How competent are fourth year med students supposed to be?

Discussion in 'Allopathic' started by Hemichordate, 09.24.14.

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  1. Hemichordate

    Hemichordate Peds 7+ Year Member

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    Yeah I know we're supposed to be able to do H&Ps right now, and to be able to come up with a reasonable assessment and plan, and do a reasonably good job at presenting patients, but overall how competent are we supposed to be at this point?
     
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  3. DermViser

    DermViser 5+ Year Member

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    You may want to look at this PDF from the AAMC: https://members.aamc.org/eweb/Dynam..._prd_key=E3229B10-BFE7-4B35-89E7-512BBB01AE3B

    It's a list of "competencies" you need to have achieved by the time you enter residency on July 1. Obviously if you're behind on a lot of them then it's something you need to improve on during your MS-4 year. I think your MS-4 will highly vary, some schools still have you do innane requirements, other schools have a fully elective MS-4.
     
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  4. SoundofSilver

    SoundofSilver 5+ Year Member

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    Ostensibly, if you can pass USMLE step 1 and step 2 CS/CK, then you have achieved the minimum competency required to start residency. Obviously, there's going to be a huge learning curve when you're first starting out and I doubt anyone walks into their first day of residency feeling adequately prepared. I sure as hell know I won't.
     
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  5. TooMuchResearch

    TooMuchResearch i'm goin' to Kathmandu... Lifetime Donor 7+ Year Member

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    Passing Step 1/2 only means one has the minimum test taking ability necessary to complete medical school. It has little or nothing to do with being able to competently translate book knowledge into clinical competence.
     
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  6. Snoopy2006

    Snoopy2006 7+ Year Member

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    Depends. March of your M4 year? Subspecialists will be amazed you're around past 1 pm.

    I'm assuming you're asking about early M4 year, when you're doing sub-I's. The general idea is to try to function as close to an intern level as possible, with the caveat that you'll make more mistakes and there will be a resident paired with you to guide you through the process. By M4 year you should be able to do more than gather info and give strong presentations, you should be able to make higher-level decisions at this point. Your A/P may need some refining from your senior, but for the most common medical problems, you should be on the right track. You're expected to function at close to an intern level, just with less patients.

    E.g. you should know the concept of rate control when you get a patient with atrial fibrillation w/RVR. You should know what immediate steps to take when you get an ascites patient and what antibiotics empirically cover for SBP. CAP vs HCAP. Complicated vs uncomplicated UTIs. How to work up AKI. Basic bread-and-butter medicine.

    The higher-level stuff that a good sub-I will pick up on includes putting in admission orders, watching how your resident handles cross-cover calls, etc.

    The key for me on a sub-I was coming in early enough so that I had time to read for 5-10 minutes on each patient's condition, so that I had as accurate a plan as possible.
     
  7. Priapism4tooLong

    Priapism4tooLong 2+ Year Member

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    And most importantly you should know when to have fun!
     
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  8. mvenus929

    mvenus929 10+ Year Member

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    Except for that annoyingly expensive part of Step 2 where you actually have to have enough clinical competence to counsel a patient and come up with a reasonable differential and plan.

    As an M4, I expect you to be able to do an H&P and get all the pertinent information related to the patient's complaint. I expect you to be able to come up with a reasonable differential, including why some of those diagnoses are less or more likely. I expect you to, in some capacity, mentor the third year students (even if it's just giving tips on how the rotation runs, assuming you're at your home school). I expect you to have time to read up on what's going on with your patient and be able to talk about it on rounds (or during teaching sessions), cause when I'm seeing three times as many patients as you in the same amount of time, I don't always have that extra time to look up additional information. I expect you to have a reasonably good oral presentation on rounds, at least above that of the third years.

    A good fourth year will also do basic intern work without prompting. They will attempt to write prescriptions (if your school still does paper prescriptions like mine), work on discharge summaries, etc. They can't put in orders and aren't the first line when nurses have concerns, so they're often left out of the loop, but they should be able to check in on their patients during the day and note any changes in the clinical progress.

    I do not expect fourth years to have a perfect plan, or always ask the right questions, because even I forget important questions sometimes. I do not expect fourth years to know dosing for medications, though they should be starting to look up common dosing and helping with orders.
     
