Med school curricula: Lots of fluff?

[deleted65604]

You've got to put yourself in the seat of test question writers. I wrote a couple hundred questions for EM-based curriculum a couple of months back. It is extremely hard to put together a question that
A. has a definitive RIGHT answer (I would spend sometimes an hour on one question researching and refining the question and answers)
B. is challenging

The resultant small subset of testable, interesting, challenging ER trivia is at times esoteric. I would argue that people do well on ER standardized tests because they remember things and PERCIEVE the clinical dilemma in the question and understand the appropriate response.

People who score poorly either have a difficult time PERCIEVING the nuances, or don't remember the appropriate response. Why is either trait acceptable in an ER doctor?

I just got done reading the book "Outliers" by Gladwell, the same guy that wrote "Blink". It started out great, making you appreciate that to achieve greatness, there is often massive amounts of luck and extenuating circumstances that contribute. It ended with a plea for socialism, basically trying to say that we should help all those who don't perform quite as well as their peers.

I disagree with the notion that great performance shouldn't be rewarded. Sure, a person with not so great board scores might be a great doctor. However, I view testing as similar to job performance. If you test well, that represents first, a talent for learning and second, an underlying work ethic that leads to high level of performance.

I will grant that there is a certain point over which, a good score is a good score and a higher score isn't going to necessarily lead to a better doctor. After that, there are other intangible factors that will lead to greatness, much more likely than scores.

A disturbing trend that I viewed in my residency was a tendency to put people higher on the list, or even consider them for ranking after glaringly low board scores.

Why would you not want to reward greatness?

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[EM2BE]

If any of you have been on the bad end of boards, you would fully understand how you can know a lot of things but just don't do written tests well. If proposed a question with the patient in front of you and you can answer it, but when put on paper have more difficulty, you would understand why scores on these exams aren't everything.

 

[tncekm]

It's actually kind of interesting how MS-1's and MS-2's are speaking about what part of their education IS and what ISN'T "clinically relevant" and what IS "fluff" as they have NO idea how to answer that and will not until they actually get in a clinical setting and see it first hand.

Well, I don't think anybody is trying to say that MS1/2's can determine what is/isn't clinically relevant in every single topics we study or every single test question we read, but there are a few obvious cases. E.g. knowing physiological mechanisms IS important. Knowing "why" we perform a psoas test, look for a babinski sign, etc are all obviously clinically relevant because competence requires understanding. Knowing what the "exact" success rate of a properly applied IUD is just stupid. Regurgitating names of historical researchers is beyond stupid. Trivia is useless unless you're on Jeopardy.

If any of you have been on the bad end of boards, you would fully understand how you can know a lot of things but just don't do written tests well. If proposed a question with the patient in front of you and you can answer it, but when put on paper have more difficulty, you would understand why scores on these exams aren't everything.

Unfortunately, "bad test takers" are definitely a minority of medical students, so it's a moot point.

 

[coldweatherblue]

Speaking from the perspective of a second-year student studying for Step 1, I can only say that the feeling of complaining about having to learn random stuff in the curriculum is completely overshadowed by the realization I get seeing attendings/residents in clinic manage patients using areas of basic science beyond what I would consider "fluff" to treat patients, and the knowledge/fear that very soon I am going to be expected to perform at the same level. It may be a PITA to figure out how to recognize the ridiculous way the NBME presents every lysosomal storage disease and electrolyte abnormality on board exams, but I can honestly say that my fear and respect of licensing exams is responsible for a HUGE amount of my medical knowledge and that can really only be a good thing... for patients.

 

[GreenShirt]

I come from a new school that is trying to change the way that medical education is taught so I'm not afraid to challenge the status quo. The current model has been in place since 1910 and there's not many things we use in the modern day that are 100 years old. After having done rotations in both the traditional curriculum and my school's more modern program, I can tell you that there's a lot of room for improvement and better efficiency. Most of this thread deals with the basic science years of medical school but in my opinion the clinic years are even more inefficient. Rotations are completed at programs that are designed to teach residents NOT medical students. Medical students are treated like children in this system and relegated to quiet observers. They are not challenged to progress and apply their skills. The focus of medical schools should be their clinical training programs. If the efficiency of the training was improved, medical students could easy complete their training in 3 years and come out more prepared than in the current system.

