"Quit worrying about your health. It'll go away."
Robert Orben
Every Medical Student Needs To Know All Of This
Simplified
In a perfect medical school the basic science education would be cut down. What I mean is that the focus on minute ‘physiologic’ biological processes would be limited. The basic sciences, especially in the first year, have become too complex and unnecessary. Too often what students are introduced to is influenced by the research of the faculty of the school. At the perfect medical school such would be limited with strict curriculum oversight. Further cutting of the basic science years would be limited by the National Board of Medical Examiners and their continued insistence that memorizing a host of biochemical pathways is somehow imperative for a single test day, somehow is imperative to becoming a physician. If that obstacle was removed the perfect medical school would significantly cut down on the traditional ‘first year’ material.
Early Clinical Exposure
The perfect medical school would also compress the basic science years. Already there are schools which do the first “two years” in eighteen months. An applause to such schools. The perfect medical school would do the same. The key is to get the medical student out of the classroom as soon as possible.
As I’ll discuss in the clinical sciences post, clinical exposure would be early in the first year and often. The 18 months at the beginning of the perfect medical school could hardly be called ‘basic science,’ despite the title of this post.
Integrated Curriculum
The perfect medical school would have a truly integrated curriculum. There would be no distinction between ‘first’ and ’second’ year. You would progress through the 18 months of basic science in modules focusing on various topics (i.e. cellular metabolism, cardiovascular system, GI system, etc.) in which you would cover the physiology, anatomy, pathology, related pharmacology, etc. The basics, which are hard to integrate, would be covered in the first two months in the classroom and then it would be off.
Despite the abandonment of the anatomy lab by some schools, gross anatomy and human dissection would remain a strong component of the perfect medical school.
Technology
The perfect medical school would be the most integrated school in the country, technology wise. The obvious things, done in most schools nowadays, would include virtual microscopy (no student should ever have to fix a path or histo slide), online lectures, online grades, online syllabi, computerized test taking.
Summary
- Remove frivolous basic science minutia
- Condense the basic science education to 18 months of less
- Early clinical exposure
- Strongly integrated curriculum with no distinction between ‘first’ and ’second’ year
- Gross anatomy lab
- Integrated use of technology in teaching
[Return To The Perfect Medical School]
Several in the medical blogosphere (here and here) have picked up on a front page WSJ story concerning specialist income and shortages.
Probably an overblown story.
But a look at specialist income got me thinking. Is it just me or is diagnostic radiology the specialty most likely to be disappointed over the next couple of decades? When I was writing my previous posts on physician income I started really thinking that radiology may be in for a significant slow down in earnings growth. There are two factors which I think will contribute to disappointing growth in radiologist income:
1) Their rise in income over the past two decades has been precipitous and outpaced the growth in median income of just about every other specialty. And not all of that has been driven by the rise of interventional procedures. Radiology thus, as a specialty, has some of the most to “give back,” if and when physician income growth slows as cost sharing measures.
2) The rise of outsourcing is probably a little overstated but it seems real enough. With rising healthcare costs concerns over international radiologist work (liability issues, etc) may not be enough to prevent the outsourcing trend from speeding up a bit and driving down reimbursement.
This isn’t to make a claim as to the value of radiology or to say that diagnostic radiologists are currently over reimbursed (I don’t think they are). I’m just trying to imagine the future. Radiologists will never be ‘hurting,’ but in my career I think they’ll be doing more work for less dough.
I’m No Radiologist But Something Ain’t Right Here
I have a lot of respect for the ACR and RadPAC’s efforts but diagnostic radiology may not be in a completely defendable position with some of it’s unique aspects as a specialty.
Our Dean of Admissions Welcomes You
Pre-Requisites
Pre-requisites for medical school admission should be extremely limited. Indeed, I think in the perfect school, they would not exist at all. Completion of say an undergraduate biochemistry has absolutely no independent predictive value of medical school success. A reliance on standardized tests to assess the pre-medical school basic science knowledge base in appropriate and required pre-requisite classes are simply redundant. Indeed the MCAT is an excellent predictor of medical school success; probably the best single predictor.
As many medical schools there would be no specific requirement for an undergraduate degree. Indeed, I would propose allowing mature high school students sure of their future to study for and take the MCAT without any college preparation and to enter medical school immediately following high school. And I’m not talking about an extended course here (like the 6 year European programs).
