How Would You Reimagine Med-School Education?

[DermViser]

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@Brain Bucket

I'm going to try for just a general response to some of your concerns. Here is, from my experience, some common behaviors of BAD medical student on our clerkship. **Please note, that I would guess a substantial number of the students who fell into this pattern probably still received a high pass. The med school affiliated with my residency program is one of those ones where a P is a scarlet letter.

The first and foremost way to be a bad student is to not care, or more accurately give off the perception of not caring. I don't mean that you should be a kiss ass. But some people, likely due to nerves or social awkwardness or whatever, will naturally gravitate to the back of the crowd on rounds, or hesitate to make eye contact and speak up assertively. People who legitimately don't care get bad evaluations deservedly; people who lack the awareness of how their behavior is perceived by others get bad evaluations undeservedly.

The next way to be a bad student is to be late. Don't ever be late. In fact...being on time is late. Be early.

Another way to be a bad student is to be disorganized. This will come across in your presentations, your ability to assess a patient, your interactions with the team.

Next up: bad students don't progress. I understand that on day one your presentation is going to be far from perfect, will probably include too much information, and you won't really know the plan for a postop patient. But by your fourth week with us? You still can't make a decent assessment and plan? That is not acceptable.

Lack of anticipation. Same patient has the exact same wound on rounds every day. Every day we have to change the dressing. Every day I have to push and remind the student to put gloves on and get the dressing supplies. What happened? Did you forget? Did you think the wound healed overnight? We have been changing this same dressing. Similar thing happens in the OR. How many sutures in a row does the attending have to specifically ask you to cut before you start just doing it without being asked?

There are I am sure a million more things I could think of if . But what you'll notice is that these examples have very little to do with medical knowledge. They are all more about interpersonal skills, understanding and interacting with a team dynamic, and emotional intelligence.


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That said, I have said it before and I will say it again. I think this SDN notion that the bell curve switches from M1-M2 and M3-M4, and that all the "average" pre-clinical student will become a clinical rockstar is largely a myth. It is also a defense mechanism for the M1-2 who is average or below average and can't accept it - they reassure themselves that when they reach the clinical years the gunners will get their comeuppance and they will magically get honors due to their superior interpersonal skills.

The majority of students who do well in M1-M2 year still do well as M3s, because they are smart and hard working. Sure, some of them have a personality disorder and drop off a bit, but that's not that common.

Does it happen to some? Certainly.

And as others just posted - you also see the gung-ho students who absolutely dive in on the clinical side thinking it will pay off in their evals. The residents love those students because they help out the team and they generally seem like the kind of person you'd want to work with. But they get so tired from working that they don't study enough, so they don't get honors on the clerkship because they had a middling shelf score.

I swear yours and @mimelim's posts on medical student behavior on MS-3 rotations should be stickied. I see more posts on how to ace the shelf, than skills on how to do well on rotations.

 

[DermViser]

Thanks. I agree with all of that. Bookmarked this thread for re-reading in a few months, once I have better perspective. If I find I'm not getting the evals I need, I'll definitely ask you guys for help again.

There are books also: First Aid for the Wards, the Samir Desai book series on clerkships: 250 mistakes not to make in your third year, and his clerkship specific books as well, etc.

 

[Brain Bucket]

There are books also: First Aid for the Wards, the Samir Desai book series on clerkships: 250 mistakes not to make in your third year, and his clerkship specific books as well, etc.

Already on my desk 😛. Thanks!

 

[DermViser]

@Brain Bucket
Next up: bad students don't progress. I understand that on day one your presentation is going to be far from perfect, will probably include too much information, and you won't really know the plan for a postop patient. But by your fourth week with us? You still can't make a decent assessment and plan? That is not acceptable.

Lack of anticipation. Same patient has the exact same wound on rounds every day. Every day we have to change the dressing. Every day I have to push and remind the student to put gloves on and get the dressing supplies. What happened? Did you forget? Did you think the wound healed overnight? We have been changing this same dressing. Similar thing happens in the OR. How many sutures in a row does the attending have to specifically ask you to cut before you start just doing it without being asked?

Reminds me of this: http://www.ama-assn.org/ama/pub/edu...question-of-month/graduates-being-denied.page
Secondly, and sadly, US medical graduates have been passed through courses in medical school with inadequate training, despite enormous increases in tuition. Too much of their "clinical" education occurs on simulators or computers. You can pass a clinical surgery rotation without learning how to do a sterile scrub, prep a patient, or suture a wound. Most students pass obstetrics without delivering a single baby and they have never seen a pelvic exam done when they pass gynecology. Sure, they watch from the corner, but that falls short of truly educating them. Most are, however, quite adept at delivering a plastic fetus from a plastic pelvis. It is time to correct this deficiency in our medical education. The "clinical" years need to return to clinical medicine. Graduates should be able to suture, scrub, tie knots, maintain sterile technique, give at least a limited differential diagnosis, and write a progress note or operative report. If you can't do these simple things, you should not be labeled as a physician. Graduates should be able to talk to patients, not input data to manikins. I know that patient safety concerns have driven education away from direct patient care, but all this has accomplished is to defer the patient safety issues until the newly minted physicians finally do encounter real patients in residency. At some point, medicine must be learned by practicing (under supervision) on real patients.

