How to gauge the quality of a school's clinical years?

[Redpancreas]

This thread is inspired by the insightful PSA offered by Planes2Doc which can be found about 30 threads below this one where he or she offers several factors being most important for MS1-2. In case you're lazy, according to him or her, the ones most important for medical school performance are:


1. Minimal Mandatory Lecture time: To increase time to study your own way.
2. P/F grading as opposed to numerous grade assignments: In order to be able to focus less on the minute details and dedicate more time to Step 1 studying.
3. Minimal PBL time for the same general reasons as 1&2.


Somewhere down the thread a member pointed out how Planes2Doc didn't have much to say about clinical education and that's what I wanted this thread to be about:

What I'd like the purpose of this thread to be is to be a starting point on the conversation of how to practically gauge a school's clinical years.

http://forums.studentdoctor.net/threads/how-to-tell-strength-of-clinical-years.1048294/

^ This linked thread is useful and Southern IM does give an answer to my question and I think it's a pretty good one. The problem I'm having though is that it's very difficult to figure out the answers to these questions even at the day where everyone seems super eager to tell you everything about their school: the Interview Day. At this time, schools seem more interested on telling you what's going on in years one and two and even the medical school students available to answer questions are from one of these years. Also, the medical students that are in the M3s/M4s/residents/attendings are usually the ones evaluating me in the form of an MMI (no time to ask) or traditional interview. (It also doesn't help that everyone knows that MS1/MS2 prepare you for Step 1 which many know to be a specialty filter) Also, since not many people have been answering the questions posed by Southern IM on a consistent basis, no one really knows the answers to them for each medical school so even if I were to find out all the answers to these questions Southern IM listed for a particular medical school I wouldn't have much to compare those answers to.

After reading the book Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care by Marty Makary (pancreatic cancer surgeon from John Hopkins), I feel as if I've got some idea of what practical questions need to be asked. For the many of you who haven't read this book, a large part of it is about medical mistakes and how they can be avoided. Now I understand this may not be the most reliable book out there and as even the title implies, the book is probably a bit contrarian (like many books have to be to gain significant readership). Still though, it raises some points that I've heard echoed on SDN and by the few friends I do have in the M3+ years. I was wondering if some M3/M4 medical students could take some time out of their day to answer to answer ANY of the questions below (many of which are inspired by the book I mentioned):

***I know you've all got loyalty (whether it be genuine or contractual) to your medical institutions and I hope I'm not violating any privacy rules/TOS by asking for answers to such questions. I understand disclosing your medical institution is a big breach in privacy so I would request that you answer the following questions in message format (WILL NOT DISCLOSE). If you just have criticism to my analysis of any of this or have suggestions of better (perhaps more objective) questions that can be asked, I'd love for you to post in this thread. In order to objectify things, I added a poll but it's pretty much useless as I can't sort it by school and will have to make some statistical assumptions while analyzing the results. I understand that these questions may vary department to department, but if you could find a way to generalize please do so (otherwise just say it depends). Speaking of generalizing, please try to include stuff that's happened to you and others on multiple occasions as opposed to using this as a place to dump all your latest frustrations during your clinical years.***

Questions:

1. What school/residency program do you attend or which one are you answering questions for based on hearsay?

2. Would you be comfortable and reasonably confident in being treated by the hospital you work/train/learn at?

3. What is your teaching institution's general reaction to questions being asked? Ex. Why are we doing this test/procedure? Could you show me how to do this again?

4. Kind of related to number 3, but do you feel that your institution treats those lower in the medical hierarchy (i.e. medical students, interns, nurses)? Are medical students allowed to ask honest questions? How are residents treated when they question their attending's decisions in a polite manner with good intentions? Are nurses empowered to speak up if they see something wrong?



The reason I ask these questions is because, as the type of learner that I am, I feel I would not be able to learn effectively in a cut-throat hierarchical environment where I'm pressured into doing everything by protocol without feeling that I can ask honest questions. Of course, there's definitely a balance one has achieve. You can't be too much of a smart-ass either and question every decision because most residents/attendings are way more experienced than medical students. Overall though, I feel these questions will determine which medical schools offer the best clinical educations (at least for me). Feel free to reply with any criticism to my assertion.