 

[VA Hopeful Dr]

I come from a new school that is trying to change the way that medical education is taught so I'm not afraid to challenge the status quo. The current model has been in place since 1910 and there's not many things we use in the modern day that are 100 years old. After having done rotations in both the traditional curriculum and my school's more modern program, I can tell you that there's a lot of room for improvement and better efficiency. Most of this thread deals with the basic science years of medical school but in my opinion the clinic years are even more inefficient. Rotations are completed at programs that are designed to teach residents NOT medical students. Medical students are treated like children in this system and relegated to quiet observers. They are not challenged to progress and apply their skills. The focus of medical schools should be their clinical training programs. If the efficiency of the training was improved, medical students could easy complete their training in 3 years and come out more prepared than in the current system.

This is highly location and attending dependent.

 

[deleted65604]

The only relatively useless stuff in med school, so far IMHO as an MS1, has been in anatomy. I mean, really... who the hell cares where the prostatic utricle is

I had the same attitude until on numerous times I had to evaluate a wound that required in depth knowledge of anatomy.

For example, I had a kid with a laceration/degloving injury to has penis from a bull stepping on his crotch. I had to break out netter's to remind myself of the anatomy and make sure I felt comfortable repairing it myself and that I wasn't missing damage to vital structures.

It's also nice when radiology describes a ct finding to not have to say,"She's got a whatsawhosa in her where?"

 

[reedman]

I had the same attitude until on numerous times I had to evaluate a wound that required in depth knowledge of anatomy.

For example, I had a kid with a laceration/degloving injury to has penis from a bull stepping on his crotch. I had to break out netter's to remind myself of the anatomy and make sure I felt comfortable repairing it myself and that I wasn't missing damage to vital structures.

It's also nice when radiology describes a ct finding to not have to say,"She's got a whatsawhosa in her where?"

degloving injuries?!? i didn't know that em docs repair that kind of thing.

 

[deleted65604]

edited and lost, see below

 

[GeneralVeers]

It didn't take off much of the skin, just opened about a centimeter wide gaping wound that was about 5 cms long. It left the superficial and deep fascia intact (No, I never thought I would ever say the words Buck's Fascia as an ER doctor) I tried to get ahold of a urologist to come in and repair it, or at least give me some advice. Alas, urologists aren't consistently available to me.

Sorry for the pun but you've got a lot of "balls" to fix an injury like that. I wouldn't touch it with a 10-foot forceps. I would transfer if necessary to the closest hospital with urology call. If that kid every develops any impotence issues or sexual problems you will be liable, and likely loose in court.

 

[deleted65604]

It didn't take off much of the skin, just tore a straight laceration from the midline dorsum of the penis at the base, extending laterally. It left the superficial and deep fascia intact (No, I never thought I would ever say the words Buck's Fascia as an ER doctor) Sensation distally was intact. I tried to get ahold of a urologist to come in and repair it, or at least give me some advice. Alas, urologists aren't consistently available to me, and I thought that getting closed sooner rather than later would be better for the patient. Iguess degloving makes it sound worse than it was. It was only about 1 cms of degloving, and the rest was a simple laceration.

When you train solely in academic institutions, you develop this belief that ER doctors don't have to do certain things.

A good example would be my experience of orthopedic surgery in an academic ER. My attendings in residency would consult ortho for EVERYTHING. One of my most eye-opening experiences on my ortho rotations was for the head of the department to call me in from home to put a splint on a patient who he thought had increased scapholunate distance. I looked at the x-ray, my senior resident looked at the x-ray and the radiologist looked at the x-ray and we all thought it was normal. Regardless, if it wasn't abnormal, would we do emergent surgery that night? Insane.

When I started my job, I realized that ortho didn't want to be called about anything. I found that reducing fractures wasn't that hard and wondered why my attendings all consulted ortho so much. In retrospect, I think it is an easy way to dispo patients and not spend your own time on them. Some academic ER attendings walk around the department like the consult fairy..."You my child, get a consult." Then they walk away from the patient having spent about 3 minutes total on the patient, patting themselves on the back because they saw well over 2 patients per hour during their shift, not realizing that they didn't repair a single laceration, set a single broken bone, do a single pelvic exam, rectal exam, or document much more than, "I personally examined the patient and agree with the above."

