Tuesday, August 10, 2010

Medical School and Surgery

A rising second year medical student read some of my posts and wrote me a kind note asking if I would write something for students. I taught students and ran surgical clerkships at community teaching hospitals for my entire career until about 19 months ago. I also was prompted to address this subject after reading a recent New York Times story about a new admissions policy at Mt. Sinai Medical School. The school is accepting some students who are majoring in the humanities and are not required to take the usual science courses or the MCAT. In the words of one of the participants in the program: “I didn’t want to waste a class on physics, or waste a class on orgo [organic chemistry]. The social determinants of health are so much more pervasive than the immediate biology of it.” I agree that possibly “orgo” and probably physics are not necessarily essential for medical school applicants. But I think these courses are still relevant because they assess one’s ability to think. According to the article, these humanities students are faring as well as traditional students as far as grades and class rankings are concerned. Is this because science doesn’t really matter or could there be another reason?

Grades in medical schools are a joke. Let’s talk about the third year. If you look at the explanation of grades that comes with a student’s medical school transcript, you will find that the average distribution of grades in third-year clerkships in all subjects is something like this: honors 30%; pass 68%; low pass 2%. It is almost impossible to flunk out of any medical school in the United States. I once received an application for residency from a student who had been matriculating at a single medical school for TEN YEARS! I assure you that dean’s letter was a masterpiece. [More on deans’ letters below] And the fourth year of medical school is even worse. With few exceptions, most schools allow students to choose electives which may be taken just about anywhere on the planet. There are no objective measures of performance on electives and students are even more likely to receive honors grades in electives than in required courses.

“‘When I use a word,’ Humpty Dumpty said, in a rather scornful tone, ‘it means just what I choose it to mean—neither more nor less.’" [Lewis Carroll, Through the Looking-Glass. See also Bill Clinton "It depends on what the meaning of the words 'is' is." And "It depends on how you define alone…"] Carroll's quotation is not only applicable to Humpty Dumpty but it also describes most deans’ letters supporting student applications to residency training programs. Obfuscation is the name of the game. Until just a few years ago, deans did not even have to mention such things as failing a course, dropping out of school for a year or disciplinary actions. The letters all continue to read like public relations releases. The best part is the end where the dean uses an adjective, which in many instances is a code that tells the reader what the student’s class rank is, to describe the student. Some of my favorites from real dean's letters are as follows [highest to lowest and, where indicated, % of the class receiving that adjective]:

School A—outstanding, excellent, superior, very good, good;
School B— superior 20%, outstanding 20%, excellent 30%, very good 20%, good 7%, solid 3% [I guess “solid” could mean the student is dense as a rock.];
School C—superior “a few,” outstanding 25%, excellent 65%, very good 20%. I know it doesn’t add up to 100% so talk to the dean. Also, the worst student in the class was very good.

Yes, medical school resembles that famous fictional town in the Midwest. “Welcome to Lake Wobegon, where all the women are strong, all the men are good-looking, and all the children are above average.” [Garrison Keillor]

As far as I know, most medical schools are teaching surgery just like they did 40 years ago. What is Hesselbach’s triangle? What is Charcot’s triad? Second assist on a bunch of cases. Get the lab results from the computer so they can be re-entered in the computer in a progress note. And so on. Now that an entire surgical textbook can be carried in your cell phone, why don’t we change the paradigm? Rather than forcing you to memorize information, we should be teaching you how analyze and synthesize information as it relates to your patient.

The third-year surgery rotation in medical school is not a necessarily a good simulation of what it’s like to be a surgical resident. I can’t say what goes on in every school, but the last school I was affiliated with allowed students to take off the day after call. I never could figure out why since we only woke them for major cases at night and they usually slept most of the time. All I could say was, “It’s your tuition [$45K/year] and if you want to go home, it’s OK with me.” By the way, we at the affiliated hospitals never saw a penny of that tuition money. I’m not sure exactly where it was spent. I think that the way students are coddled on surgery rotations might be a factor resulting in the high attrition rate [about 25%] of surgery residents; i.e., it looks easy from the perspective of a student who does not do much.

Fourth year is out of control. In addition to the grade problem mentioned above, students are permitted to choose just about any rotation they want in the fourth year. This leads to tragic situations such as the student who takes four or five orthopedic electives in order to get noticed and then does not secure an orthopedic residency in the match. He will have wasted a good part of his fourth year.

One of the many unintended consequences of the electronic medical record [EMR] is the demise of medical student progress notes and orders. There is no provision for such activities in most EMRs. I have no idea how students are learning how to do these things.

My advice to my new friend, the rising second-year student, is that you should work hard and study hard during your surgery rotation in the third year. Be inquisitive. Be skeptical. Ask why. In my 38 years or so of teaching students, I estimate that I was challenged by a student on something I said fewer than five times. [Disclaimer #1: Not all authority figures like to be challenged. Choose your targets wisely. Be respectful.] If you want to be a general surgeon, take one surgery elective in the fourth year just to be sure you are making the right choice. Then take electives in gastroenterology, critical care, radiology [Not just because of the hours. You will need to know how to read a CT scan in the middle of the night unless you want to wait a couple of hours for the nighthawk to fax a reading.], anesthesiology and other non-surgical rotations. [Disclaimer #2: This is my opinion and it may not be shared by others.]