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[Law2Doc]

Couple of things. First, a hospital isn't homogeneous in terms of quality. You might be totally comfortable being treated by the surgeons at a place but not want medicine docs there to touch you. Also there are privacy reasons a Staff member might not want to get medical attention at his own institution. So that question is flawed.

Second, every specialty has it's own hierarchy, protocols and rules -- it isn't hospital based. you might be on one rotation and encouraged to ask questions and on another need to stay quiet until the attending acknowledges you.

Third, while I'm not sure what you mean by a cut throat hierarchical environment, i won't kid you, some specialties you will have to rotate through will at EVERY hospital have a hierarchy and set protocol. I'd say medicine is up there with hierarchical jobs not very far below armed forces. From what I'm reading into your post, you might have a tough time in the clinical years.

 

[pietachok]

I think you believe there is a lot more variability in learning environment/culture from hospital to hospital than there is. That stuff tends to vary more regionally (east vs west) attending to attending or department to department than grossly hospital to hospital, and many if not most teaching institutions have gone to great lengths to bring an end to the less supportive teaching methods. There are bad seeds everywhere, so I think a more prudent question might be how the school addresses the problem they pose-- are students thrown to the wolves, or do they collect lots of continuous feedback & stop assigning students to malignant attendings & track academic abuse (anonymously/annually, not just by complaints, b/c it will otherwise get underreported) to ensure it's decreasing?

 

[NickNaylor]

These are the kinds of questions I would ask to try and get a sense of the "quality" of the clinical years. Understand, though, that this is extremely difficult to assess without actually doing it, and the answer to these questions will depend on who you ask. My advice would be to try and talk with current students, particularly MS4s if you can, to see what they have to say. Some attendings that you interview with may not work frequently with med students, and, as mentioned above, their responses will likely be quite different depending upon the specialty they're in.

-What is the role of a typical medical student on the wards?
-What's a typical schedule like? Do you have time to study for shelf exams?
-How involved are students in patient care? Do they just pre-round and present to attendings?
-How many students are on a typical service team? Will students usually work with each other? Or will there typically be one student per team?
-Are the number of grades for each clerkship pre-set (i.e., on a curve)? Or can anyone theoretically earn honors?
-How frequently do students interact with the attendings on the service? (will likely vary quite a bit depending on the specialty)

From the perspective of someone trying to pick a med school, I think those questions touch on the most important things. You want to make sure that you: get to actually do "patient care" rather than largely scut, though scut will be in your future no matter what; small teams with 1 med student are ideal IMO; are not graded on a curve, if at all possible; and have significant facetime with the attendings if at all possible. You may not find a program where all of those things are true, but that's really what's important from the perspective of your education.

As far as this "cut throat hierarchial environment," I agree with L2D: it is going to be effectively inescapable depending upon what you're rotating on. That really isn't something I would worry about, though - it's much further down on the "list of things that will actually affect my education" compared to, say, the above stuff.

 

[SouthernSurgeon]

One of the surgeons I'd most want operating on me is one of the ones I'd least recommend for medical students to rotate with. So your poll doesn't pass the sniff test, in my opinion.

 

[Catalystik]

but [how] do you feel that your institution treats those lower in the medical hierarchy (i.e. medical students, interns . . .

A given school or residency program may rotate students/residents through multiple training sites, from university hospitals, to VA hospitals, to specialty hospitals, to community hospitals, to clinics. Each site has multiple attendings, each of whom teach/train in their own way. As a med student, each senior person you work under will have their own ideas of what your role should include and how hard you should work, or how much you should stay out from under foot. For example, a student might be sent home at 10 pm when on "call", or could be expected to stay through the night. They might be expected to take one admission only, or be capped after several. They might be allowed to try a procedure, or might never do more than watch, because their intern/senior resident wants the practice.

I feel these questions will determine which medical schools offer the best clinical educations (at least for me). Feel free to reply with any criticism to my assertion.]

So, neither within a given med school, nor within a given institution or specialty, would it be possible to make a meaningful comparison. There are too many variables.

