Med school curricula: Lots of fluff?

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RxnMan

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This is a redirecting of a conversation that started in another thread.
I've heard this "an EXPERIENCED PA....beats a... whatever" argument more than a few times.

Everyone needs to remember this: experience is not a function of degree. Experience is experience. You can re-write the above sentence to read "an EXPERIENCED EM physician", and the statement holds true. You're always going to want an experienced individual making the calls over an inexperienced individual.

The dove-tail argument here is that being an MD and completing an EM residency gives you more experience by definition as a sheer function of hours spent in training. Period.

My two-cents is as follows: Is there a lot of completely irrelevant nonsense taught in medical school? You bet. Nobody cares about things like JAK-STAT pathways and naming the cofactors in the oxidative phosphorylation. Can medical school be streamlined to create better physicians in less time? Sure; I'm doing my 'academic project' on how a lot of med-school material is just useless and shouldn't be taught. However, I've also taught a number of PA-school lectures, and there's no comparison. MDs know more because they learn more material; MDs have a broader and deeper understanding of pathophysiology. Period. Graduate an MD and a PA at the same time; and you're going to have two individuals with an equal number of years of experience as they both go on. One is always going to know more.

I disagree with the bolded section. I rediscovered the utility of knowing those cofactors in a project I'm working on as a marker of disease. A couple of fellows in my program tested drugs that take advantage of JAK-STAT pathways in SCC. We should not downplay the general preparation and wide information base the MD provides, just because every doc doesn't use 100% of it. You will not know when one of those random facts becomes relevant.

I welcome your criticism, as its good for my project.

Counterargument: While your projects are important (and sound very cool) you're doing academic research; not clinical medicine. Until it becomes clinically applicable medicine; it could be left out of medical school and save we clinicians a lot of suffering and time. The vast majority of MDs out there never do what you're doing, and as a result don't care and don't need to care. I propose keeping "medical school" for clinicians, and streamlining the process to get more docs out there, faster, with better clinical acumen. That's what the nation needs right now.

Your research sounds cool; but its PhD work; not MD work. If we cut out the PhD work; you can spend more time learning clinical medicine and coming out of school more competent. If the knowledge is very specialty-specific (say, the SCC that you mention); then it can and should be learned in that specific residency/fellowship. Your average say, Anesthesiologist is never going to use that data; so why torture him/her by making him learn it?

This all stemmed from the following phenomenon, which I know wasn't unique to me. During my intern year, I found myself able to recite all sorts of USELESS knowledge about PKB and signaling pathways; and was mystified by the 'routine' things that went into clinical decision-making. All the nurses knew that you had to double-cover for Pseudomonas, but why didn't I? I spent a large portion of medical school forcefeeding myself clinically useless junk. Bogus. I felt like I was robbed of time. Make me a better clinician; I thought that's what you learned in medical school.

More comments/criticism welcome.

Heh, how else would we know who deserves to be the neuro surgeons?:rolleyes: From my perspective it seems those in power will never get rid of a way to stratify individuals, unless you provide an alternative.

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I agree completely that a TON of time is wasted in medical school. The root of the problem lies in the fact that most courses are taught by non-practicing MDs or PhDs. My professors were clueless as to what constituted clinically useful information.

However, as was pointed out above, you never know when an obscure piece of knowledge could become the foundation for a revolutionary treatment or vital to the understanding of the pathophysiology of a disease. MDs with a thourough knowledge of minutia can make huge impacts in the advancement of medical technology. Why? Because they are the ones at the bedside running out of options and forced to think outside the box and advance the practice of medicine.
 
Note - I've done a little cutting and pasting to group my responses. If I take anything too far out of context, then tell me and specify what you meant.

...Counterargument: While your projects are important (and sound very cool) you're doing academic research; not clinical medicine...Your research sounds cool; but its PhD work; not MD work...
My research is as clinical as it gets. Specifically, I'm developing biomarkers for acute organ failure. Just about any clinician on this forum would use a lab test that allows them to detect and determine the severity of occult disease, especially when that information will influence their treatment or patient outcome. Whenever you order an ABG or a Panel 1, you're looking at biomarkers. I'm just finding another one.

...Until it becomes clinically applicable medicine; it could be left out of medical school and save we clinicians a lot of suffering and time...The vast majority of MDs out there never do what you're doing, and as a result don't care and don't need to care...
Research is translated into clinical practice when clinicians look at the literature and judge how this new information will change their decisions. You need a deep understanding of the research and the concepts that guide that research in order to critically appraise the literature. Research doesn't become clinically applicable medicine until a MD with a strong understanding of the science says so.

