If you could change the 6 core clerkships...

[OnePunchBiopsy]

As we know, the 6 core clerkships are:

Internal Medicine
Family Medicine
Periatrics
Ob/Gyn
Psychiatry
General Surgery

If you had the ability, what specialties would you add/subtract from the list? This change would affect all US medical school curricula.

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[TBV]

The middle 4 on your list could go and I wouldn't be mad at it. As far as replacements my biases would show (as they already have)

 

[karayaa]

As we know, the 6 core clerkships are:

Internal Medicine
Family Medicine
Periatrics
Ob/Gyn
Psychiatry
General Surgery

If you had the ability, what specialties would you add/subtract from the list? This change would affect all US medical school curricula.

It'd be interesting to make IM cover all inpatient/hospital procedures, and FM all outpatient/office procedures, expand FM to cover the Peds and ObGyn material, combine Psych with Neuro, add Anes to GS, and expand it to cover multiple surgical specialties, such as Ortho, Ophth and Urology.

But then, we'd lose a little of the "flavor" of different fields, because their personalities wouldn't be as distinct. It might make it more difficult to choose a residency, because there's less contrast bt fields and and less immersion in each one.

 

[amichel]

It'd be interesting to make IM cover all inpatient/hospital procedures, and FM all outpatient/office procedures, expand FM to cover the Peds and ObGyn material, combine Psych with Neuro, add Anes to GS, and expand it to cover multiple surgical specialties, such as Ortho, Ophth and Urology.

But then, we'd lose a little of the "flavor" of different fields, because their personalities wouldn't be as distinct. It might make it more difficult to choose a residency, because there's less contrast bt fields and and less immersion in each one.

Then who would cover the Peds inpatients?

 

[235009]

It'd be interesting to make IM cover all inpatient/hospital procedures, and FM all outpatient/office procedures, expand FM to cover the Peds and ObGyn material, combine Psych with Neuro, add Anes to GS, and expand it to cover multiple surgical specialties, such as Ortho, Ophth and Urology.

But then, we'd lose a little of the "flavor" of different fields, because their personalities wouldn't be as distinct. It might make it more difficult to choose a residency, because there's less contrast bt fields and and less immersion in each one.

You realize we aren't just talking about covering material in lecture right? And procedures? Huh?

You don't see nearly enough OB/GYN in family med and as previously mentioned you only see outpatient peds.

I think the problem isn't which specialties you rotate through but how much time you spend in each. If there was some redistribution then you can add a couple that would be most useful. At my school EM and radiology were actually also core rotations. I'd also like to see ophtho added as I feel like i just never learned anything about the eye to this day.

FM, psych and ob/gyn definitely need to be shorter rotations (or at least shorter than I remember them being at my school).

 

[notbobtrustme]

3rd year really should be 12 weeks IM and 8 weeks surgery and that's it. That leaves nearly 6 months to do electives before you send out ERAS giving you plenty of time to find the specialty that's right for you.

 

[22031 Alum]

My school did not have an FM clerkship. We did Neuro instead. Looking back I think it was a fine setup.

 

[PL198]

Removing ob and adding rads makes sense to me.

 

[TheShaker]

Removing ob and adding rads makes sense to me.

Don't students get enough exposure to rads and path in preclinical though? I'm not saying it makes us any good at it but I think most people have an idea if they love or hate the field.

 

[Stagg737]

3rd year really should be 12 weeks IM and 8 weeks surgery and that's it. That leaves nearly 6 months to do electives before you send out ERAS giving you plenty of time to find the specialty that's right for you.

The problem with that is that 12 weeks of IM is pointless for anyone that wants nothing to do with the field. Perhaps some of the more experienced people here could comment on whether they think 12 weeks of IM would be necessary as a core rotation?

 

[RustBeltOnc]

The problem with that is that 12 weeks of IM is pointless for anyone that wants nothing to do with the field. Perhaps some of the more experienced people here could comment on whether they think 12 weeks of IM would be necessary as a core rotation?

12 weeks, with broad exposure to gen med and sub specialties (including hem onc) would benefit everyone. You could argue for even more time.

to OP: neurology should be required of everyone, and it should be a "real" rotation

 

[22031 Alum]

The problem with that is that 12 weeks of IM is pointless for anyone that wants nothing to do with the field. Perhaps some of the more experienced people here could comment on whether they think 12 weeks of IM would be necessary as a core rotation?