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  9. samuelp

    samuelp 7+ Year Member

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    Ok. good argument. Now what do you say about the step 3? i.e. including CCS
     
  10. samuelp

    samuelp 7+ Year Member

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    I also believe that the USMLE website states on their pages something similar

    "applying the necessary knowledge and skills for supervised practice." not the test taking ability as you said it. and they're also the ones who actually design the test with psychometrics... but go ahead continue....
     
  11. DermViser

    DermViser 5+ Year Member

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    Again Step 3 and CCS are not indicative of residency performance.

    Yes, for an unrestricted license. Not for a board certified specialty.
     
  12. samuelp

    samuelp 7+ Year Member

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    ok. is passing step 3 statistically indicative of being competent to enter training as a resident......


    provided med student has taken exam 1 day after graduation, for example.

    also I'm not talking about board certification. residency training only with regard to these USMLE exams. I know it is asinine to think a doctor practice cardiology or neurosurgery for ex. right out of medical school. the quote you commented on was for step 2 ck.

    please continue your argument.
     
  13. DermViser

    DermViser 5+ Year Member

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    Most people take Step 3 during internship long after they've entered training as a resident. The fact that one can take Step 3 and pass even before stepping foot inside residency shows that the test is not indicative of being able to practice independently.
     
  14. samuelp

    samuelp 7+ Year Member

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    ok. even though the NBME and FSMB say the complete opposite of what you say, let's continue.

    Step 3 is for unsupervised practice. but with that being passed, surely you cannot disagree with that being more than adequate to train supervised. unless these tests are a total sham and money making scheme, which then means that the administrators of the exam are criminals.

    If you still disagree I want to know your logic and reasoning.

    I hypothesize that around 80-85% of medical students who would be allowed to sit for step 3 at any random time around middle of 4th year would pass the exam.
     
  15. DermViser

    DermViser 5+ Year Member

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    Are you actually serious? You're going to take the words of a licensing, regulatory body than actual program directors? You think their words are swallowed whole by program directors who have to work with residents all the time and see the reality of the situation?

    Program Directors don't look only at Step scores when it comes to choosing residents bc being able to answer multiple choice exams is not the only criteria to being a resident. Same with the in-training exams during residency. There are many people who can ace multiple choice exams, and aren't good house officers. There are IMGs who take years to study for the Steps and get 250/260s. That doesn't mean they'll be great residents. It means they gamed the system well.

    Yes, Step 3 is for unsupervised practice, which for residency purposes is more that you're allowed to moonlight. Your hypothesis proves that Step 3 is a joke when it comes to unsupervised practice in reality.
     
  16. samuelp

    samuelp 7+ Year Member

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    "The fact that one can take Step 3 and pass even before stepping foot inside residency shows that the test is not indicative of being able to practice independently."

    can you even provide any supporting evidence for this. otherwise, you state it as fact with nothing to back it up.
     
  17. samuelp

    samuelp 7+ Year Member

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    The step 3 is not a completely multiple choice exam. The CCS is rather very much like a simulation of care involving EMR. In my opinion. Tell me how you can game that...
     
  18. DermViser

    DermViser 5+ Year Member

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    There are tons of books that teach you about how to ace the CCS: http://www.amazon.com/s/ref=nb_sb_n...field-keywords=USMLE+CCS&rh=i:aps,k:USMLE+CCS

    So yes, it can be gamed. Not to mention, the CCS cases, are ridiculously easy, bread and butter topics to begin with.
     
  19. Raryn

    Raryn Infernal Internist Gold Donor 7+ Year Member

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    An intern on the first day of residency is expected to be able to gather the data, come up with a semblance of a plan, discuss it in an organized fashion, take the corrections generated by the discussion, and implement as discussed. Does that mean they should be able to manage a complex ICU patient with 12 separate problems in an integrated fashion? Hell no. If that was the case, we wouldn't need residency. But they should be able to meaningfully participate in the process and then put in the orders and follow up on them without being badgered to do so. While being supervised the entire way.

