4TH Year - Total Waste of Time & Money

[mvenus929]

I went to a medical school that where just a handful of sites were not allowing students to write 'real' notes. and where procedures were strictly for residents. There was no question that those rotations were wasted, and it wasn't my fault for not finding any education in them. You can't always find water in a desert regardless of your motivation, and you can't practice medicine if no one will let you. Its not as though my work ethic improved dramatically when I did my rotations in public and military hospitals were MS3s could still be a functioning member of the team, but I can say confidently that those were the rotations where I learned to be a doctor. If all of my rotations were shadowing, rather than just a few sites, I would have started Intern year functionally identical to how I started MS3.

On the other side of the coin, the students that we have rotating through peds at my program still complain and we make them do a lot. They are supposed to follow patients and develop plans, follow-up on patients, and admit new patients while writing H&Ps. They complain because they have to come in at the same time or before our interns so they can get signout from the night team--so our clerkship directors made sign out optional. They complained that they sometimes had to work 12 hour days when our interns always work 12 hour days and we often let the med students go home early, and there's plenty of down-time during the day to study, or be taught if one of the senior residents has a slow afternoon. They are supposed to write notes and have them on the chart well before rounds, but often just skip out on doing them.

So even when opportunities are available to them, many med students will still complain that they're working too hard and aren't getting enough time to study.

Notes yes. There is no risk to a note other than the Intern having to rewrite it. Procedures should only be given to students who are going to do them as residents. There is a high risk of complications the first time anyone does a procedure, and the trade off has to be that they'll be able to help future patients. I think intubations and LPs are pretty much universal. Central lines, deliveries, surgeries, and chest tubes not so much. Those should be for Residents or students who have matches into a specialty that uses those procedures.

I'd argue that everyone should know the basics of delivering a baby. And should know the basic emergencies you might encounter in real life--heart attacks (CPR), basic injuries, and hemostasis. You don't necessarily need to know how to suture well, but knowing how to immobilize a suspected fracture can be useful regardless of what you end up practicing. You never know what's gonna happen on those planes or while you're watching your child's baseball game.

But please, rhetorically ask me why we need to know the 4th intermediary in the Krebs cycle to admit a CHF patient. I feel like these asinine strawman questions always arise in a discussion such as this.

Some of those super basic science things come in real handy when managing patients with metabolic disorders. Which, granted, most people don't do, but when they present to the closest emergency room, it's a good thing to at least have heard of once.

---

Members don't see this ad.

 

[Perrotfish]

On the other side of the coin, the students that we have rotating through peds at my program still complain and we make them do a lot. They are supposed to follow patients and develop plans, follow-up on patients, and admit new patients while writing H&Ps. They complain because they have to come in at the same time or before our interns so they can get signout from the night team--so our clerkship directors made sign out optional. They complained that they sometimes had to work 12 hour days when our interns always work 12 hour days and we often let the med students go home early, and there's plenty of down-time during the day to study, or be taught if one of the senior residents has a slow afternoon. They are supposed to write notes and have them on the chart well before rounds, but often just skip out on doing them.

So even when opportunities are available to them, many med students will still complain that they're working too hard and aren't getting enough time to study.

A smaller and more potentially fixable complaint about the structure of our Medical school: it is stupid to have our students studying for standardized tests at the same time they are on wards. When they study instead of focusing on wards we call them lazy and when they fail the test they can't honor no matter how hard they work on wards. Its a no win situation designed to lower morale. It would make much more sense to have an academic block for each rotation, where they just study and take classes, followed by a longer clinical block, where they just see patients and read on the patients they see. Also I think that students would be much better on the wards if they always started after a dedicated two week block of studying for a test.

I'd argue that everyone should know the basics of delivering a baby. And should know the basic emergencies you might encounter in real life--heart attacks (CPR), basic injuries, and hemostasis. You don't necessarily need to know how to suture well, but knowing how to immobilize a suspected fracture can be useful regardless of what you end up practicing. You never know what's gonna happen on those planes or while you're watching your child's baseball game.