When I was an MS3, we did 12 weeks of medicine: 3 weeks on each of three different services, then 3 weeks of outpatient. I think. I could dig up my old journals and tell you for sure. I know for a fact that I rotated through the GI service, the Pulm service, and general medicine and then spent time in several outpatient clinics (both general and subspecialty). 12 weeks of general medicine would have certainly been overkill, but as it was I loved the exposure I got to different aspects of the field. The same goes for my 12 weeks of Surgery.

I think you get into trouble when you start declaring what's pointless for people who "want nothing to do with the field." If I'd had my way as a student I wouldn't have done an OB rotation at all, and you can see how that turned out for me.

 

[OnePunchBiopsy]

to OP: neurology should be required of everyone, and it should be a "real" rotation

I have always thought it would be cool to have neuro and psych integrated.

 

[PL198]

Don't students get enough exposure to rads and path in preclinical though? I'm not saying it makes us any good at it but I think most people have an idea if they love or hate the field.

meh I don't think so. and not even talking about trying to get people into field or not. I think just having an experience in rads is going to do way more for most people in their future jobs than OB will.

 

[NontradCA]

3rd year really should be 12 weeks IM and 8 weeks surgery and that's it. That leaves nearly 6 months to do electives before you send out ERAS giving you plenty of time to find the specialty that's right for you.

RIP

 

[Mad Jack]

I feel like psych should be scrapped for a critical care rotation in medicine or surgery, and OB and peds should be merged with a full scope FM program. But hey, I don't like kids or babies, and I don't believe one psych rotation won't be enough to markedly improve anyone's competence in the area. Plus I am quite biased toward critical care, though I don't know how much a third year would get out of a critical care rotation (maybe have it late in third year?).

 

[BigRedBeta]

As a pediatric critical care attending, I'll of course have to take the contrarian view about the validity of pediatrics.

First, the true "core" clerkships are really just 5 - IM/Peds/Surgery/Psych/Ob-Gyn. I don't know of a single medical school that doesn't include those, while many different variations of EM, FM, Rads, Neuro and even anesthesia are utilized at a number of schools.

Each of those core 5 are important because they do represent a significant patient population with unique considerations. However, residents in most fields will still see patients that fit in those categories throughout the career even though it may not seem like it. You're not on OB to learn to birth babies, you're there to learn how to take care of pregnant ladies and the unique considerations they require. You're required to go to the children's hospital not because kids cry, parents are crazy and liquid clindamycin tastes god awful, but because you will have to do pediatric rotations as a resident (IM excluded) and despite your inevitable groan, it's true, children aren't just little adults and need to be treated differently (ask the EM attending I had to put in their place when they nearly killed a 14 y/o DKA patient a couple weeks ago for failing to recognize the difference), not to mention that all you IM people are going to be getting an ever increasing number of adult patients who had major childhood illnesses and now need medical care into their 50's and 60's and at least some cognizance of those conditions is helpful.

Now could there be a change in the overall exposure to each of these 5? Absolutely. It doesn't make sense for every clerkship to be the same length. 8 weeks of OB/GYN and psych is likely too much. Is 8 weeks of general surgery necessary or could you get by with 4 weeks ? Exposure to subspecialties both medical and surgical would be of benefit for many students. Could 6 weeks of pediatrics be sufficient if split into 3 weeks of inpatient, 1 week of gen peds clinic, 1 week of subspecialty peds clinic and 1 week of PICU (my bias!), yeah, very likely. Would 4 weeks of neuro be useful for most everyone? Yes! Does the ED represent a place where a lot of learning can happen? Without a doubt.

The thing is that for each of you saying that you only need IM and gen surgery, there's someone interested in psych saying the opposite.

Bottom line, as a 3rd year student, with your limited knowledge and experience, there is literally something that you can learn on every single patient put in front of you. Whether it is an exam skill, a lab finding, an xray read, dealing with social issues, ethics, whatever, there's an opportunity to get better. The only true wastes of your time are the attendings and residents that ignore you or worse, utilize you to make their jobs easier.

 

[22031 Alum]

@BigRedBeta, if I posted memes there would be one saying "PREACH" right here.

 

[Psai]

3rd year really should be 12 weeks IM and 8 weeks surgery and that's it. That leaves nearly 6 months to do electives before you send out ERAS giving you plenty of time to find the specialty that's right for you.

not sure why you're gone

 

[xffan624]

I have always thought it would be cool to have neuro and psych integrated.