    A fourth year student acting as a "subintern" should be able to do the same, except for a smaller number of patients and under even closer supervision by a resident. That means the gathering data bit isn't the sum total of your job but the absolute bare minimum that would get you through without flat out failing. Obviously, putting in orders is something that you can't do on your own, but you should know what the orders are that need to be put in. It was easier with paper charts because at least you could write them out and just let someone else sign them. Things ordered in the AM should be followed up on in the afternoon without explicit prompting.

    A fourth year student on a rotation outside of their intended specialty who is not acting as a "subintern" is expected to generally show up (close to) on time, not fall asleep mid-conversation, and not disappear from the service too frequently.

    The skills for absolutely none of the above groups are appropriately represented on any of the steps, not 1, CK, CS, 3 (including the case based portion). Passing all those tests is an even lower bare minimum standard than anything else required. It means you might have the bricks to begin your further training, but not the tools yet to assemble them.
     
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  20. DermViser

    DermViser 5+ Year Member

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    Yes, the USMLE website:
    http://www.usmle.org/
    "no Step can stand alone in the assessment of readiness for medical licensure."
     
  21. samuelp

    samuelp 7+ Year Member

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    Thanks. Now let's say that the subject has all three exams passed. Continue.
     
  22. Raryn

    Raryn Infernal Internist Gold Donor 7+ Year Member

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    Well, then that means that the subject is ready enough that, with only 1-3 years of additional training (depending on their state and type of medical degree), they might meet the minimum requirements for independent licensure.
     
    Last edited: 09.26.14
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  23. SouthernSurgeon

    SouthernSurgeon Lifetime Donor 7+ Year Member

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    DVs citation above makes it clear as day.

    As do the requirements of any state board.

    The USMLE exams are necessary for a medical license. They are not sufficient for a medical license.

    An unrestricted license has additional requirements above and beyond being able to pass the exams, including but not limited to graduating from medical school and completing at least some defined period of supervised training
     
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  24. samuelp

    samuelp 7+ Year Member

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    ok excellent. now that all of that has been established. let's go back and look at my original statement.

    "Step 3 is for unsupervised practice. but with that being passed, surely you cannot disagree with that being more than adequate to train while supervised. unless these tests are a total sham and money making scheme, which then means that the administrators of the exam are criminals."

    STEP 2 CK
    Step 2 assesses whether you can apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision and includes emphasis on health promotion and disease prevention. Step 2 ensures that due attention is devoted to principles of clinical sciences and basic patient-centered skills that provide the foundation for the safe and competent practice of medicine. http://usmle.org/step-2-ck/

    Apparently the medical examiners are using objective complex statistical evidence based on questions asked to say that that a subject is competent to being residency training.

    You still disagree. I have thus taken it a step further.

    Step 3

    The purpose of Step 3 is to determine if a physician possesses and can apply the medical knowledge and understanding of clinical science considered essential for the unsupervised practice of medicine, with emphasis on patient management in ambulatory care settings. The inclusion of Step 3 in the USMLE sequence of licensing examinations ensures that attention is devoted to the importance of assessing the knowledge and skills of physicians who are assuming independent responsibility for providing general medical care to patients.

    Again, all three steps need to be passed. easy as 1,2, 3. maybe tripping up a bit on counting to 2. but still.

    If you need me to make the font bigger then I can.
     
  25. samuelp

    samuelp 7+ Year Member

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    If a physician subject thinks he or she can practice primary care independently and safely after completing these exams, are you willing to bet your entire career on it that they can't, DV?
     
  26. SouthernSurgeon

    SouthernSurgeon Lifetime Donor 7+ Year Member

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    What does DVs career have to do with it?

    Every state in the US has already determined that passing the exams alone does not make you qualified for independent practice
     
  27. samuelp

    samuelp 7+ Year Member

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    His career has absolutely nothing to do with it. I'm using it as a tool to see how confident he is in his opinion.
     
  28. samuelp

    samuelp 7+ Year Member

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    "see the reality of the situation? "

    So if residents and attendings take these same exams.... and let's say a resident barely passes them or even fails the objective knowledge parts....

    how can I, as a medical student, or intern, actually trust them to be teaching me what is true. Especially if they can only get 60% of the questions correct on the exam.

    Is it possible that a 4th year STUDENT may be more competent than a RESIDENT?! In my rotations, it seemed as if they expected me to have that level of competency!
     