In these cases a Pediatrician shouldcall for help and, if necessary, do the same BLS we would expect from any teacher or high school coach. I have no idea why we would expect someone to be a different kind of doctor that they are, and in an emergency there is nothing more dangerous than a little bit of knowledge. And, again, our time is a zero sum game. Those two months learning 'the basics' of delivering a baby you will never deliver are two months not spent getting beyond the basics of doing NRP on the shoulder dystocia the OB will be handing you.

 

[Perrotfish]

Some of those super basic science things come in real handy when managing patients with metabolic disorders. Which, granted, most people don't do, but when they present to the closest emergency room, it's a good thing to at least have heard of once.

Again, no. When they present in the ED you need to know

1) they need glucose.
2) how to order basic work up for metabolic disorder
3) the number for the on call metabolic geneticist at your area children's hospital..

Knowing the Krebbs cycle does not help with that. On the other hand an inpatient metabolic team rotation WOULD help tremendously with that. But you won't be doing one because you spent that month taking a biochemistry class, learning and forgetting the Krebbs cycle.

 

[username456789]

,

I would ask you that. I would also tell you that I cannot think of ANY knowledge I gained from my undergraduate histology, neuroanatomy, or biochemistry classes that are relevant to my practice. Or for that matter from my surgery/EM/IM rotations other than general knowledge of working in a hospital (like how to write a note) that I could have learned just as effectively on Pediatric wards. I would ask you why it was valuable enough for me to do those rotations that it was worth an opportunity cost of hundreds of thousands of dollars. Or, alternatively, an opportunity cost of NOT working in Pediatric cinic/wards/ICU. Once or twice a month I have I am called for a code Purple. Was it really worth not giving me an extra three months of NICU, night float, with all of those extra reps of neonatal resuscitation, so that I could spend three months holding a camera for cholecystectomies on an MS3 surgery rotation? What the ability to 'relate to my patients' when they talk about their upcoming stent worth me never having done the Peds Anesthesia rotations where I could have learned to place difficult IVs on their children? Were the months of titrating statins in Family medicine clinic worth me not having the extra months titrating the medicines I actually use every day in Pediatric clinic?

One of the best signs that this broad, general knowledge of medicine isn't relevant is that we don't maintain it. If this knowledge really mattered we would be forcing physicians to regularly update their knowledge. They certainly make sure I am up to date on Pediatrics, in fact I am posting so much today because I dragging myself through December's PedsRAP and I am posting as a break between each podcast. But everyone knows that Pediatricians don't actually need to know IM/Surgery/Adult EM, so everyone is happy to let me stay licensed even though my knowledge of adults is both fading quickly from my memory and hasn't been updated since 2011.

All I really gather from your posts is that you feel very unprepared for your specialty with your current level of training. While I do find that very unfortunate, I do not find it grounds for overhauling all of medical education in the the way you've suggested.

Also, I still had no idea what I was going to go into midway through 3rd year of medical school. Part of what helped me decide what I didn't want to do was experiencing the diverse offerings that are the core rotations. My surgery rotation completely sent me in a different direction. Prior to that, I was dead set on ortho, even after extensively shadowing in the first two years of medical school. I know that this issue was not necessarily the crux of your argument, and you very well may have a reasonable workaround for it. I just wanted to add it as one additional reason why I didn't mind all those "unrelated" things.

And in hindsight, I'm really glad I dominated biochem/genetics and histology (among other things) in the preclinical years. I had no idea at that time that I would go into dermatology and use those so extensively (more so in residency vs as an attending).

 

[Perrotfish]

All I really gather from your posts is that you feel very unprepared for your specialty with your current level of training. Well I do find that very unfortunate, I do not find it grounds for overhauling all of medical education in the the way you've suggested.