...If the knowledge is very specialty-specific (say, the SCC that you mention); then it can and should be learned in that specific residency/fellowship. Your average say, Anesthesiologist is never going to use that data; so why torture him/her by making him learn it?
In your view, should we just train orthopods from the get-go? Remove the MD curriculum and just train specialists? I think that would be a horrible idea.

Diseases don't respect specialty barriers. How could specialists talk to each other about the different organ-specific aspects of same disease if they didn't share the same basic language of medical concepts? How could medical students make intelligent decisions about how to specialize before they've done a clinical rotation? How would an orthopod effectively communicate with an internist if they hadn't done an IM rotation as a student? How would the orthopod know what the anesthesiologist does? What about those who leave clinical medicine and go onto careers in law, government, and science?

Practically speaking, it would be incredibly difficult to make 20 different med school curricula for the different specialties. Furthermore, how would one decide what information belongs in what curricula? How do we decide what's, as you put it, "PhD" vs "MD' territory?

Also, SCC has an incidence of ~0.5-1.5% per year in US Caucasians. It's the most common cancer of the head and neck and significant risk factors are EtOH and smoking. It's common and it isn't going away any time soon.

...During my intern year, I found myself able to recite all sorts of USELESS knowledge about PKB and signaling pathways; and was mystified by the 'routine' things that went into clinical decision-making. All the nurses knew that you had to double-cover for Pseudomonas, but why didn't I? I spent a large portion of medical school forcefeeding myself clinically useless junk. Bogus. I felt like I was robbed of time. Make me a better clinician; I thought that's what you learned in medical school..
PKB would be of interest to an oncologist. Did you know you were going to do EM when you started med school? IIRC, ~70% of students change their minds about what specialty they want to pursue. How long did it take you to learn to double cover for pseudomonas?

Our first real exposure to medicine should be broad and diverse, to enable clinicians across all specialties to share a common language. It allows us to appraise literature not only from our specialty, but to give an educated guess as to what is going on in other specialties. It also allows us to translate technical jargon into something that is accessible to our patients. It allows us to know the "why" of what we do, not just "what" to do.

As an aside, I believe we need more critical thinking in medicine. While many on this board think research is onerous, and believe me it is, it gives the researcher many of the abilities I listed above. Done well, it will make you a better clinician, if only by showing you how to make educated guesses based on a thorough understanding of the literature.
 
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For these esoteric random bits of knowledge you guys are referring to as maybe being helpful one day: how do you remember them? Wouldn't these little nuggets be lost from the mind if they aren't used in day-to-day medicine?
 
Perhaps the root of the problem is that teaching and preparing lectures is not as well reimbursed as the practice of medicine. It would be ideal for all core courses to be taught by a bench-side researcher/clinician team, who could maximize the clinical relevance, while providing a core understanding of how some of these concepts were discovered in the lab.

For example, wouldn't it be incredible to have a surgeon teaching groin anatomy and to have them point out the importance of the landmarks in placing central lines? At the same time, wouldn't the input of a bench-side researcher who DOES PCR be important in discussing genetics? (ideally, with the input of a clinical geneticist.)
 
There is far too much fluff that is not clinically relevant. I doubt most practicing MDs would do well on Step I without preparation, yet the volume of facts taught in the first two years of med school is far in excess of what one needs even to do extremely well on that test. Most of it is forgotten since it is never reinforced or used. That time is therefore wasted.

Yes, you never know when some bit of knowledge may be useful. That's the defense of the pathological hoarder. The fact is, we ought to be able to determine what is and is not likely to be used (i.e., needed to progress into clinical training) and by reducing the preclinical curriculum to that essential body, we can make more time for clinical education. (Which, BTW, ought to mostly take place during residency since medical students are allowed no responsibility in today's litigious society. No responsibility, no learning.)

Part of the problem is that much of the preclinical curriculum is designed and delivered by nonclinicians. I think an even bigger problem is the attitude that there is no drawback to cramming more and more trivia into the curriculum, that this is not a zero-sum game we are playing. Time spent memorizing neural pathways is time not spent learning about the management of CHF exacerbation, or learning how to understand the literature.
 
For these esoteric random bits of knowledge you guys are referring to as maybe being helpful one day: how do you remember them? Wouldn't these little nuggets be lost from the mind if they aren't used in day-to-day medicine?

There is a vast cloud of knowledge floating above my head. For example, the hexose monophosphate shunt. It is not available to my pitifully small brain. However, the key words are there, and with the help of googling emedicine, it is accessible within thirty seconds for me to read and say, "Oh Yeah! Now I remember. Hmm, that is a worthless tidbit of information."
 