Admissions Criteria
As above, great emphasis would be placed on standardized measures (i.e. the MCAT). True, there are anecdotes of those who are merely poor standardized test takers and otherwise excellent students and perform as excellent physicians but in general the MCAT is an excellent predictor, not only of future standardized test performance, but of performance in medical school in general.
Very little weight would be put on prior GPA, which is entirely impossible to standardize versus other applicants. Such would probably help the pre-med attitude a bit.
More than lip service would be given to the intangibles that make a good physician and a demonstration of the right motives for going into medicine, a commitment to research, etc. would be elicited in part through self reporting, letters of recommendation and the unique interview process.
Interview Process
The admissions committee interview team would be entirely limited to physicians and current medical students and basic science faculty would be barred. The idea is that the interview process should solely serve in trying to determine the intangibles which make a good clinician. Hopefully things like a dedication to research can be derived from the applicants’ previous activities.
The interview process would be given a huge amount of weight, as a measuring tool of applicants’ intangibles as mentioned above. I imagine a full day ‘interview’ or perhaps two half day ‘interviews’ to standardize the rankings the admission committee members give to the applicants they interview.
What I mean, is that the admissions committee members would give an entire half day to interact with the applicant. Your a clinician in clinic then the applicant comes along or he scrubs into that surgery. The applicant and interviewer sit down for lunch together and then perhaps dinner with a second interviewer.
Summary
- No pre-requisite courses
- Potential for admission directly from high school in unique circumstances
- Essentially ignore undergraduate/high school GPA
- Strong emphasis on MCAT performance
- Day long, informal interview process
[Return To The Perfect Medical School]
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Photo: Laffy4k/CC License
Prestige, Baby, Prestige
If I was creating a medical school from scratch there are some specific things I would incorporate. Many of these ideas exist at various medical schools here or across the world. Some of these ideas are wholly new. This is essentially just a random collection of thoughts and not exactly an outline of how to start a school (no duh). For obvious reasons these ideas ignore current accreditation standards.
This series was inspired by a lengthy conversation I participated in (admittedly over drinks) concerning the perfect medical school. It was a group discussion amongst second and third year medical students from schools all across the country. It obviously focuses largely on ‘undergraduate’ medical education, which should be the primary focus of any medical school (many medical schools lose sight of this).
1. Pre-requisites & Admissions
2. Basic Science Education
3. Clinical Education
4. Special Topics
If you have any ideas on the perfect medical school please leave them in the comments.
This Can Be Dangerous To The User
Today an obstetrics patient came in a month out from being treated for chlamydia. In non-pregnant women you treat and let it slide but rip-roaring chlamydia in a pregnant woman can have some bad effects. Pregnant women with active chlamydia infections are more likely to go into pre-term labor and during delivery it ain’t so good for the little fella to be passing through an infected vaginal canal. Because of that we need to actually test for cure and that calls for a speculum exam.
I’m more than comfortable with pelvic exams now and as in the one I had done earlier in the day, everything went relatively smoothly in this one. I do what needs to be done, pull out and reach across myself to throw the disposable speculum into the biohazard can when a big honking glob of…well, I’ll spare you the details; it is enough to say something dripped off the speculum and onto my slacks. Something that might make you consider incinerating those pants rather than taking them to the dry cleaners.
There are much worse stories of pelvic exams out there, so I’m hoping this relatively tiny mishap will be enough to appease the Ob/Gyn gods. And it was kind’ve funny and my resident got a kick out of it.
Fourth year medical students all across the country learn where they matched for residency today at noon central time.
For the uninitiated: Medical school is four years in length. While curriculums can differ slightly most schools break it down like this,
First Year: In the classroom learning about how the body works (anatomy, physiology, etc)
Second Year: In the classroom learning about what happens and what you do when things go wrong (pathology, pathophysiology, pharmacology, etc)
Third Year: In the hospitals and clinics doing the ’standard’ set of rotations (medicine, surgery, pediatrics, etc)
Fourth Year: In the hospitals and clinics doing electives, interviewing for residency, and taking lots of time off
Early in your fourth year (if not earlier) you have to decide what you want to do with the rest of your life. You have to apply for residency in a specific medical specialty. You fill out an online application and send it out to the residency programs you’re interested in.
Residency programs review your application and then, hopefully, invite you out for an interview. Some students may interview at 20+ residency programs. When interview season is over both the residency programs and the students submit rank lists. You can only include programs you interviewed at on your rank list.