Also, I still had no idea what I was going to go into midway through 3rd year of medical school. Part of what helped me decide what I didn't want to do was experiencing the diverse offerings that are the core rotations. My surgery rotation completely sent me in a different direction. Prior to that, I was dead set on ortho, even after extensively shadowing in the first two years of medical school. I know that this issue was not necessarily the crux of your argument, and you very well may have a reasonable workaround for it. I just wanted to add it as one additional reason why I didn't mind all those "unrelated" things.
And in hindsight, I'm really glad I dominated biochem/genetics and histology (among other things) in the preclinical years. I had no idea time that I would go into dermatology and use those so extensively.

If 3rd year rotations are about choosing your career,, why don't we rotate through all of them? We don't do rads, or most subspecialties, or PM&R, or path. Also, why is nothing else in the world structured this way? College students are choosing a career just as much as physicians, but they don't rotate through sales, HR, engineering, and medicine before choosing a profession. For that matter high schools don't have to rotate through the enlisted military, factory work, agriculture, and tech support before deciding to go to college. Why is it only physicians that are unable to make their own decisions without an 8 week test drive of every possible option?

To respond to your first comment, I don't feel very unprepared for my job, at least no more unprepared than the average attending feels coming out of residency. However I do feel cheated out of a lot of knowledge and supervision I could have used. I felt more than ready to get out into the world by the end of R3, but truth be told another 6 months of electives would have made me a better doctor, and I definitely would have traded any of the 5 or so irrelevant years of my training for those 6 months. Its very hard to pick up new knowledge now that I'm out. I'm making it happen: I've progressing towards credentials in half a dozen minor procedures and I've done a lot of CME, but actual rotations with subspecialists would have been a lot easier and more effective than trying to cobble supervision together from other providers in my clinic and doing all of these podcasts.

 

[sliceofbread136]

We'll probably have to just agree to disagree here.

But the way you're saying things should be is EXACTLY why post-graduate training is getting more and more onerous, at least in terms of years put in. It used to be that you could graduate medical school and become a general practitioner - because it was expected that you would graduate with the competency to make an assessment and plan, deliver a baby, drain an abscess, so on and so forth. Now days it's become so bad that half the time you have to do a fellowship to train for something that a graduating medical student was competent to do 30 years ago.

If it's not important for people going into psych to learn how to do a line, for someone going into ortho to learn how to intubate, or for someone going into EM to learn how to do a MMSE, then maybe we should just get rid of medical school all together? Maybe the MD/DO degree is just a relic of the past? Perhaps we should just have "medical students" go to anesthesiologist schools, EM schools, ortho schools, etc, where they learn the skills only inherent to their specialties. Kind of like how nurse practitioner students can get a pscyh NP degree, geriatric NP degree, etc.

I hate to say it, but if this is the attitude amongst medical students nowdays - that they should only learn what is relevant to their chosen specialty - then I guess the midlevels are right that the MD/DO degree is just a big waste of time. Honest to God we may as well just let PA's and NP's match into residencies now, because it's not like medical students are doing anything special anymore that they are not.

When was it expected that you could graduate and become a general practitioner? The days before osler?

Medical school, imo, should be about learning how to gather patient data with a history and physical, looking up what you don't know and then synthesizing all of that information and coming up with an assessment and plan. You then compare your plan to the actual one and see where you messed up and adjust from there. You are learning how to learn clinically. If your medical school is not doing this then it is failing.

Procedures are another story. I just don't see them as nearly as important. It's much easier to learn how to do some procedure than to learn how to think like a physician. Maybe it's because I don't have much interest in them, but I never understood the obsession medical students had with procedures, like creaming themselves over chest tubes. My exceptions would be suturing and probably intubation.