I'll take the opposite view, if only for the sake of argument, but there's still been a lot of times during third/fourth year where one of those little factoids did end up being relevant even though I told myself otherwise as I was wondering why I was even studying it.

Aside from the relevance, I think one of the main unintended (or possibly intended) benefits is that by having to dedicate yourselves to the minutiae and devote the first two years of your medical lives to learning the details, it weeds out those who would otherwise cut corners later on when the stakes are much higher than a multiple choice test.

For those who have ever been part of a basic training environment in the military, you'll realize that 90% of the stuff they make you do has no relevance to warfighting, but it's tremendously important in making soldiers, if for no other reason than it quickly identifies the people who will cause the organization to fail and stratifies the rest. Only after basic (i.e. med school) do soldiers learn the actual day-to-day of their jobs (i.e. residency)
 
Does anyone remember all of the tendons in the arm and their attachments? I certainly can't, yet I recall hours spent gazing at an anatomy textbook trying to memorize them (without success).

If I really need to know I will look it up in a textbook.

The meaningless factoids and trivia are designed to weed out those who are not committed to medicine, and those who are poor learners.
 
Does anyone remember all of the tendons in the arm and their attachments? I certainly can't, yet I recall hours spent gazing at an anatomy textbook trying to memorize them (without success).

If I really need to know I will look it up in a textbook.

The meaningless factoids and trivia are designed to weed out those who are not committed to medicine, and those who are poor learners.

I will agree that a lot of what one learns during the 1st two years of medical school is "fluff" and long forgotten by the time you start your residency, but that doesn't mean that all the time that you spent studying it was a waste of time. 1st two years are meant to build a foundation of knowledge that you will hopefully build on as you advance into your clinical rotations, residency and practice. Of course no one remembers the little details of neural pathways or specific enzymes and byproducts of some biochem pathway, but as long as you remember the main idea, all it takes is a little bit of a refresher (i.e. uptodate, emedicine, google, etc.) and you can catch up on what you need to know for that particular case or patient. If you didn't learn the facts and basics properly the 1st time, it will be a lot harder to catch up and will take longer. Still, I do wish that we were taught more clinically relevant material during the 1st few years, but because most of the professors are not practicing medicine in a clinical setting (as others have mentioned) this is unrealistic.

I still remember a quote from one of my pathophysiology professors who was an active Emergency Medicine physician. He said that "I am sure that you guys know a lot more than me about biochemistry, immunology and genetics and will do much better than me on USMLE step 1 if I would take it right now, but I am an expert in Emergency Medicine from 20 years of practice and that's what I'm here to teach you." His lectures included details on the presentation, diagnosis and treatment of the top 10 diseases that one sees as an EP (AMI, CHF exacerbation, DKA, COPD exacerbation, etc.) and it made the students feel like they were actually in MEDICAL school and not in a PhD course.
 
I will agree wholeheartedly that there is a ton of fluff in the modern day medical school curriculum, however, I believe it is instrumental in the development of a competent physician. As M.D.s we are scientists, and as scientists we are benefited by knowing the biochemical/physiological/pathological processes behind a given disease. If we were to forgo that knowledge, we might as well call ourselves (insert mid-level practitioner here).

I think we should condense medical school into one year. We could spend the entire time memorizing symptom checklists and treatment algorithms for diseases we don't understand. Then we would be blindly-trained simians practicing medicine...hmm, "Idiocracy"....what a great movie.:eek:
 
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Hi Everybody!

Since I started this, I need to get in the middle and dance; I would have gotten involved earlier; but I was s.i.c.k. last night. Yuk.

Anyways, thank you for all the opinions/details/data/replies. This is something of serious interest to me. It all started by identifying the problem:

1. America has a serious shortage of doctors.
2. I'm a new doctor.
3. Wow! I know very little about practical clinical medicine, and lots of useless esoteric nonsense about signaling pathways and ligands. It feels like medical school could be much better put together to make me a better doc in less time; and be less frustrating, expensive, and soul-sucking in the process.

So, fellow denizens of SDN - give me your thoughts, opinions, data, research papers, etc. Another post to cover the meat and potatoes to follow.
 
RxnMan:
My research is as clinical as it gets. Specifically, I'm developing biomarkers for acute organ failure. Just about any clinician on this forum would use a lab test that allows them to detect and determine the severity of occult disease, especially when that information will influence their treatment or patient outcome. Whenever you order an ABG or a Panel 1, you're looking at biomarkers. I'm just finding another one.

