Based on information from four medical schools, medical schools rarely address ME/CFS in basic instruction or as case studies.
The University of North Carolina School of Medicine is ranked second in primary care in the 2017 U.S. News and World Report. Kurt Gilliland, PhD, is its assistant director of curriculum and evaluation. When interviewed, he stated that he didn’t know whether ME/CFS was in the curriculum, but added that the focus is on diseases appearing on the U.S. Medical Licensing Examination. Other neurological disorders are on the exam, including Parkinson’s and multiple sclerosis, but ME/CFS is not.
Along with basic anatomy and physiology, students receive clinical instruction, Gilliland said. Three hours a week, students also learn how to interact with patients, take a medical history, and conduct a physical to determine a diagnosis – all without covering an illness that affects approximately 1 million Americans.
The University of Nebraska Medical Center College of Medicine is ranked fifth in primary care in the 2017 U.S. News and World Report. Gary Beck Dallaghan, PhD, is its assistant dean for medical education and director of its Office of Medical Education.
“Students are trained on how to take complete histories and physical examinations,” he said. “They are coached on how to keep an eye out for things that may be a source of the illness.”
However, the preclinical curriculum doesn’t include ME/CFS. Dallaghan said rotations in clinics “will hit on this when a patient is either diagnosed with ME/CFS or is presently under treatment for it.”
This presumes, however, that the students in clinic will have a chance encounter with a patient who has ME/CFS – likely – but that the individual will have the diagnosis of ME/CFS – far less likely, since it has been estimated that approximately 80% of those with the illness go undiagnosed.
John O’Donnell, MD, MS, FACP, director for preclinical curriculum at Michigan State University College of Human Medicine, described his institution’s preclinical curriculum as “problem based.”
Students practice diagnosing illnesses with and without biomarkers while learning basic sciences by solving case studies, called paper cases. To prepare to diagnose illnesses not covered in paper cases, including ME/CFS, O’Donnell said students learn how to obtain a medical history and conduct a physical that includes asking questions about every organ system and about constitutional symptoms, meaning symptoms affecting overall well-being.
If College of Human Medicine graduates encounter an illness they cannot diagnose, “we expect them to go to what we consider to be reliable resources,” O’Donnell said. He said an example of such a resource is UpToDate, a subscription-based, online collection of medical information. It frequently cites journal articles and is written, edited, and reviewed by physicians, according to its About page.
Despite being an osteopathic medicine school, the College of Osteopathic Medicine at University of North Texas Health Science Center also has little coverage of ME/CFS in its curriculum. Osteopathic medicine schools grant the degree Doctor of Osteopathy, or DO, rather than MD. Their medical training is as rigorous as MD-granting schools’ training; what differs is their underlying philosophy, which focuses on integrating all techniques that serve the patient. The College of Osteopathic Medicine is ranked number two in primary care among osteopathic medicine schools in the 2017 U.S. News and World Report.
“[ME/CFS] is not something that we deal with significantly,” said Michael Oglesby, a professor of pharmacology and the second-year curriculum director, citing limited space and time in the curriculum of the first two years. He added that ME/CFS may be addressed in years three and four or during residency.
All students diagnose by combinations of history, physical examination, and then lab work. “The lab is the definitive diagnosis. The initial is almost always done off the history and physical,” Oglesby explained.
Differential diagnosis, considering possible causes of a set of symptoms to identify which best fits a clinical presentation, is taught primarily in years three and four, Oglesby said. Many illnesses have overlapping features, requiring physicians to conduct differential diagnosis when diagnosing illnesses like ME/CFS.
“That is why they are difficult to diagnose. They have very few distinguishing features,” Oglesby said.
This lack of training by some of the top medical schools in the country highlights the urgent need for better training for clinicians to help them understand the illness, diagnose ME/CFS swiftly and accurately, and provide sensible, symptom-based treatment recommendations while medical research continues to work towards a cure. Visit the #MillionsMissing protest demands to learn more.
To read the next article in our series on medical education in ME/CFS, click here.