 

[kittykattat]

I agree with Nick that if you are trying to decide between a few schools it would be most helpful to ask said schools if they could put you into contact with an M4 of whom you could ask a lot of your questions. Also it seems like your post, despite the title, was made more because you want to know if you will thrive in a particular school's clinical years. This is extremely hard to determine without doing some rotations yourself because everyone is different and learns differently and some adjust to different or adverse learning environments faster than others, etc.

However, if you actually do want to determine the QUALITY of a school's clinical years in terms of preparing you for intern year and for impressing programs on your away rotations, I do have a suggestion. If you know or are able to get in contact with any attending physicians at the hospital's associated with the school or a school in the area of the ones you are trying to learn more about, they can be a somewhat reliable resource. I am lucky enough that my PI from undergrad was actually a faculty member at both Northwestern (for many many years) and now my state school (Wisconsin) so I was able to ask him about the quality of rotating med students and residents he has gotten, regarding pretty much all of the midwest schools I interviewed at. One school I interviewed at was really hush hush about years 3 and 4 on the interview day and that worried me a bit, and sure enough when I went to ask my PI about that school he said that the first year residents he has gotten from that school have definitely not been up to snuff with the one's coming from my state school and some other schools in the area. I was so glad I asked!

Anyway, hope this helped a tiny bit. Good luck with your data collection

 

[Redpancreas]

Thank you LizzyM, Law2Doc, Catalystik, and NickNaylor, (seasoned SDNers) and Southern IM/KittyKater for taking the time to read that and provide a valuable critique. What you've all said makes sense as the questions I've posted aren't very practical as dpt/specialty/individual person's preferences, etc. adds too much variability. With that being said, according to Dr. Makary, some entire hospitals can share positive cultures that translate to enhanced quality of care. An example that he talks about in his book is Mayo Medical Graduate School (Minn campus only). Do you guys think this is true and do you know of any examples? (Let's shy away from negative examples).

I will definitely ask the questions NickNaylor posed to those ahead of me during medical school. As a side note, I'm not really using this to pick medical schools since as of now I really only have 3 options so I'm going with the standard tuition, recognition, curriculum fit decision making process. I just thought thought this info would be valuable information for all of us here and it might be useful when looking into residency options...but ya, definitely far down the road. Also, I doubt you care L2D but I have confidence that I'll be able to deal with the strict hierarchal structure when the time comes. Given the luxury/choice, I think not just me but anyone would prefer a place that encourages those of the lesser ranks to speak up every once in a while but again quality care is probably not homogenous through hospitals...I also want to clarify that I don't intend on being a maverick/medical hipster that wants to start arguments with residents/attendings.

 

[mvenus929]

If anyone is concerned about clinical years and doesn't feel like they got enough information during interview day, contact the admissions office and ask for the e-mails of fourth year students.

The quality of the residency program doesn't necessarily reflect the overall education a student gets. For instance, I don't think my school has a very good EM residency (primarily because we don't get a lot of traumas and we do get a ton of transfers who stop in the ED on their way to the floor or ICU), but as a student rotating through, you get a good experience and a chance to learn about how the ED functions.

But I agree that the overall clinical training of a school can be determined by how well students are prepared for residency. Attendings at a given school are more likely to be able to answer those questions than anyone else.

 

[tantacles]

These are the kinds of questions I would ask to try and get a sense of the "quality" of the clinical years. Understand, though, that this is extremely difficult to assess without actually doing it, and the answer to these questions will depend on who you ask. My advice would be to try and talk with current students, particularly MS4s if you can, to see what they have to say. Some attendings that you interview with may not work frequently with med students, and, as mentioned above, their responses will likely be quite different depending upon the specialty they're in.

-What is the role of a typical medical student on the wards?
-What's a typical schedule like? Do you have time to study for shelf exams?
-How involved are students in patient care? Do they just pre-round and present to attendings?
-How many students are on a typical service team? Will students usually work with each other? Or will there typically be one student per team?
-Are the number of grades for each clerkship pre-set (i.e., on a curve)? Or can anyone theoretically earn honors?
-How frequently do students interact with the attendings on the service? (will likely vary quite a bit depending on the specialty)

From the perspective of someone trying to pick a med school, I think those questions touch on the most important things. You want to make sure that you: get to actually do "patient care" rather than largely scut, though scut will be in your future no matter what; small teams with 1 med student are ideal IMO; are not graded on a curve, if at all possible; and have significant facetime with the attendings if at all possible. You may not find a program where all of those things are true, but that's really what's important from the perspective of your education.