RustedFox:
Agreed, biomarkers are amazingly clinically relevant. I liken your research to a time when PhDs discovered a molecule called BNP. It was proven to be amazingly clinically useful; and it was integrated into med-school curriculum. Until it hits that point; the medical student, clinician, and patient are NOT interested in having their time wasted by learning the minutiae of something that may never bear any relevance to management of the condition. I hope that your research makes the same leap; but until it does; we just don't have an application for that knowledge. Thus, you're doing PhD work, not MD work.

RxnMan:
Research is translated into clinical practice when clinicians look at the literature and judge how this new information will change their decisions. You need a deep understanding of the research and the concepts that guide that research in order to critically appraise the literature. Research doesn't become clinically applicable medicine until a MD with a strong understanding of the science says so.

RustedFox:
Agreed, agreed. But that process needs to come from the top-down. Research fellows and venerated attendings need to read the literature and make that decision with regard to their specialized clinical practice; not the first-and-second year medical students.

RxnMan:
In your view, should we just train orthopods from the get-go? Remove the MD curriculum and just train specialists? I think that would be a horrible idea.

RustedFox:
It would be a horrible idea; but the process as it exists could be seriously streamlined to make it less expensive and more CLINICALLY relevant. Everyone needs to know a little about everything, yes - but we can come up with thousands of examples how this guideline is poorly followed in vivo. Example: Right now, I'm a PGY-1 in his last month studying for STEP-3. Somehow, its terribly important for me to know how to do a pap smear, and know the management of LSIL vs. ASCUS vs. HSIL... something which I will never do for the rest of my life. Keep this out of my way; and watch job/life satisfaction go up across the boards... also, watch as rates of substance abuse, messy divorce, and suicide fall. Bottom line: the pieces of the picture need to be put in the right order. I would much rather be graduating MDs/DOs who are minimally clinically competent right out of school rather than have them know about the molecular structure of... whatever.

RxnMan:
Practically speaking, it would be incredibly difficult to make 20 different med school curricula for the different specialties. Furthermore, how would one decide what information belongs in what curricula? How do we decide what's, as you put it, "PhD" vs "MD' territory?

RustedFox:
It would be stupidly difficult; but we can do better than what we're doing now; as evidenced by my statement: "I'm a new doctor. I don't know a lot of clinically relevant medicine." Some stuff just needs to GO. Memorizing which DNA polymerases (alpha, beta, xanadu) are responsible for the leading/lagging strands in prokaryotes? Useless. "Tetracyclenes stop the translation process by binding up the ribosome" will do just fine for 99% of clinical medicine. Remember learning about the TATA box? Interested in the upstream promoter sequence of gene product 36DCUPS? That's PhD territory, not MD territory. If you sit down and examine things like this; you can put a lot of curriculum into its appropriate "box".

RxnMan:
Also, SCC has an incidence of ~0.5-1.5% per year in US Caucasians. It's the most common cancer of the head and neck and significant risk factors are EtOH and smoking. It's common and it isn't going away any time soon.

PKB would be of interest to an oncologist. Did you know you were going to do EM when you started med school? IIRC, ~70% of students change their minds about what specialty they want to pursue. How long did it take you to learn to double cover for pseudomonas?

RustedFox:
It took me one instance to learn to double-cover pseudomonas. PKB/JAK-STAT/Cytochrome steve? I still don't know and don't care. Learn that during your elective onc. rotation - not during second term.

RxnMan:
Our first real exposure to medicine should be broad and diverse, to enable clinicians across all specialties to share a common language. It allows us to appraise literature not only from our specialty, but to give an educated guess as to what is going on in other specialties. It also allows us to translate technical jargon into something that is accessible to our patients. It allows us to know the "why" of what we do, not just "what" to do.

As an aside, I believe we need more critical thinking in medicine. While many on this board think research is onerous, and believe me it is, it gives the researcher many of the abilities I listed above. Done well, it will make you a better clinician, if only by showing you how to make educated guesses based on a thorough understanding of the literature.

RustedFox:
Agreed, but we can do better than what we're doing. Don't make the mistake of thinking that I'm saying that "what you're doing is useless". Its terribly useful; and we need more of what you're doing. Its just not of interest/use until after a certain point in its proving process or until a certain point in one's career. The cart should never come before the horse.
 