#MEAction would like to thank Darla N. for her investigative reporting in this series! Read the stories in order by clicking on the links below:
1) Top Medical Schools Teach Little about ME/CFS
2) Medical Textbooks Earn a Failing Grade in ME/CFS – 1 of 2
3) Medical Textbooks Earn a Failing Grade in ME/CFS – 2 of 2
4) Three Schools of Alternative Medicine Teach about ME
8 thoughts on “Top Medical Schools Teach Little about ME/CFS”
The widely used medical reference, Merck Manual, which Wikipedia calls “the world’s best-selling medical textbook” https://en.wikipedia.org/wiki/Merck_Manual_of_Diagnosis_and_Therapy, states the following in bold letters at the top of the Merck Manual, Professional Version, Chronic Fatigue Syndrome page https://www.merckmanuals.com/professional/special-subjects/chronic-fatigue-syndrome/chronic-fatigue-syndrome:
“Chronic fatigue syndrome (CFS) is a syndrome of life-altering fatigue lasting > 6 mo that is unexplained and is accompanied by a number of associated symptoms. Management includes validating the patient’s disability, treating specific symptoms, cognitive behavioral therapy, and a graded exercise program.”
Further down the page it says:
“Cognitive-behavioral therapy and a graded exercise program are the only interventions proven helpful.”
Under Key Points it says:
“Validate patients’ symptoms, encourage them to accept and accommodate to their disabilities, and treat using cognitive-behavioral therapy and graded exercise.”
Also under Key Points:
“Diagnose CFS based on characteristic symptoms in patients with a normal examination and normal basic laboratory test results; CDC criteria may be helpful but are not strictly applied to individual patients.”
From Merck Manual, Consumer Version, Chronic Fatigue Syndrome page https://www.merckmanuals.com/home/special-subjects/chronic-fatigue-syndrome/chronic-fatigue-syndrome:
Under Causes:
“Controversy exists as to whether there is a single cause or many causes and whether the cause is physical or mental, but either way the symptoms are very real to the person.”
“People with chronic fatigue syndrome do not have a medically serious problem with their immune system.”
“Chronic fatigue syndrome seems to run in families, possibly supporting a genetic component or an environmental trigger. Alternatively, members of the same family may respond similarly to physical and psychosocial stress and/or may have been exposed to the same substances.”
Under Diagnosis:
“The diagnosis of chronic fatigue syndrome is made only if no other cause, including side effects of drugs, is found to explain the fatigue and other symptoms.”
They list criteria but then state:
“However, most doctors agree that these criteria should not be applied strictly to every person. The criteria are more useful as a common definition in research studies.”
Under Treatment:
“In most cases, symptoms of chronic fatigue syndrome lessen over time.”
“The only treatments proven effective for chronic fatigue syndrome itself are cognitive-behavioral therapy and graded exercise.”
“Cognitive-behavioral therapy is usually a brief course of psychotherapy aimed at redirecting hidden thoughts that could discourage people and prevent positive outlook and recovery.”
Yes, can you send Merck, UpToDate, A.D.A.M. (medical encyclopedia), and similar organizations information and tell them we expect them to use current information (that is not riddled with statistical errors and COIs)?
Telling these companies and publishers to update their info on ME is a great idea. In the fall I gave my feedback to one publisher that was easy to communicate with. The problem I have is that because I’m not a clinician or a PhD, I lack credibility with medical publishers. UpToDate relies on journal articles, so as we continue to see better peer-reviewed studies (i.e., not the PACE trial), I hope to see it gain updated content. Some publishers and schools also pull content from the CDC’s webpages about ME, so until those are updated, we’ll continue to see inaccurate ME education. It seems we need a push for reform from the government and an ambassador to publishers with a PhD or extensive clinical experience. If anyone here knows someone who could be that ambassador, reach out to him or her or tell me who that person is. Thanks for reading!
Good interviewing and reporting!
The saddest part of all this? It is better that med students get *no* medical education regarding ME than them getting false and harmful education, i.e. that GET is supposedly a good treatment. I know too many patients who got much worse (outright disabled) as a result of exercise.
This is why we fight. This treatment is longer acceptable in 2016. Unfortunately it is our burden to be the pioneers of ME/CFS so that future generations don’t have to suffer as we do.
Thank you Darla N. for exposing this medical neglect and abuse.
Keep holding on, PWME, biomarkers are coming.
You might want to edit this to say that while O’Donnell recommends UpToDate as a resource for doctors, UptoDate is not up to date re ME and CFS. They redid their info after the IOM came out, and in the patient info they miss the key symptoms + say CBT and GET are the treatments. They also say most patients are depressed, and that patients do not die or get organ failure. In the professional pages they say CBT and GET are the only therapies proven to help. At least they say they are not curative.
Leela,
Stay tuned for the next article, which will be linked to that statement!
-Jaime
if anyone comes up with a brilliant idea to get medical schools to update their curriculum, would you mind tweeting me @redruddyred? i’d love to be involved. the best i can come up with is a letter writing campaign.
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