As far as this "cut throat hierarchial environment," I agree with L2D: it is going to be effectively inescapable depending upon what you're rotating on. That really isn't something I would worry about, though - it's much further down on the "list of things that will actually affect my education" compared to, say, the above stuff.

On top of those questions, I would ask: What are the required third year rotations? Is there any elective time in third year?

I would say this is a pretty important question. While you won't see too much variance, getting some early exposure to a field like emergency medicine early can be helpful in making decisions related to residency selection.

 

[mvenus929]

On top of those questions, I would ask: What are the required third year rotations? Is there any elective time in third year?

I would say this is a pretty important question. While you won't see too much variance, getting some early exposure to a field like emergency medicine early can be helpful in making decisions related to residency selection.

Or, alternatively, when do the clinical years start. My school doesn't offer third year electives (though we do have an EM block), but we start fourth year in March, so you still have that opportunity to explore other specialties before residency applications are due, compared to someone who starts fourth year in July or August.

 

[tantacles]

Or, alternatively, when do the clinical years start. My school doesn't offer third year electives (though we do have an EM block), but we start fourth year in March, so you still have that opportunity to explore other specialties before residency applications are due, compared to someone who starts fourth year in July or August.

Completely agree, and the school I interviewed at that had that schedule heavily emphasized it.

 

[QuantumJ]

Perhaps just a small added bit that's not important for the larger named schools but one of the more important things for me is to have a home program in the residency you're interested in. It's easier to find research, get lors and such if you can stick your pretty little face in the department early on. Of course not everyone knows and some change their mind so perhaps a broader tip would be to look for schools with a wide range of specialties represented.

 

[Law2Doc]

Perhaps just a small added bit that's not important for the larger named schools but one of the more important things for me is to have a home program in the residency you're interested in. It's easier to find research, get lors and such if you can stick your pretty little face in the department early on. Of course not everyone knows and some change their mind so perhaps a broader tip would be to look for schools with a wide range of specialties represented.

There are so many opportunities to do away rotations that this really isn't that big a deal. Plus you will statistically change your mind about specialty choice at least once as you get more exposure.

 

[Law2Doc]

... Also, I doubt you care L2D but I have confidence that I'll be able to deal with the strict hierarchal structure when the time comes. Given the luxury/choice, I think not just me but anyone would prefer a place that encourages those of the lesser ranks to speak up every once in a while but again quality care is probably not homogenous through hospitals...I also want to clarify that I don't intend on being a maverick/medical hipster that wants to start arguments with residents/attendings.

First, I can guaranty that at no hospital, even mayo, is there a single culture. If someone is telling you that the culture in surgery and eg family medicine there is identical you had better stop listening/ find a more honest resource.

Second, I think a lot of people who go into the more regimented fields actually do like the hierarchy and structure, although they like it better each year as they move up the ranks. It's not that you don't ever get to chime in, it's that you chime in to the interns who serve as filters and decide if it's worth it to bring to the seniors, who in turn act as filters to the chiefs and they ultimately the attending. Saves you the Embarrassment of saying something really stupid to your attending except when he's in teaching mode and chooses to engage you directly. And it's much more "quality care" when ideas get vetted through multiple levels.

 

[wholeheartedly]

. An example that he talks about in his book is Mayo Medical Graduate School (Minn campus only). Do you guys think this is true and do you know of any examples? (Let's shy away from negative examples).
.

I've got 6 years in at Mayo and can say that I agree with L2D. Even at place like that you still have a ton of variability in terms of cultures of different departments as well as quality of care. That along with individual variations among consultants's ( attendings) styles.