Your specific examples:
Delivering a baby-ya sure an uncomplicated one (which a monkey could do), other than that should probably be an ob gyn
Access drain- isn't this just cut and squeeze?
Line- don't see the point, someone going to psych or w/e would never really have to place one
Intubation- everyone should probably know this one, agreed
Mmse- yes everyone should atleast learn this as it's part of the basic exam. I've never met an Em guy who didn't know how to do a basic one, not sure why you used that as an example

 

[cbrons]

When was it expected that you could graduate and become a general practitioner? The days before osler?

Medical school, imo, should be about learning how to gather patient data with a history and physical, looking up what you don't know and then synthesizing all of that information and coming up with an assessment and plan. You then compare your plan to the actual one and see where you messed up and adjust from there. You are learning how to learn clinically. If your medical school is not doing this then it is failing.

Procedures are another story. I just don't see them as nearly as important. It's much easier to learn how to do some procedure than to learn how to think like a physician. Maybe it's because I don't have much interest in them, but I never understood the obsession medical students had with procedures, like creaming themselves over chest tubes. My exceptions would be suturing and probably intubation.

Your specific examples:
Delivering a baby-ya sure an uncomplicated one (which a monkey could do), other than that should probably be an ob gyn
Access drain- isn't this just cut and squeeze?
Line- don't see the point, someone going to psych or w/e would never really have to place one
Intubation- everyone should probably know this one, agreed
Mmse- yes everyone should atleast learn this as it's part of the basic exam. I've never met an Em guy who didn't know how to do a basic one, not sure why you used that as an example

Many medical schools do not even teach students how to adequately do an H&P. This was the reason (ostensibly) for having U.S. grads start taking Step 2 CS (not that Step 2 CS actually tests H&P skills so much as acting and script memorization).

Sent from my SM-N910P using SDN mobile

 

[cbrons]

I went to a medical school that where just a handful of sites were not allowing students to write 'real' notes. and where procedures were strictly for residents. There was no question that those rotations were wasted, and it wasn't my fault for not finding any education in them. You can't always find water in a desert regardless of your motivation, and you can't practice medicine if no one will let you. Its not as though my work ethic improved dramatically when I did my rotations in public and military hospitals were MS3s could still be a functioning member of the team, but I can say confidently that those were the rotations where I learned to be a doctor. If all of my rotations were shadowing, rather than just a few sites, I would have started Intern year functionally identical to how I started MS3.

Students SHOULD complain about their schools screwing them over. Their schools are screwing them over! They are taking ever more money and providing ever less education. If M1-M2 is just studying Goljan in your room, and M3-M4 is just waiting quietly for residency to start without actually doing anything, then what value is the school providing in exchange for their 300K in tuition? Most of your students will need to earn nearly a million dollars just pay back their student loans, is it really so unreasonable that they should expect more than 'self-learning'?

I did 4 Sub-Is during M4 year at different hospitals. It was hard and it was jarring, and I certainly could have just created a more chill schedule. But then it would've been a massive waste of my time and money.

The status quo is basically get ripped off just to shadow preceptors who often aren't even paid to teach you.

There needs to be a rennaissance in U.S. medical education.

Sent from my SM-N910P using SDN mobile

 

[sliceofbread136]

Many medical schools do not even teach students how to adequately do an H&P. This was the reason (ostensibly) for having U.S. grads start taking Step 2 CS (not that Step 2 CS actually tests H&P skills so much as acting and script memorization).

Sent from my SM-N910P using SDN mobile

Then those schools are failing. And step 2 CS is nothing but a scam

No offense, but reading all of your posts on here it seems like you went to a really crappy school. That would be very frustrating for sure

 

[VisionaryTics]

Procedures are another story. I just don't see them as nearly as important. It's much easier to learn how to do some procedure than to learn how to think like a physician. Maybe it's because I don't have much interest in them, but I never understood the obsession medical students had with procedures, like creaming themselves over chest tubes. My exceptions would be suturing and probably intubation.

Of course I'm biased, but I think of procedures as vitally important. Physicians should be facile with their hands: putting in a line, arterial puncture, IVs, suturing, wound care and debridements, intubation.