Ideally, ER residents would train in a place where there were no other residencies, so that every consult at three in the morning woke surly attendings who are highly likely to complain to administration. In the real world, this behavior could cost you your job.

 

[deleted109597]

Uh, about that.
So, yes, many consults and admissions in academia wouldn't fly. Also, there are often admissions that would be slam dunk in the real work, but you can't get the resident to stop arguing about who to consult next to get them to see the patient.
I don't care if the bull didn't deglove any of the penis. If it stomped on it, then the urologist has to come in. Sorry, but them's the breaks. It isn't an every day thing. I don't call the orthopod for anything that doesn't require an operation. Simple fractures, yeah, you reduce them. Nasty supracondylar, you don't. We don't have an ortho residency here. Or urology.
If our attendings saw two patients per hour then it's because they had a stroke. Our residents see more than that frequently.

 

[Hawkeye Kid]

Getting off track, but there's a flip side to this...

I'm at an academic place and I'm more than happy to reduce, splint and f/u with ortho. Or for tendon lacs, suture, splint and f/u with whoever's doing hand that day/week. But, for example, our plastics folks won't see any ED referrals that they don't see in the ED. I don't know if it's a billing thing or a training thing or what, but that's their policy.

Perfect example: tonight I saw a guy with 15-20% mostly partial-, some full-thickness burns. I'm willing/able to treat and arrange f/u. But I HAVE to call in the plastics resident if I want this guy to follow-up. And so I did. Same goes for when plastics is on hand, and occasionally other services will do this as well (thankfully the residents rarely complain or I'd have an even bigger beef). So it's not always laziness that causes this sort of nonsense, though obviously at times it is.

Now back to the med school fluff debate...

 

[deleted65604]

I don't care if the bull didn't deglove any of the penis. If it stomped on it, then the urologist has to come in. Sorry, but them's the breaks.

It is reasonable to consult on anything you don't feel completely comfortable with, but getting the consultant to come in is going to be much easier if you speak intelligently about the anatomy involved and what kind of injuries you suspect.

 

[bulgethetwine]

Getting off track, but there's a flip side to this...

I'm at an academic place and I'm more than happy to reduce, splint and f/u with ortho. Or for tendon lacs, suture, splint and f/u with whoever's doing hand that day/week. But, for example, our plastics folks won't see any ED referrals that they don't see in the ED. I don't know if it's a billing thing or a training thing or what, but that's their policy.

Perfect example: tonight I saw a guy with 15-20% mostly partial-, some full-thickness burns. I'm willing/able to treat and arrange f/u. But I HAVE to call in the plastics resident if I want this guy to follow-up. And so I did. Same goes for when plastics is on hand, and occasionally other services will do this as well (thankfully the residents rarely complain or I'd have an even bigger beef). So it's not always laziness that causes this sort of nonsense, though obviously at times it is.

Now back to the med school fluff debate...

This is unique to the United States and is, I believe, a result of the lack of respect for the specialty of emergency medicine. If there was respect, your director would be able to say to the plastics group -- academic institution or not --

"Really? You don't want the referral? Fine - we'll find another group who will".

This sh iii t doesn't fly in the community because a) EDs aren't betrothed to one, in-house group if the latter isn't collegial and b) real-world (READ: non-academic) practices recognize that referrals are their bread and butter.

The fact that your plastics group doesn't trust you to tell who needs an ED consult and who can follow up the next day (as evidenced by their insistence to either see everyone in the ED or not even follow up) is just professional disrespect.

Your ED director should have the balls to fix this, but then again, I understand how in his position in Charlottesville, he doesn't ahve the collateral to do that.

Where I was a resident, the ortho service tried to pull the same crap. Even as a senior resident, the attendings didn't mind (re: blissful ignorance, they knew, but could certainly maintain deniability) when I started referring patients to the community group outside our academic instituion.

 

[RustedFox]

Yes, now back to the action:

Okay, now that the memorial day holiday is over (and my company has left), I can take the time to formulate a worthwhile reply. The whole point of this centered around a few simple ideas:

1. A lot of med. school curriculum is useless/wasted/repeated.

Now, every MS-(insert number here) can find an example of something clinically important (but not all that common) and throw it in my face and go - "See, that's why you're wrong" and it makes them feel good. That's easy. If you're going to do that, please - you're missing the entire point of the thread. The majority of things taught in med-school ARE clinically relevant, but there are a LOT that aren't, or would better be suited for a different arena. Examples:

- Viral taxonomy. Can anybody remember which family Coxsackie virus belongs to? Is it flavivirus, togavirus, or reovirus? Does it matter? Would it be better for a graduate student/researcher studying viral genetics to know this rather than a second-year MS? Seems like I wasted days before Step-1 studying all those families. Never will know 'em again.