 

[alpinism]

-What is the role of a typical medical student on the wards?
-What's a typical schedule like? Do you have time to study for shelf exams?
-How involved are students in patient care? Do they just pre-round and present to attendings?
-How many students are on a typical service team? Will students usually work with each other? Or will there typically be one student per team?
-Are the number of grades for each clerkship pre-set (i.e., on a curve)? Or can anyone theoretically earn honors?
-How frequently do students interact with the attendings on the service? (will likely vary quite a bit depending on the specialty)

These are the questions you should be asking.

However, I would try to ask them in a more focused manner. Most students aren't going to talk down their school, so asking open ended questions like these are going to be met with mostly vague and unhelpful responses (i.e. yes we see patients then present to residents, we're very involved in patient care, and we get a great clinical education).

Disclaimer: the following is my opinion and every med student/resident/attending views things a little differently based on their personal preferences.

The purpose of the clinical years (M3 especially) is to prepare you to shine on your M4 away rotations and hit the ground running as an intern. Because of this, you want to go to a program where you have the ability to learn by doing and gain experience managing patients on your own with appropriate supervision. Basically, they're watching you care for patients and asking questions, teaching, and making sure you don't screw up. Not the opposite, where you're watching them care for patients and asking questions. This is a very important distinction. (obviously this applies to non-surgical specialties more since you be observing most of the time on surgery) There are many schools and rotations where its the latter and you're basically doing nothing more than glorified shadowing.

Unfortunately, there is a lot of variability between rotations and even the faculty/residents themselves on a single rotation. One person might get lucky and had a great team, while another might not be so lucky. Also, much of what you get out of rotations depends on what you put into it. If you're not enthusiastic and a putting forth the effort, you'll likely get to do less than other classmates on the same rotation.

Taking the previous 2 statements into account, I'd ask the following questions:

- Can you describe in detail a typical day on your medicine and surgery rotations?
- What do you do when you see a new patient?
- Can you write in the patient's chart and put in orders for labs or medications?
- What types of procedures have you done? How many procedures have you done? (LPs, deliveries, intubations, suturing, casting, etc…)
- How often did you hang out with your team outside of work? (going out to restaurants/bars/clubs, birthday and holiday parties, etc... )
- Are you allowed to bring books/notes with you and study during any downtime?
- How many students are on a team for each rotation?
- How are grades determined and can everyone get honors?

 

[NickNaylor]

These are the questions you should be asking.

However, I would try to ask them in a more focused manner. Most students aren't going to talk down their school, so asking open ended questions like these are going to be met with mostly vague and unhelpful responses (i.e. yes we see patients then present to residents, we're very involved in patient care, and we get a great clinical education).

Disclaimer: the following is my opinion and every med student/resident/attending views things a little differently based on their personal preferences.

The purpose of the clinical years (M3 especially) is to prepare you to shine on your M4 away rotations and hit the ground running as an intern. Because of this, you want to go to a program where you have the ability to learn by doing and gain experience managing patients on your own with appropriate supervision. Basically, they're watching you care for patients and asking questions, teaching, and making sure you don't screw up. Not the opposite, where you're watching them care for patients and asking questions. This is a very important distinction. (obviously this applies to non-surgical specialties more since you be observing most of the time on surgery) There are many schools and rotations where its the latter and you're basically doing nothing more than glorified shadowing.

Unfortunately, there is a lot of variability between rotations and even the faculty/residents themselves on a single rotation. One person might get lucky and had a great team, while another might not be so lucky. Also, much of what you get out of rotations depends on what you put into it. If you're not enthusiastic and a putting forth the effort, you'll likely get to do less than other classmates on the same rotation.

Taking the previous 2 statements into account, I'd ask the following questions:

- Can you describe in detail a typical day on your medicine and surgery rotations?
- What do you do when you see a new patient?
- Can you write in the patient's chart and put in orders for labs or medications?
- What types of procedures have you done? How many procedures have you done? (LPs, deliveries, intubations, suturing, casting, etc…)
- How often did you hang out with your team outside of work? (going out to restaurants/bars/clubs, birthday and holiday parties, etc... )
- Are you allowed to bring books/notes with you and study during any downtime?
- How many students are on a team for each rotation?
- How are grades determined and can everyone get honors?

Definitely agree, and you're exactly right with the vague/unhelpful answers. The more specific the better.