 

[operaman]

I have to say, I think that seeing patients and busting my arse on the wards was the best shelf studying I did on any rotation. I was/am definitely the first one in/last one out, work hard, read like a fiend, etc., and I found this immensely and irreplaceably helpful in learning how to think clinically which is ultimately what shelf exams test (that and some medical trivia). Personally, I think leaving early to study is a poor choice because it's very difficult to learn the complexities of clinical medicine from any review book. Shelves are tough because the 'diagnosis' questions will give you the top 5 on your ddx while 'next step in management' questions will give you 5 good choices. Learning the nuance that leads to one dx or the factors that make one step the 'best' next step is awfully hard to glean from a book, at least for me. Acing the shelf and acing the clinical part do not need to be mutually exclusive. Shelf questions get much easier if you recognize your real patients in the vignettes and were part of the discussions and planning that went into their management decisions.

I think that interpreting any sort of 'grade' is a bit like reading the tea leaves - you see what you want to see. Acing a shelf says you have a certain base of knowledge and are a good test taker. Clinical honors says that people liked you, period. I think neither one really says much about your clinical acumen. Granted, someone who honors everything is likely a decent student and well liked and able to work well with many different people.

Personally, I would prefer to work with someone who honored every rotation clinically but only passed all the shelves than the other way around. Knowledge can be taught, but lazy/annoying/awkward/douchebaggery are all terminal conditions.

 

[DermViser]

I have to say, I think that seeing patients and busting my arse on the wards was the best shelf studying I did on any rotation. I was/am definitely the first one in/last one out, work hard, read like a fiend, etc., and I found this immensely and irreplaceably helpful in learning how to think clinically which is ultimately what shelf exams test (that and some medical trivia). Personally, I think leaving early to study is a poor choice because it's very difficult to learn the complexities of clinical medicine from any review book. Shelves are tough because the 'diagnosis' questions will give you the top 5 on your ddx while 'next step in management' questions will give you 5 good choices. Learning the nuance that leads to one dx or the factors that make one step the 'best' next step is awfully hard to glean from a book, at least for me. Acing the shelf and acing the clinical part do not need to be mutually exclusive. Shelf questions get much easier if you recognize your real patients in the vignettes and were part of the discussions and planning that went into their management decisions.

I think that interpreting any sort of 'grade' is a bit like reading the tea leaves - you see what you want to see. Acing a shelf says you have a certain base of knowledge and are a good test taker. Clinical honors says that people liked you, period. I think neither one really says much about your clinical acumen. Granted, someone who honors everything is likely a decent student and well liked and able to work well with many different people.

Personally, I would prefer to work with someone who honored every rotation clinically but only passed all the shelves than the other way around. Knowledge can be taught, but lazy/annoying/awkward/douchebaggery are all terminal conditions.

Hence why clinical clerkship grades aren't just based on one metric. Usually it's clinical evals, NBME shelf, sometimes an additional clerkship made test, quizzes, OSCEs, patient logs, etc.

 

[SouthernSurgeon]

and write a progress note or operative report. If you can't do these simple things, you should not be labeled as a physician.

You know, it's funny. I hear on this site, and from med students, that writing progress notes, or discharge summaries, or printing the list...is "scut" and not "educational"

I always find that humorous. Turns out intern year that "scut" is actually your job. And if you're good at it, it is likely because you got some practice and feedback in a supervised environment. Oh, and if you're good at it, that likely means you're a lot faster than your peers. So if you finish all that "scut" earlier, you'll either get to go home earlier if you aren't on call, get more sleep if you are on call, or (in a surgical residency) have more time to get down to the OR for the fun parts of residency.

 

[DermViser]

You know, it's funny. I hear on this site, and from med students, that writing progress notes, or discharge summaries, or printing the list...is "scut" and not "educational"

I always find that humorous. Turns out intern year that "scut" is actually your job. And if you're good at it, it is likely because you got some practice and feedback in a supervised environment. Oh, and if you're good at it, that likely means you're a lot faster than your peers. So if you finish all that "scut" earlier, you'll either get to go home earlier if you aren't on call, get more sleep if you are on call, or (in a surgical residency) have more time to get down to the OR for the fun parts of residency.

Yup, the word "scut" which was stuff like getting a resident's laundry or getting food, etc. has expanded to actual clinical care activities --- i.e. writing notes, discharge summaries, dropping off a specimen at the lab, etc. etc. Kind of like the word "malignant" or "gunner". They've morphed way beyond what their original meanings were. Residency will be a real shock to them. There is no job in which you only do what you want.

 

[Psai]

Thank you guys, I've been feeling lost and not sure what people expect from me which is a little disconcerting.