- a LOT of genetics. Leading strand, lagging strand, snURPS, DNA polymerase I or III?, RNA polymerase I, II, or III? DNA ligase, okazaki fragment. Wait; we all had this once in undergraduate as a pre-requisite for medical school. Repeating it so that we can regurgitate, then forget it later isn't doing anyone any good.

- Some biochemistry. Drawing out all the amino acid side-chains? Memorizing the makeup of a nucleosome core and making sure you get the histone makeup correct? Knowing the spiral structure and number of subunits that make up an ion channel... Also, long forgotten once you hit clinicals. Ask your current attending if he can draw serine vs. threonine. Watch as you get slapped.


2. Every year, interns come out of medical school bereft of many critically important clinical skills; How to calculate a heparin drip, how to write simple admit/transfer orders, how to adjust TPN/lytes, how to convert opiate equivalents, how to properly interpret an ABG, how to make sense of vent settings, the list goes on and on.


In fact, if we put all of our heads together, both of these lists (my list of examples, above) can go on and on. Why don't we make the "dumb intern" a "smarter" intern by eliminating the useless and emphasizing the useful. It would make everyone happier.


3. To those who retort with - "then we'll all just be PAs and NPs!" No, no we won't. Which school are you in? Are you in PA school? Are you attending their lectures? Do you know anything about their curriculum? I do, because I teach several lectures a month. The difference in depth of understanding of relevant pathophys and clinical nuance is outstanding. However, I do notice that the PA students don't spend their time worrying about whether UGA or UGG is a "stop" codon, or whether ATP or GTP is used for tRNA activation or translocation. That's knowledge that only the MD/DO students have... and knowledge that gets nothing done on the hospital floors.


4. To RxnMan, whose replies have been insightful and thought-provoking: Yes, I am arguing for the paring-down of the knowledge base and a further separation of clinical vs. scientific worlds.... within reason. There's never going to be a complete and total divide between the two, and there's never going to be a pre-clinical curriculum that's 'best' for everyone. However, we can do a lot better than we're doing now, and I think the above examples stand firmly as an illustration of what the MS-es (medical students) DO know, versus what they NEED to know to function as an MD/DO. Once your research has been proven clinically useful... by all means, include it in the curriculum! But don't make MS-es memorize whatever pathway it is that ultimately yields nothing. Your argument that "you've got to teach them how to understand the research early so they can go and do research and evaluate it" is fair... but that's only if the individual wants to go and do more research. Do that on your own time, *if you want to*. If you get rid of the "waste" in medical school.... you then have time to pursue your own niche interests and temper your skills therein. If we get rid of the "waste" in medical school.... we make time to learn new concepts and skills that we really, really need.

I have no interest in research; my thing is education. You do your research because you want to. I do my teaching because I want to. I don't seek to make 'how to be a better educator' a compulsory part of medical curriculum because its an area of specialty interest. You're not on the hook for any of it; and I don't want to be on the hook for any bench research. That's the way it has to be just to maintain sanity.

I also understand and agree with your plea that 'society needs more scientists and researchers'. But that's not all we need. We need more clinicians, badly. We need more nurses. We need more teachers. That's a different debate for a different day.

At the end of that, I apologize if any of it came out sounding rude. You have been fair and focused with all of your arguments. I accept your invitation for further discussion on this. PM me and we'll really get things done, amigo.

5. The 'paring down' of medical curriculum HAS to happen. Since the knowledge base has exploded over the past 20-30 years (largely as a function of technology and its exponential increase), there's been a concomitant increase in the amount and complexity of data that MS-es have been required to crunch. Now think about what paradigm shifts will come in the future. You can't fit much more into four years, and you can't have medical school last fourteen years. Its time to start triaging information.

Comments and criticism welcome as always. Be guided by the above. I suggest we start a new thread where we can compile a list of "useless things that were taught/repeated during medical school", so that we can review them. I especially feel strongly about a lot of the genetics. We've all had it once already and don't need it again.