My rotation had neuro/psych mixed. There was definitely overlap in material, but it was still a challenge to switch gears from psych to neuro at times.

 

[Kevin Baker]

Correctional medicine, nursing homes, and rads should be added. There should be mandated exposure to path (can just be running s specimen down from surgery, but students should be exposed to the field), outpatient psych (again, could just be a day, but most psych is done outpatient and it'd be valuable to see patients that are functional outside the ward), outpatient FM or IM, some critical care exposure on IM, exposure to palliative or hospice, and some emergency surgery.

 

[Jlaw]

One month of surgery max, 2nd month should be critical care. Second month of family med should go as well and be replaced with either EM or an IM subspecialty. IM was the only rotation I felt like the second month benefited me. I literally learned nothing on surgery other than OR etiquette. Holding retractors doesn't teach you anything, you would be better off putting all of your efforts into rounding in the ICU or on the wards.

 

[Kaustikos]

I honestly think EM should be a core. Not because it's awesome but because it teaches you quickly how to get the facts and present them to your resident/attending. You also get to see a variety of cases and exposure to trauma. It kind of let's you see it all and prepares you in presenting quickly.
But then I also say I could do without obgyn completely. So...
Surgery all third year?

 

[BigRedBeta]

I honestly think EM should be a core. Not because it's awesome but because it teaches you quickly how to get the facts and present them to your resident/attending. You also get to see a variety of cases and exposure to trauma. It kind of let's you see it all and prepares you in presenting quickly.
But then I also say I could do without obgyn completely. So...
Surgery all third year?

There's no reason why you can't learn to present quickly in other clerkships. Perhaps the pressure to do so is more apparent in the ED, but watch how your upper level residents present in any other clerkship and you'll see just as much efficiency.

 

[BigRedBeta]

@Mr. Hat Too much fluid much too fast, an IV push of insulin, not recognizing the significance of a headache...

The key is that those things are fine in adult patients who typically have type 2 diabetes and a pancreas that is actually putting out tons of insulin, they are insulin resistant. My patients are 98% type 1 diabetics who don't make insulin and are exquisitely sensitive to it. Dropping blood sugars too rapidly in DKA and altering the osmotic gradient between the brain and the vasculature lead to overwhelming cerebral edema that can cause death

 

[TBV]

@Mr. Hat Too much fluid much too fast, an IV push of insulin, not recognizing the significance of a headache...

The key is that those things are fine in adult patients who typically have type 2 diabetes and a pancreas that is actually putting out tons of insulin, they are insulin resistant. My patients are 98% type 1 diabetics who don't make insulin and are exquisitely sensitive to it. Dropping blood sugars too rapidly in DKA and altering the osmotic gradient between the brain and the vasculature lead to overwhelming cerebral edema that can cause death

IV mannitol and we're in business AMIRITE?

 

[Brigade4Radiant]

(ask the EM attending I had to put in their place when they nearly killed a 14 y/o DKA patient a couple weeks ago for failing to recognize the difference), .

So what did he do?

 

[sloop]

I feel like psych should be scrapped for a critical care rotation in medicine or surgery, and OB and peds should be merged with a full scope FM program.

No.

A lot of psych folks go to med school specifically for psychiatry. Not to say we don't like medicine and surgery too but we already get sort of shafted for much of med school in the sense that, unlike people who are interested in medical or surgical specialties, we don't get a whole lot of direct exposure to stuff that is directly related to our passion in the first two years. Psych gets totally sidelined in the first two years by being crunched into a few minor courses that people barely study for. Then, everyone interested in psych has to sit through very long rotations in general surgery and shorter ones in surgical fields like OB/GYN that have almost no relevance to psych except in convoluted or niche ways.

Your suggestion would essentially be that a group of people who go to medical school for psych must wait until 4th year to have any serious exposure to what they care most about.

If the psych folks need to sit through surgery, the surgeon folk should have to sit through psych. Besides, psych is arguably more applicable to most specialties than those specialties are to psych.

 

[PhillyMed777]

No.

A lot of psych folks go to med school specifically for psychiatry. Not to say we don't like medicine and surgery too but we already get sort of shafted for much of med school in the sense that, unlike people who are interested in medical or surgical specialties, we don't get a whole lot of direct exposure to stuff that is directly related to our passion in the first two years. Psych gets totally sidelined in the first two years by being crunched into a few minor courses that people barely study for. Then, everyone interested in psych has to sit through very long rotations in general surgery and shorter ones in surgical fields like OB/GYN that have almost no relevance to psych except in convoluted or niche ways.

