizures not the diazepam. It was the go to drug for the condition from ’66 to the end of my practicing years (2000). I’m not sure what it is presently.

    The second example is the use of beta-adrenergic blocking agents to prevent migraine headaches (but only in people who are having them at least weekly — there are plenty of such people around). This was pointed out to physicians by patients receiving them for another indication. I used them a lot for this purpose, long before the label said so and thought they worked pretty well.

    Amusingly, beta blockers initially were thought to be CONTRAINDICATED in patients with heart failure — I think it said so on the label back then (not sure). Subsequently, they became part of the treatment.

  • CMCguy  On September 4, 2009 at 1:08 am

    Admittedly prejudiced view of PhD Syn Chemist I have to concur with the potential value that O-Chem can provide to MDs, future and practicing. As noted its an essential precursors to biochem, which is mostly advanced O-Chem in extremely complex system(s). One would hope it would help MDs understand drugs better, both postulated MOA and where they come from. Even labs can help know basis for clinical testing that is relied upon for diagnostics and monitoring.

    More importantly you point out it can teach people to think, problem solve, make connections and generally exercise mental functions. Even though such can be developed from others sources/courses O-chem sort of concentrates a wide range. Unfortunately much of the teaching can be poor and not appropriately relevant unless you are lucky to get an instructor that can transfer knowledge and stimulate. It too can become mere facts and figures memorization rather than comprehension on the underlying or higher level aspects of molecules and reactions.

  • Testing Laboratory Guy  On November 2, 2009 at 12:52 am

    I believe organic chemistry is very important in Pre-meds curriculum, it is the fundamental course you need to understand before you can take the advance courses in medical curriculum.

  • Another O-chemist  On November 12, 2009 at 4:38 pm

    I am going to link this blog post for my students. I’ve been telling them for years that the purpose of O-chem is to teach them the trick of reaching into a large bag of related information and pulling out the pieces you need to solve a particular problem. That’s why we teach synthesis problems.

  • LBN  On July 24, 2011 at 1:06 am

    My experience with Organic Chemistry was nothing like this. I felt O chem was rote memorization of reactions and mechanisms that were just “probabilities.” Perhaps this was bad teaching. I felt that physics taught me a lot more about how things work together and how to apply knowledge to new situations than did any of my chemistry classes. Although, general chemistry did come in handy in my later genetics courses.

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