These rank lists, due in February, determine the match. The match is weighted towards the students rank list. Let’s imagine it with three students and three residency programs. Let’s say the programs only take one student a year each. And let’s say that all three students interviewed at all three programs.
| Bubba’s Rank List |
Claire’s Rank List |
Zack’s Rank List |
1. County Hospital
2. St. Elsewhere Hospital
3. Memorial Hospital |
1. St. Elsewhere Hospital
2. County Hospital
3. Memorial Hospital |
1. County Hospital
2. Memorial Hospital
3. St. Elsewhere Hospital |
The students’ list above hold the most weight but we need to know how the residency programs ranked the students in order to know the outcome of the match.
| County Hospital’s Rank List |
Memorial Hospital’s Rank List |
St. Elsewhere Hospital’s Rank List |
1. Claire
2. Bubba
3. Zack |
1. Claire
2. Zack
3. Bubba |
1. Claire
2. Zack
3. Bubba |
Claire ranked St. Elsewhere first, and that residency program ranked her first. Therefor she’d match to St. Elsewhere.
Bubba ranked County Hospital first. Although County ranked Claire above Bubba, Claire is already going to St. Elsewhere. Since Bubba was County Hospital’s second choice and their first choice is unavailable Bubba would go to County.
Zack would go to Memorial Hospital. Although he ranked County Hospital as his top choice, Bubba has already filled that residency spot because County Hospital ranked Bubba higher than Zack.
Just imagine doing that with thousands of applicants and residency programs which have many spots to fill.
In anycase, today, after all their hard work in medical school most medical students will find out where they’re going to be doing their residency. Students who wanted to do neurosurgery or ophthalmology have already found out (those two specialties have an early match). But for the vast majority of students today is the day. Good luck guys!
I’m a week into my surgery rotation and I want to be a surgeon.
My Fashion Statement On My First Day
I’m on a pretty tame service but it isn’t a walk in the park. I worked 78 hours my first week and loved every minute of it (well almost).
I’ve looked stupid, impressed, been chided, been shouted at, even been complimented. Haven’t had anything thrown at me yet.
I’ve been pimped much less than I thought I would, I’ve done a terrible job trying to laprascopically ‘retract’ a liver, I’ve made remarkable progress with my ‘one handed’ ties, I’ve gotten pretty good anticipating with the camera, and I’ve slowly figured out that my chief doesn’t really want to hear anything but objective info that would change his plan on a patient and my assessment. Our rounding is more than I ever could’ve expected from the myth of surgical rounds:
“She’s passing gas. She looks great.”
“Okay, advance her diet.”
And away we go.
I’ve seen my handful of lap choles, I’ve seen a thoracotomy in the resuscitation bay, I’ve seen a lap Nissen, I’ve seen my share of total and subtotal colectomies, I’ve seen a decompressive craniectomy and a ventriculostomy (while on trauma call), I’ve seen an ileostomy takedown which made my patient happier than I’ve ever seen a patient.
I’ve noticed many of the same things which Mark over at Denialism articulates,
1. Surgeons always tuck in their scrubs.
2. Surgeons must never have their stethoscope around their neck, it must be in their pocket (their least valuable tool - haha).
3. Carrying anything other than a stethoscope, some gauze and supplies, and a pen light will lead to ferocious mockery. Pity the fool who would dare to bring a reflex hammer onto the surgical wards.
4. Surgery is almost always about the “most likely” or “most common”. They don’t spend a lot of time worrying about about diagnosing things to death, and the consequences are often too severe for delaying interventions.
[…]
6. It’s amazing watching some of these open procedures than anyone can survive such rough treatment of their insides. Seeing the force put on things like retractors, you wonder how people ever recover.
And I want to do surgery or a surgical subspecialty. That isn’t really a surprise seeing as I thought I wanted to do surgery coming into school. But once here, so much was interesting. So consider this a reaffirmation. I may not know specifically what I’ll try to match into yet, but it will be something surgical.
Optimism is good for the soul most of the time.
Take a look: Forbes’ survey of the Top 25 highest earning jobs.
The survey is a gross generalization, true. Grouping all surgeons together, having categories like Physicians - NOS shows how “for the public” the survey is. I’m sure other professions on the list are likewise generalized. Physicians and surgeons obviously have a wide range of incomes. Take a look at this average physician salary survey to get a feel for the disparities.