Your suggestion would essentially be that a group of people who go to medical school for psych must wait until 4th year to have any serious exposure to what they care most about.

If the psych folks need to sit through surgery, the surgeon folk should have to sit through psych. Besides, psych is arguably more applicable to most specialties than those specialties are to psych.

I do wish school was a little more customizable

 

[Kaustikos]

There's no reason why you can't learn to present quickly in other clerkships. Perhaps the pressure to do so is more apparent in the ED, but watch how your upper level residents present in any other clerkship and you'll see just as much efficiency.

I agree. I didn't mean one isn't able to become competent at presenting, it's just the crash course in EM changed things quickly.

 

[Dave89]

Wouldn't kick any of those off of the list, as I think that each is crucial for a well-rounded medical education.

But I would shave them down to 5-6 weeks at a maximum.

 

[JJMrK]

IMO, much of the third year curriculum should cut down, and really at least half should be elective rotations. A month on medicine, general surgery, and pediatrics makes sense. Personally I don't see any reason that every medical student needs an OB or a psych rotation. The vast majority of people are not going into either field and will find more valuable learning elsewhere. The latter part of the third year, IMO, would ideally be spent doing rotations to narrow down the student's specialty choice and prepare for sub-internships.

 

[RustBeltOnc]

IMO, much of the third year curriculum should cut down, and really at least half should be elective rotations. A month on medicine, general surgery, and pediatrics makes sense. Personally I don't see any reason that every medical student needs an OB or a psych rotation.

Everyone, with the possible exception for path needs to do both. When you are an attending in the community, you encounter all sorts of mental health problems / personality structures and psych experience helps with this, if only for the physician's coping. Ob gyn is an absolute must -- for everyone. Everyone at some point sees pregnant patients and most physicians have to deal with pts with gyn issues. I do think that perhaps the Ob gyn rotation (at my school) could be easier, perhaps not graded so harshly and the housestaff could have been nicer. And yes, at least in my day, there was Ob Gyn stuff on step 3

 

[Psai]

If I'm going to be an observer most of the time, i don't see why i need to observe things for more than a month. "The interns need their numbers" yeah because they didn't get anything as a medical student and whose fault is that?

 

[amichel]

And this is why we don't let medical students pick core rotations (I say as a medical student my self). No one needs a psych rotation? Are you kidding?

The incidence of mental health issues among patients with chronic disease is really high... And, they tend to get pregnant once in a while too.

 

[PL198]

And this is why we don't let medical students pick core rotations (I say as a medical student my self). No one needs a psych rotation? Are you kidding?

The incidence of mental health issues among patients with chronic disease is really high... And, they tend to get pregnant once in a while too.

that was a physician that said that, not a student.

why do you need an OB rotation to know how to treat pregnant women? it's 1 month of 3rd year. if it was something important for your future career, you'd learn it during residency.

 

[RustBeltOnc]

that was a physician that said that, not a student.

why do you need an OB rotation to know how to treat pregnant women? it's 1 month of 3rd year. if it was something important for your future career, you'd learn it during residency.

if only.

 

[PL198]

if only.

do you disagree? I mean how academically disillusioned are we going to be here. Do you really need to have a psych rotation to know how to treat patients with depression or anxiety? Because it's not like you're going to be dealing with severe psychiatric disorder management yourself if you go into something besides psych. Lets have everyone do an onc rotation because they will have a patient with cancer someday. and PMR rotation because someone is going to need rehab as well!

 

[22031 Alum]

"The interns need their numbers" yeah because they didn't get anything as a medical student and whose fault is that?

You realize that the "numbers" interns need have nothing to do with what they did or didn't do as a student, right? I don't care if someone did 500 vaginal deliveries as a student, the count starts at zero as an intern.

 

[PL198]

aging population, why not throw geriatrics in there too? see how that works

 

[amichel]

that was a physician that said that, not a student.

why do you need an OB rotation to know how to treat pregnant women? it's 1 month of 3rd year. if it was something important for your future career, you'd learn it during residency.

Sorry, I'm on my phone and can't see that stuff. But multiple people have said it.

And that doesn't make sense. As with everything, you have to understand the normal to deal with the abnormal. If you only see pregnant patients with underlying disease, you will a) not have the background experience to know what's normal and what is related to the disease and b) not get enough volume to learn anything anyways.