Graduating students are so afraid of getting some blood on their scrubs that they never learn how to dress a wound or how an endotracheal tube works or what to do when you pull a line and the patient starts bleeding all over the place. Yes, these procedures come with complications. Just like dosing insulin or diuretics comes with complications. But with proper supervision and in appropriate cases, medical students can and should get their hands dirty.

With regards to fourth year, it is what you make of it. Try to do some ICU rotations that are known to be busy and good for student education. Do a subI at a place that lets you have ownership over a few patients. I did mine at VA, and carried 2-4 patients and wrote all orders.

I thought my fourth year rotations really helped me transition from an M3 to an intern, both in terms of floor management as well as comfort with basic procedures. However, absolutely nothing was spoon fed to me. Believe me, it only gets worse in residency.

 

[sliceofbread136]

Of course I'm biased, but I think of procedures as vitally important. Physicians should be facile with their hands: putting in a line, arterial puncture, IVs, suturing, wound care and debridements, intubation.

Graduating students are so afraid of getting some blood on their scrubs that they never learn how to dress a wound or how an endotracheal tube works or what to do when you pull a line and the patient starts bleeding all over the place. Yes, these procedures come with complications. Just like dosing insulin or diuretics comes with complications. But with proper supervision and in appropriate cases, medical students can and should get their hands dirty.

I may be biased too, but I didn't go into medical school to use my hands. I'm in this to use my head, and the only procedures I'm really interested in are the ones that I may actually have to do.

Basic wound care I'll give you. That's something everyone should know the basics. Still gonna say no to lines and IVs.

 

[mvenus929]

A smaller and more potentially fixable complaint about the structure of our Medical school: it is stupid to have our students studying for standardized tests at the same time they are on wards. When they study instead of focusing on wards we call them lazy and when they fail the test they can't honor no matter how hard they work on wards. Its a no win situation designed to lower morale. It would make much more sense to have an academic block for each rotation, where they just study and take classes, followed by a longer clinical block, where they just see patients and read on the patients they see. Also I think that students would be much better on the wards if they always started after a dedicated two week block of studying for a test.


In these cases a Pediatrician shouldcall for help and, if necessary, do the same BLS we would expect from any teacher or high school coach. I have no idea why we would expect someone to be a different kind of doctor that they are, and in an emergency there is nothing more dangerous than a little bit of knowledge. And, again, our time is a zero sum game. Those two months learning 'the basics' of delivering a baby you will never deliver are two months not spent getting beyond the basics of doing NRP on the shoulder dystocia the OB will be handing you.

Hmm... interesting thought.

As for the latter (and your following post), I certainly don't expect people to be experts in everything and agree that a little knowledge can be dangerous, but there are instances (such as on a plane), where you will have to verbally tell someone what you see in order for them to help you out. If you've never taken care of an adult or a pregnant woman, or a newborn baby, it can be difficult to say what is normal or abnormal and communicate those findings. I learned how to suture on OB and Surgery, and had I not had that experience, I doubt I would feel comfortable sewing up a lac on a two year old based on how many I've seen in residency.

And I'm not saying that all the background has to come in medical school--I feel like the biochem I took in undergrad covered the same basic information as Med school. And we learn by repetition, so if the first time you are critically thinking about the pathophys of a disorder is fellowship, you're going to be more reliant on protocols, rather than your critical thinking skills.

 

[bugsterizer83]

By the same token, the time 'wasted' by the schools and their inefficiencies are dwarfed by the time wasted by students and their inability to grow/function on their own.

I respectfully disagree. Our internal medicine rotation consisted of 6 weeks of three of us shadowing a single private practice hospitalist and six weeks of sitting in the dirty medical student lounge while our preceptor saw patients in his private clinic. The only time we ever saw patients in the latter six weeks was after the attending rounded on them at 4am, we could go "check in on them." We then studied from 7am to 4pm, with the occasional lecture or two given by a volunteer faculty member (who showed up ~70% of the time). But that last part didn't bother me, it was the fact that we weren't allowed to do anything. Of course, we also did not have residents, so that probably played a big part. You simply cannot expect volunteer private practice physicians to run M3 clerkships.