  29. DermViser

    DermViser 5+ Year Member

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    No, it's obvious, you're being belligerent for no apparent reason, and your true purpose is to argue and not actually to learn. I am very much confident in my opinion. Your ability as a capable house officer is not fully encompassed in a multiple choice exam whether it be the USMLEs or the ITEs during residency, or the specialty boards (ABSITE, CREOG, ABIM exam, whatever). Instead you're quoting websites, not realizing that the theoretical reasons stated doesn't always translate to reality.

    There are states that for IMGs, after passing USMLE Step 3 will not give them an unrestricted license unless they've completed at least 2-3 years of postgraduate education also: http://www.fsmb.org/public/public-resources/state_specific. That there disproves your contention that licensure exams entitle you to automatic licensure, practicing independently, and validate competency.

    Education is much more than multiple choice exams.
     
  30. DermViser

    DermViser 5+ Year Member

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    It's not just me that believes that. It's many state licensing boards, its many hospitals who are now requiring doctors to have completed a residency and be board certified, it's insurance companies who will not allow you to be a part of their networks unless you've completed a residency and are board certified, etc. Are they all wrong?
     
  31. samuelp

    samuelp 7+ Year Member

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    I don't know if they are all wrong. And I am not being belligerent. I am trying to convince you to see something from my point of view. Do not respond to tone. read the words.

    I am absolutely not saying education is not more important than multiple choice exams. What I would like to ask at this point is... if one entity is so educated, then why does another particular entity outscore or outguess you IF and only if, they took their exams in relatively the same time frame as you.... (Instead of 200 years worth of studying time as you suggested so they can get a 280 and be omniscient), if their level of education could be considered inferior in your eyes.

    I've said it I think three or four times now in this thread. Show me something tangible to help your view. I guess you could use the recent Dr. Lim case, but no one has proven that she caused that death. all you showed me is that yes, the state boards currently require 3 yrs of training.... I think I can practice GP on my own at this point, comfortably in a group of peers with whom to confer. I may not be able to handle a patient volume like someone right out of residency (that's my problem not anyone else's), but I could practice effectively and safely. SO no. It wouldn't be wise to bet your career against that. You may end up stripped of everything.

    I think I can do it. I have shown objective evidence, by my passing a statistical psychometric measurement over 40 collective hours of testing.

    If I'm wrong, I will look like an ignorant fool, and I won't apply to the match for five years.

    But if I'm right. You have to put your career on hold, and sell food on the side of the street in nyc for 2 years. Still wanna take those odds?
     
    Last edited: 09.30.14
  32. samuelp

    samuelp 7+ Year Member

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    leave your ego at the door. what I'm trying to tell you is that by passing the step 2, yes you are competent to train. passing the step 3 is total overkill. If you're still not convinced, then I don't care anymore.
     
  33. samuelp

    samuelp 7+ Year Member

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    whatcha say....
     
  34. DermViser

    DermViser 5+ Year Member

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    What I am telling you is that your view is not backed by reality. It's why you're quoting websites. Carribean medical schools are very known to essentially be board prep courses for 2 years. Their entire curriculum in the first 2 years is built around preparing for the Step 1 exam. Program Directors know this and are well aware of this. Medicine competency is a lot more than what appears on the Step exams even Step 2 CK or Step 3. Medical school's sole objective is not to be a board prep course in the first 2 years.

    As far as you thinking you can practice GP on your own, unsupervised, that is not for you to decide, regardless of volume (which is irrelevant here). State medical licensing boards have also decided this which is why IMGs in many states can not get an unrestricted license without being in postgraduate education for at least 2-3 years even after passing Step 3.

    The fact that you continue to say that you can do medical practice unsupervised, bc you passed 40 hours of standardized medical exams, regardless of what state medical licensing boards say, etc. then I really don't know what to tell you. But I guess it's why you're in the position you're in.
     
  35. samuelp

    samuelp 7+ Year Member

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    Then take the bet. No one on here even has to know. It can be arranged. I didn't quote websites. I quoted what the FSMB wrote about what their exam was designed for. The average for those schools is actually slightly lower than stateside I think, (avg for most of the ones offshore).