That aside, the Forbes piece is still a reminder of how lucky I will be.
I love it when people say if you want to make money don’t go into medicine. While true in a way…
No One Aspires To Bill Gates-esque Wealth As A Physician
…I think it still grossly fails to appreciate the lifestyle most physicians enjoy. There is a real debate about the undervaluing of physicians. Merely looking at income levels fails to weigh things like years in training or education and business debt. And the reimbursement pressures are very real and I imagine very stressful.
But that isn’t what you hear out here as a physician-in-training or potential physician-in-training. I hear over and over, “If you want to make money go into business or become a lawyer or whatever.”
But really? The implication is there are guaranteed greener pastures elsewhere. It certainly doesn’t seem like that is the case when you step back and take a look.
Sure, there are some personal injury attorneys who earn millions and do better than the docs they’re suing. There are personal injury attorneys who can’t pay the rent on their office space.
Sure there are your friends with the bachelor degrees in finance who are pulling in the dough working their way up in some I-Banking job. There are your college friends trying to figure out how to earn with an English degree as well.
Anecdotes.
In reality even by the hourly pay (also see here), many if not most specialties (my apologies to PCPs), do really, really well. And yet I hear advice to stay away from medicine from ophthalmologists and ortho spine docs. That doesn’t seem right.
Being a doctor may not mean the relative wealth it did at its peak, but my God, for a profession that offers so much else, the earning potential is still pretty remarkable.
That said, by no means are physicians overpaid. Not here and not elsewhere. Far, far from it.
There’s a reasonable argument that physicians should be amongst society’s highest paid individuals. I think most of the public, realizing the relative value of health, buy that argument.
But whether physicians earn their true weight, it is worth stepping back and realizing how comparatively blessed this profession is. Even as students accumulate debt, even as payments fall and practice costs rise. Because while I could be earning more in some other profession, it is much more likely that my lifetime earning power would be less.
Plus, it’s just good for the soul to see the glass as half full.
She Is A UCLA Bruin Though
There’s an LA Times story floating around about a pretty remarkable UCLA medical student. Well, not medical student anymore, she’s probably Dr. Lim by now considering UCLA’s graduation/Hippocratic Oath ceremony has come and gone.
But whatever her title her’s is a truly encouraging story.
Struck with a ravaging bacterial infection that destroys limbs, she became a triple amputee at age 8 and soon faced a life of prosthetics, wheelchairs and often-painful rehabilitation.
But from that suffering, Lim forged a life of achievement. On Friday, she will graduate from UCLA’s medical school and then will begin a residency program at the medical center there.
Her chosen specialty? Pediatrics, with a possible concentration later on childhood allergies and infectious diseases.
Colleagues say Lim’s calmness in a hospital’s hectic environment puts others at ease.
“With Kellie, at first you notice her hand is not there. But after about five minutes, she is so comfortable and so competent that you take her at face value and don’t ask questions so much. She has an aura of competence about her that you don’t worry,” said Dr. Elijah Wasson, who supervised Lim during a rotation in internal medicine at Olive View-UCLA Medical Center in Sylmar.
A Los Angeles Times piece looks at medical students considering abortion work as obstetricians.
Each spring, the advocacy group Medical Students for Choice brings several hundred students — nearly 90% of them women — to a weekend convention to nudge them into considering abortion work. One of the most effective tools: introducing them to veteran providers.
[Y]oung doctors-in-training have found their own motivation to enter a field that they know will put them at risk of isolation, harassment and hatred. For them, doing abortions is an act of defiance — a way of pushing back against mounting restrictions on a right they’ve taken for granted all their lives.
“It’s like when your big brother says you can’t do something,” [Fourth Year Megan] Lederer said. “That just makes you want to do it even more.”
Abortion is one of the most common surgical procedures in the U.S., terminating about one in four pregnancies, not counting miscarriages. Yet the number of providers has fallen steadily for decades, dropping 37% between 1982 and 2000, the last year a census was taken. (During the same period, the number of abortions fell 17%.)
Coming to terms with doing this as part of your practice must be…tough…
Lederer does not know how she will handle such emotion; the closest she’s come to performing an abortion was suctioning the seeds out of a papaya to learn a first-trimester technique. She may, in the end, restrict her practice to early abortions. But that’s not an easy solution to accept. She can’t see how she could ever justify taking one woman as a patient while turning away another because her pregnancy is a few weeks more advanced.
