Thank you for the feedback. It's hard to hear but needed to be said. I spent most of my first two years desperately trying to keep up but have been doing better in my third-year. If I want to salvage and improve what I can as far as clinical reasoning skills, basic science fundamentals etc goes during fourth-year, what do you think I should do before residency starts?
In order not to become just a protocolized drone, you need to understand the WHY behind everything you do as a doctor. That means a strong foundation in physiology, pathology and pharmacology. How can you become better at them fast? Borrow a set of Kaplan USMLE Step 1 Lecture Notes, and learn the respective books by heart (I haven't looked at them in like 15 years, but I am sure they are still good).
For immunology, the best book I have encountered is How The Immune System Works by Lauren Sompayrac's. For microbiology, Clinical Microbiology Made Ridiculously Simple. These two are just fantastic. I should definitely buy the new editions for myself. Infectious diseases are the most frequent diseases in nature, and yet few doctors have a decent knowledge of them.
If you know well these 5 books, you will have a decent basic science foundation. Nothing replaces reading great books during a rotation (especially great pathology learning books), but there is no time for that. On top of these, you should develop some Terminator-strong statistics knowledge and analytical skills, but that's really the frosting on the cake. Otherwise, you will become just one of the many docs fooled by "evidence"-based medicine on a daily basis.
The best anesthesiologists I have met have the intellectual skills of internists and the practical skills of surgeons. Neither the former nor the latter are enough. (Most anesthesiologists in practice have the latter and lack the former, most people with problems during anesthesiology residency the other way round. Most anesthesiologists with the former also tend to become intensivists, but that's a different story.)
Anytime you find yourself knowing how or what and not why, you have basic science gaps to fill. The American healthcare market does not care about the why, until you get sued. That's why many of our doctors are not that impressive over a midlevel, and probably why the US has medical "schools" and not "universities", like the rest of the world. We tend to emphasize doing over thinking.
Medicine is not a trade; it should be a strongly intellectual activity. Nobody tells you that, because Big Pharma and Big Healthcare and other Big conspiracies have zero interest in having truly good doctors who think for themselves. They need brainwashed monkeys who do what they are told, and who can't even analyze a research paper, let's not mention bayesian decision making. In a capitalist healthcare system, one gets hired based on what one can do, not what one knows. Still, one can't excel at being a doctor if one doesn't understand deeply why one does the what, or why this how is better than that how.
Good luck! The first step in fixing a problem is acknowledging you have one.
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