I'm actually quite shocked the LCME allows this kind of thing at a U.S. MD school but evidently they do.

 

[FindMeOnTheLinks]

I respectfully disagree. Our internal medicine rotation consisted of 6 weeks of three of us shadowing a single private practice hospitalist and six weeks of sitting in the dirty medical student lounge while our preceptor saw patients in his private clinic. The only time we ever saw patients in the latter six weeks was after the attending rounded on them at 4am, we could go "check in on them." We then studied from 7am to 4pm, with the occasional lecture or two given by a volunteer faculty member (who showed up ~70% of the time). But that last part didn't bother me, it was the fact that we weren't allowed to do anything. Of course, we also did not have residents, so that probably played a big part. You simply cannot expect volunteer private practice physicians to run M3 clerkships.

I'm actually quite shocked the LCME allows this kind of thing at a U.S. MD school but evidently they do.

Please give the name of your school so people can be informed of this bull**** before they consider attending there


Sent from my iPhone using SDN mobile

 

[mimelim]

I respectfully disagree. Our internal medicine rotation consisted of 6 weeks of three of us shadowing a single private practice hospitalist and six weeks of sitting in the dirty medical student lounge while our preceptor saw patients in his private clinic. The only time we ever saw patients in the latter six weeks was after the attending rounded on them at 4am, we could go "check in on them." We then studied from 7am to 4pm, with the occasional lecture or two given by a volunteer faculty member (who showed up ~70% of the time). But that last part didn't bother me, it was the fact that we weren't allowed to do anything. Of course, we also did not have residents, so that probably played a big part. You simply cannot expect volunteer private practice physicians to run M3 clerkships.

I'm actually quite shocked the LCME allows this kind of thing at a U.S. MD school but evidently they do.

As you likely know, this is not the norm. While volunteer private practice physicians are increasingly common, your IM rotation sounds like an extreme example and I am truly sorry that you lost out on that education. I would never argue that there aren't very poor educators out there. I likewise would never argue that schools can't always do more to improve the quality of education that they provide. However, my point is simply that for every bad rotation site, there are a dozen students complaining about lack of opportunities/education when usually the biggest culprit is lack of initiative on the part of the students.

 

[cbrons]

ok so crank out wards/ICU at your home base.

I really don't see how it could be shortened, still have time to study for steps, interview and learn clinical stuff. I truly have no idea how the 3 yr med schools work. Yes there's some pork but there's not 1 yr of pork .

"Crank out wards/ICU at your home base"
wtf you talking about kid? Did you smoke something before you wrote this?

 

[PL198]

? do a bunch of wards or ICU months at your home institution. I didn't think it was that hard to understand

 

[cbrons]

? do a bunch of wards or ICU months at your home institution. I didn't think it was that hard to understand

If the rotations at his home institution are garbage, your solution is to do rotations at his home institution?

If you want to do strong rotations when your home ones are weak, then you do aways.

Sent from my SM-N910P using SDN mobile

 

[PL198]

If the rotations at his home institution are garbage, your solution is to do rotations at his home institution?

If you want to do strong rotations when your home ones are weak, then you do aways.

Sent from my SM-N910P using SDN mobile

Correct except you said you didn't have money to pay for housing at an away....

 

[Redpancreas]

I've always been confused about the following:

If Sub I's are so intense and you are supposed to be learning how to be an intern then why is MS4 universally acknowledge to be the easiest year in med school? Maybe you work less in total but it sounds like when you are actually working it would be a lot harder.

The start of M4 just like high school and college is actually where stress peaks (pre-application, CK, and SubI) but then starting January where interview invites die down stress dies down and comes back to crescendo on match day.