She also knows that the few doctors who perform late second- and third-trimester abortions are mostly in their 60s or 70s. “Who’s going to do this when they leave? Someone has to,” Lederer said. “I feel in my heart of hearts that it’s the right thing to do.”
The trashing of stents, those little things which caused so much angst for the cardiothoracic surgeons, continues. Freakonomics (h/t Kevin, MD via OnThePharm) predicts stenting will be looked upon as a failed experiment in coming years.
By the time any of my class is approaching the end of a general surgery residency all of these things will probably have come to pass and be obvious. But for anyone currently in a surgical residency maybe CT surgery deserves another look.
Despite that advice, I have some trouble with the post and the BMJ editorial which Freakonomics is commenting on. From the BMJ,
It’s easy to feel contempt for deluded practitioners of the past who advocated bloodletting and tonsillectomies for all. Easy, that is, until one considers emerging evidence that coronary stenting and postmenopausal hormone replacement therapy may well be the contemporary equivalents of those now discredited practices.
Now that the dangers of hormonal treatments have been revealed, we are left with a paucity of effective treatment alternatives. A few that have modest evidence of benefit include clonidine, some selective serotonoin and noradrenaline reuptake inhibitors, gabapentin and Vitamin E.
Emphasis is my own. But the BMJ’s editorial is being published on the heels of this.
Read More »
Laparoscopic surgery skill tied to video game playing.
Try Not To Need Surgery Until This Next Generation Of Surgeons Comes Of Age…
This must be a follow up because I heard of laparoscopic outcomes and times being tied to Super Monkey Ball 2 year(s) ago. I swear. In any case, anything tying a childhood (and sometimes continued) life of playing video games to success is fine with me.
From a link from Kevin, MD comes a brief look at how medical students see Arnuhld’s new health care proposal in California.
University of Southern California medical student Julia Cormano says she would stay in California—but reconsider her choice of specialties. Cormano, co-president of the med school’s students’ association, says the talk on campus is whether students, who can carry as much as $200,000 in loans, would be forced out of general medicine with the additional drain on future income. “(The plan) would make it that much more difficult to go into fields that aren’t well-compensated,” says Cormano.
If you don’t remember the plan calls for a 2% tax on physician practice gross income. The feeling is this will hurt PCPs (with comparatively high overheads versus earnings) the most.
Just A Funny Picture. That Is Him Actually Announcing The Coverage Plan.
“In Other Words, Ron Burgundy Derm & Plastics Were The Balls.”
I truly believe these two specialties are in a class far and above all others right now in terms of how competitive they are.
1. Plastic Surgery (Integrated)
2. Dermatology
Plastic Surgery has two routes. General Surgery/Oto + Fellowship or the direct match integrated programs. In some ways the integrated programs are a bit of a failure. Most (if not all) surgical sub specialties used to require a general surgery residency but now things like ortho and neurosurgery are COMPLETELY separate training routes.
Not the case with plastics where the integrated approach still co-exists with the plastics fellowship.
In anycase, while still difficult, going through general surgery and then finding a fellowship is considerably “easier” (but not easy) than matching into these integrated programs.
These are the most difficult programs in the land.
Consistently less than 50% of U.S. Seniors match. That is by far the worst figure of any specialty. Now granted there is certainly less self selection going on here, because they know they have a “better” shot at going and doing general surgery and then plastics.
But even with a “de”flated matching percentage Plastic Surgery has the highest median Step 1 score for matched U.S. Seniors at 242 - 243. Think about that, the median student matching has a score above 240, more than 20 - 30 points higher than the national average on Step 1.
It also has the second highest AOA %.
The highest goes to Dermatology. Clearly Dermatologists love AOA. The percentage of students is so disproportionate to other specialties that it is clear they weigh that part of the application far more than any other specialty. It is disillusioning to even think about Derm without being AOA considering 50% are.
That might be surprising - only 50%? First, plenty of allopathic schools lack AOA. Second, consider that just 10 - 15% of the graduating class (from all schools) is AOA. Dermatology snatches up a hugely disproportionate (stop using that word!) number of those kids, it is easy to see.
The Step 1 median is no slouch either. It is the second highest coming in just under 240 last year.
Dermatology has much more self selection than plastics, yet its matching % for U.S. Seniors was consistently ~60% before last year (where it shot up somewhat).
I hope this little series has been interesting. Maybe even put some things in perspective.
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