Health Train Express said...

Dear Skeptical: I came across your post on KevinMD. I could not agree with you more. Your grade on a clinical rotation most likely depended upon the intern or residents appraisal of how much 'scut work: you did. Now you and I are probably about the same vintage, but you have had the benefit of teaching recently. My appraisal of 'outside rotations' by interns, medical students, etc is that they were a 'vacation' to be enjoyed. The attendings were more than happy to have any help at all, distracted by their own demands, and would usually take you out to dinner at some point.
EMRs basically suck big time. They will destroy what is left of real medicine only to be read by a high school graduate who is looking for key words such as beta blocker after heart attack (even if it is an incomplete sentence of fragment. You and I are retiring at the right moment (maybe about ten years too late). Enjoy blogging as I do and other avenues of accomplishment. Read me on Health Train Express

Anonymous said...

As someone currently active in both medical student & resident surgical education I would agree with most of scepscalp's comments. I would modify the comments on the 4th year electives as follows: Do take some away elective in your specialty of interest at your top choices for residency in the beginnning of the year. This not only lets them know you but you know them. You'd be surprised how many students rank orders change on that basis. Don't repeat if possible (ie: do Vascular, Colorectal, Trauma, etc. instead of 3 Gen Surg subs in a row). After that branch out, stay away from Surgery as the scepscalp suggests. Take Cardiology, Nephrology, Infectious Disease, etc.

Skeptical Scalpel said...

Anon-I agree with everything you said.

qtipp said...

A very sincere thanks for this post. Looking forward to more student related posts in the future.

-An older guy entering medical school this summer.

Anonymous said...

The fourth year is no longer used to learn medicine. It exists as a jet-set ass-kissing year.

Skeptical Scalpel said...

Anon, I have news for you. It's been that way fr over 20 years.

Anonymous said...

A quick follow-up question: As an MS3 who works hard and willingly learns, I have been disappointed by the mediocre grades and generic evaluations I received on my rotations ("hard worker, enthusiastic, team player, etc). Meanwhile, there are the clever (i.e. manipulative) suck-ups and backstabbers out there getting honors. Should I take heart in knowing that residencies view grades/evals as all fluff, or should I sacrifice my honor and dignity for that elusive honors grade?

Skeptical Scalpel said...

Anon, that is a great question. I'm not sure all program directors think grades and evals are fluff. I honestly can't speak for all PDs. I know that most still value USMLE scores more. I hope yours are good.

This post is 3 years old but I'll try to see if I can get some current PDs to comment.
I don't know what to say about your dilemma. I believe in honor and dignity so I'm leaning that way, but it would be nice to get an honors grade in surgery, even if 40% of the class got one too.

Doctor Which said...

Oh, please listen... for everybody's sake, the profession and patients alike...

Please put Skeptical Scalpel in charge of medical education

Anonymous said...

@MS3: Here is advice passed onto me by my mentor who was a PD for many years. Make yourself a known entity. Go to the surgery clerkship director and your attendings at the start of your rotation and let them know that you want to be a surgeon. Then give it your all. Volunteer for tasks. Show up early. Work hard. If you display enthusiasm, competence, and get along with the team (and are on their radar), then your attendings should go to bat for you. Get a strong surgery clerkship evaluation and letters of rec from surgeons who know you. Solid step scores are important. As for your other clerkships evals? Approach each rotation as you have been, trying to get as much learning as possible out of them. So long as there are no 'red flag comments' of concern in them, don't worry. Hope that helps. All the best to you.

Anonymous said...

I don't agree with everything in this post (I think most medical students are very hard working), but have to agree that grading and assessments in med school are for the most part, complete bogus. I've seen students I thought should have been required to remediate get "exceeds expectations". It is at least 50% dependent on who you get evaluating you and what kind of mood they are in. Absurd. I've also witnessed students get better evaluations on a rotation just because they either knew someone in the dept or they wanted to do that specialty (NB: even if their performance was way worse than someone who wanted to get as far away from that area of medicine as possible). It makes no sense.

As for being skeptical, I’ve learned my lesson on this one and would caution fellow medical students. An attending had ordered a test and I was genuinely curious as to why. I figured there must be a reason and I just wasn’t aware of it. I thought about it for a while and couldn’t see how knowing results of this investigation would change management. I finally asked, and the rotation took a turn from there….. I’m aware that there are certain ways to go about asking these things, but I felt “Hi Dr. X, I’m just wondering what your reasoning was for ordering test Y.” was respectful.

Skeptical Scalpel said...

Dr. Which and the two anons, thanks for commenting.

I doubt I will be put in charge of medical education but I appreciate the vote of confidence.

Good advice from both anons, but second anon, I'm not sure how you meant your last paragraph. Did the fact that you questioned the attending work out OK for you or not?

Anonymous said...

Surgery (more than other specialties) is apprenticeship - manual labor with deep insight: skilled craft, giving great satisfaction, but does not scale. Slogging is for life.
If one shows up and works hard with integrity, rewards are most likely.

Skeptical Scalpel said...

Anon, well said.

Mark Dawkins said...

Keep writing more interesting posts.

Skeptical Scalpel said...

Mark, thanks. I wasn't sure if you meant that I should write posts that are more interesting or keep writing posts that are already more interesting.

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