    And you still can't provide any actual supporting evidence that a fresh graduate, who has attained a certain score on step 3, can't safely practice unsupervised. Just showing that the board of medicine says you need 3 years isn't any evidence saying someone can't practice effectively and safely independently. The point I'm trying to make is that it's beyond qualified for starting at pgy-1. But you appear to be in total denial.

    I will give you one more piece of data. Just so you're informed. That's it. http://www.ncbi.nlm.nih.gov/pubmed/21879372

    and just as a side note, you really think a PA or NP is more seasoned, lol NPs getting unrestricted licenses...

    You need to get past the 4th tier. Your entire stance is a contradiction - a house of cards. Mine is based on numbers and probability. So unless all my exams were totally falsified, or there is some other meaning to those numbers, I'm staying with my opinion. But I will just agree to disagree.
     
  36. samuelp

    samuelp 7+ Year Member

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    just fold.
     
  37. DermViser

    DermViser 5+ Year Member

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    The FSMB doesn't write the USMLE Step 3 exam. The NBME does.

    Again, like I said individual state medical boards who give licenses that allow one to practice medicine have stated as one of their requirements is that besides completing Step 3 - you also have to have completed 2-3 years of postgraduate medical education for IMGs. They wouldn't just make a requirement for the hell of it.

    As far as unsupervised practice -- the taking USMLE Step 3 and being ready for practice after 1 year of postgrad was more for back decades ago, when many docs became general practitioners. That's no longer the case, where most places you work will want to see residency board certification.

    Areas that are underserved or rural have no choice and thus won't put board certification as a requirement.

    Also, NPs are not given unrestricted by the Board of Medicine, they're given by the Board of Nursing, a totally different entity. I never said a PA or NP is more seasoned, but good job making up my position.

    Your mind is obviously made up, with no chance of having it changed, so it was a fool's errand to engage in an actual discussion with you to begin with.
     
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  38. SouthernSurgeon

    SouthernSurgeon Lifetime Donor 7+ Year Member

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    That's really all there is to say.

    It's an absolutely absurd stance, but it's the one he's taking because there is an obvious personal stake in it.

    What's really sad, is that samuelp's story should be a major lesson to pre-meds. He posted here when he was applying to medical school, that he wasn't going to "waste" two years repairing his GPA, and advised others to pursue the Caribbean route as well. He looked down on the DO option (and continues to do so).

    Now, he's reaping what he sowed, but still has yet to gain a lick of maturity from the entire experience.

    Instead of being a resource as, if nothing else, a cautionary tale, he takes an absurd stance that because he passed a test, he's a better candidate than those who did the process the right way, obtained a quality medical education, and succeeded in gaining a residency.
     
  39. DermViser

    DermViser 5+ Year Member

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    What's ridiculous is that he derives his full competency to practice medicine based on licensure score exams. And I think he has thoroughly convinced himself of it, by nitpicking and quoting websites. By now he should know what is said doesn't always match reality. The NBME also says that Step scores shouldn't be used for promotion decisions in med school --- but oops, medical schools do that. The NBME also says that Step scores shouldn't be used w/regards to residency --- but oops, residencies do that.

    USMLE scores are meant to be used in conjunction with OTHER metrics and factors to provide an overall picture. USMLE scores are not the SOLE metric for very good reason and it's bc Carribean schools know how to game the system. I mean literally the teacher is going out of First Aid and other review books and students pound away at them. It's literally a board prep course for a full 2 years. I expect an MS-1/MS-2 to believe that USMLE scores are indicative of how good a doctor/house officer you'll be, definitely not by MS-4. Don't get me wrong they are hurdles every student must get thru, but by themselves, are not all-encompassing.

    It's the same way being in the top percentile on the ITE scores in residency doesn't mean you'll be the best IM doc/Surgeon/etc house officer. The capabilities and abilities being tested are different. That's why the ITE exams are put together with other criteria to give your PD the full picture. Multiple choice exams only address one ACGME competency.
     
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  40. dermaway

    dermaway

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    i'm a great test taker and i am absolutely terrified of residency because of how incompetent i feel like i will be :/
     
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  41. dermaway

    dermaway

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    "This patient is coding!! What should we do?!?!?!" - nurse

    "Uhhhh..... what are my options?" - me
     
  42. jakeislove

    jakeislove MS IV 2+ Year Member

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    In regards to repairing his g.p.a. and applying to a US school: Hindsight is usually 20/20 vision but the "all-in" policy was already taking effect so unless he went to one of the big 4, it was probably short-sighted.