 

[amichel]

do you disagree? I mean how academically disillusioned are we going to be here. Do you really need to have a psych rotation to know how to treat patients with depression or anxiety? Because it's not like you're going to be dealing with severe psychiatric disorder management yourself if you go into something besides psych. Lets have everyone do an onc rotation because they will have a patient with cancer someday. and PMR rotation because someone is going to need rehab as well!

Why do you need an internal medicine rotation to learn how to treat COPD and diabetes? Let's just get rid of the clinical years all together... If we learn everything we need in residency.

The examples you mentioned are simply a function of the fact that there is limited time in medical school. Most people probably could benefit from PMR and oncology rotations.

 

[RustBeltOnc]

Do you really need to have a psych rotation to know how to treat patients with depression or anxiety? Because it's not like you're going to be dealing with severe psychiatric disorder management yourself if you go into something besides psych. Lets have everyone do an onc rotation because they will have a patient with cancer someday. and PMR rotation because someone is going to need rehab as well!

As an independent physician (of almost any type) yes, you will be dealing with severe psychiatric disorder management even if you aren't the doctor writing the risperidone script. Residency in IM (and most fields) is ultimately about service rendered to the hospital and department, education in your own field and that's it.

Where we could probably agree is, should the psych rotation be two months? No. Should it be graded harshly? No. Should it be physically challenging? No. Does it need a "shelf" exam? Perhaps not.

 

[RustBeltOnc]

The examples you mentioned are simply a function of the fact that there is limited time in medical school. Most people probably could benefit from PMR and oncology rotations.

There is so much oncology on many gen med services, I am willing to say oncology rotation is overkill. But certainly, the gen med attendings should incorporate the attending oncologists into rounds if possible.

 

[Dave89]

that was a physician that said that, not a student.

why do you need an OB rotation to know how to treat pregnant women? it's 1 month of 3rd year. if it was something important for your future career, you'd learn it during residency.

Is kicking the training can down the road really the best attitude to take? After all, many of us would like to see the medical training path streamlined; not prolonged.

 

[PL198]

Is kicking the training can down the road really the best attitude to take? After all, many of us would like to see the medical training path streamlined; not prolonged.

it's not kicking it down the road, it's just about realizing that you're going to deal with imaging 10x the amount of times you will see a pregnant patient in any field other than OB

 

[sloop]

Everyone saying psych is unnecessary is being totally dumb. Psych is just as important as IM is. Even if you're some generalist IM/FM doc, what are you going to do? Refer everyone with uncomplicated anxiety or major depression to a psychiatrist? Really? Not to mention communicating with patients with schizophrenia, bipolar, personality disorders, etc. who have medical issues that need treatment. Are you just going to refuse to treat these people?

Psych is an incredibly important rotation—one of the most important, actually. Just because you don't like psych doesn't mean it's not important.

Even if you don't believe it's necessary, what about fairness? Why do people think it makes substantially more sense to have psych folks sit through surgery than it does to have surgeon folk sit through psych? It seems obvious to me that psych is far more applicable to the field of surgery than the reverse . . .

 

[quickfeet]

3rd year and 4th year are huge scams the way they are setup at most schools. The entire thing could (and should) be shaved down to 9 or 10 months maximum.

 

[Psai]

Everyone saying psych is unnecessary is being totally dumb. Psych is just as important as IM is. Even if you're some generalist IM/FM doc, what are you going to do? Refer everyone with uncomplicated anxiety or major depression to a psychiatrist? Really? Not to mention communicating with patients with schizophrenia, bipolar, personality disorders, etc. who have medical issues that need treatment. Are you just going to refuse to treat these people?

Psych is an incredibly important rotation—one of the most important, actually. Just because you don't like psych doesn't mean it's not important.

Even if you don't believe it's necessary, what about fairness? Why do people think it makes substantially more sense to have psych folks sit through surgery than it does to have surgeon folk sit through psych? It seems obvious to me that psych is far more applicable to the field of surgery than the reverse . . .

Everyone consuls everyone anyway. It's not that they can't handle the problem but for medicolegal issues.

 

[Psai]

You realize that the "numbers" interns need have nothing to do with what they did or didn't do as a student, right? I don't care if someone did 500 vaginal deliveries as a student, the count starts at zero as an intern.

Yeah but a student that comes in with 500 will be much better prepared than someone who has done zero from being constantly told that the residents need their numbers. The fact that attendings don't give a **** about students says a lot. I wonder why things have changed so drastically in the past few years? I'm thinking emrs and increased medicolegal burden