    Some people people look at DOs as US MD rejects. It's pretty silly opinion but there's no telling how long until the culture surrounding medical education changes.

    Someone from an American school who scores a 250 is smart, but a Caribbean student with the same score has somehow "gamed the system" is a funny opinion (to me). It's a little confusing that samuellp doesn't get the joke and insists upon tilting at the windmill of prejudice. :)

    It's not personal and is DV's sincere opinion. He's actually doing you a favor by expressing it. I don't believe overweight women should even be sold stretch pants but there is a horde of women exercising their right to disagree. My point is that you shouldn't personalize everything and respect that people can have different opinions.

    The culture is only going to get more hostile, sp. Do whatever it takes to out-compete the lowest 10% of US students and move on with life. Scores alone aren't going to do the trick.
     
  43. TooMuchResearch

    TooMuchResearch i'm goin' to Kathmandu... Lifetime Donor 7+ Year Member

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    Fixed that for you. CS is a slightly more advanced version of the "intro to doctoring" type courses many MS1s take. It was designed to ensure foreign grads speak enough English to train in the US.
     
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  44. TooMuchResearch

    TooMuchResearch i'm goin' to Kathmandu... Lifetime Donor 7+ Year Member

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    Step 3 is (caveat: haven't taken it yet) closer to requiring some clinical competency and less board exam BS...that's why they say 2 months, 2 weeks, number 2 pencil. I don't really see the purpose of it though, and some of the recently graduated attendings I know call it the stupidest exam they've taken. By the time most people take it, they've been working down their own specialty path for 6-12 months.
     
  45. DermViser

    DermViser 5+ Year Member

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    Most American med schools don't "teach to the boards" like a 24/7 board review course like Caribbean schools do. They don't let boards dictate the curriculum. Go to any medical school PhD basic science lecturer and ask them if they know what First Aid is. They'll seriously think you're talking about CPR. That's why a 250 from the Carribean is different than a 250 from a U.S. school.
     
  46. TooMuchResearch

    TooMuchResearch i'm goin' to Kathmandu... Lifetime Donor 7+ Year Member

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    The group that makes the test, NBME, says their very expensive test is very important and relevant for all new doctors to take. That doesn't make it true.
     
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  47. TooMuchResearch

    TooMuchResearch i'm goin' to Kathmandu... Lifetime Donor 7+ Year Member

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    ITT: Random guy on the internet figuratively sh*ts on primary care by saying it can be done by anyone right out of medical school if they can pass Steps 1-3.
     
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  48. TooMuchResearch

    TooMuchResearch i'm goin' to Kathmandu... Lifetime Donor 7+ Year Member

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    Um, I don't know this one. C?
     
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  49. SouthernSurgeon

    SouthernSurgeon Lifetime Donor 7+ Year Member

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    It's not just DVs opinion - it's also the opinion of a lot of program directors.

    It's not a question of "smart" - it's that IMGs are well known to be in a different prep environment. Basically a prolonged boot camp for the boards. And IMGs are known for taking extended periods of time - often six months or more - to solely study for the USMLE. So, yeah, I'd hope their scores are better

    This is a random comparison - but it's kind of like the guy who won the diet dr pepper football challenge (the one where you have to put as many throws through a hoop in under a minute) last year. He practiced for months and perfected a shot put throwing style that was way faster than anyone else. Hell I bet you could have put him against a pro quarterback and he still would have won. Does that mean I want him quarterbacking my team?
     
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  50. KnuxNole

    KnuxNole Sweets Addict 10+ Year Member

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    Why do you care? Those "tests" are meaningless in terms of practicing medicine....if you "pass" Step 3, I wouldn't assume you'll be a good resident. At all. You do that by doing stuff that matters, which is seeing actual patients and making actual decisions.
     
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  51. KnuxNole

    KnuxNole Sweets Addict 10+ Year Member

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    NOt really. it's perfectly reasonable to have someone pass Step 2, but be pathetically horrible as a resident, and very un-trainable.
     

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