You're arguing for several things:

1) Paring down of the medical curriculum to a "clinically relevant" ideal. This doesn't, and can't exist. As undifferentiated students, there's no one curriculum that will serve all possible specialties equally well. Obvious examples are IM vs. surgery, or any patient-oriented field to non-patient oriented. The goal of the LCME and the NBME is to train students in general basic medicine. Any US medical school student should be able to take all parts of the USMLE and be able to matriculate into any residency. Thus, by necessity, there will be some "slop" in the data presented to you.

There is no good definition of "clinically relevant". Ask a room of docs to define "clinically relevant." A 100 docs will give you 150 answers. If those docs are from different specialties, the number of definitions increases. How do you know what information will be relevant to your future practice or not? This gets back in part to the undifferentiated student issue. Another problem is how to decide when to introduce a new piece of evidence? (like a new test, technique, etc.) When a test becomes grade C level evidence? How about when it becomes part of USPSTF guidelines? How do we teach clinicians how to fit the treatment to the patient? (i.e., when to throw away the cookbook?) How about when one field thinks a test is relevant but another doesn't? The continuum from bench to bedside is much finer than you seem to think.

2) A departure from a standardized MD curriculum. Since it is impossible to accomplish #1, the only practical alternative to create many separate curricula. The creation of multiple curricula for the different specialties has many practical problems in the school (how do we create them, what content belongs in each, how do we support multiple different streams of students) and in medical practice (how do specialists manage patients with multiple complaints or with multifaceted disease, communication between specialties, research between specialties, etc.). It also creates serious problems for the student (have to choose specialty before med school, cannot switch residency).

3) Separation of clinical practice and medical progress. A strength of MDs, and a defining difference from other health professionals, is that we have the ability (via medical license) to make our own decisions based on a critical evaluation of the information for our patients. This requires a deep understanding of the literature. We should be thinkers, not automatons guided from on high. A dispersed decision-making process allows for evolution of ideas (like this thread) and selects the best for our patients. Authoritarian structure allows for dangerous things like "in my experience..."

Those venerable attendings and research fellows you mentioned take years to develop and they don't arrive de novo. It starts in med school (again, a strength of a general MD degree). And how do the clincians in private practice know that those venerable attendings and fellows aren't selling them down the river? All MDs need some sort of exposure to the information in order to make intelligent and informed decisions.

Lastly, we need more MDs in research. Our focus on the patient and what is possible is sorely lacking in medical research. We need more MDs to translate basic findings into clinical tools.

By the way - I don't want anyone to think my work is the subject of the discussion. I don't care what anyone thinks of my projects, and nobody is going to hurt my feelings over what is said here. Besides, they're both unfair subject of debate (I hold an unfair knowledge advantage) and they're anecdotal. I'm only debating the issues.
 
It's all about jumping through hoops. How much physics did you learn in medical school? How much was on the MCAT? How do you weed out those that just want to do it, and those that can do it?

So there are a lot of clinically relevant things taught in medical school that I don't use daily, but are important. Physiology, path. Others I use daily, like pharm.
There are other things taught that are minutiae and aren't important. I did biochem grad school. Biochem wasn't hard in med school. I don't use any of it on a day to day basis. The important biochem was part of pathophys. I suppose an understanding of normal helps understand what isn't normal, but at the same time, a lot of my medical teaching seemed to be "whatever the Ph.D. at the SMART board does his research on". Histology was a waste. I don't look at slides. I don't care what immature red cells look like.
Neurology seemed to be pretty dense too. I now know that the visual cortex is organized in a hypercube. I still don't care.
The difficult part would be getting out the parts that are completely worthless without leaving holes in your "base of knowledge".
 
Was that the bald, gay dude with the beard from Columbia?

No it wasn't (I went to a caribbean medical school), but I'm glad to see that there are similar professors out there.
 
Yeah, I know. I went to the same one. And there was a guy who taught a segment of pathophys that was an active EP.

Well, if you mean SGU, than we're probably talking about the same person.

Regarding the topic of the thread, I think eventhough it would benefit the medical students to slightly decrease all of the "fluff" and try to instill more "clinically relevant" material and include more professors such as the one above, this task is extremely difficult to execute and unrealistic. First of all, the current structure of medical education has been around for 90-100 years and is the schools are used to doing things a certain way and it would be difficult to get them to do things another way, even if you can prove that it would be benefitial to the students (if this is actually the case). Most of the people that run medical schools are in administration and maybe don't practice medicine as much anymore and so trying to sell them the idea that what they've been teaching us is "full of fluff" will be hard to accomplish. Second, even if you can change the structure of medical education and maybe decrease the time spent in medical school, there has to be a strandard that schools keep to make sure that the students that finish their program have learned a core set of principles and material and so one would have to come up with this "new standard" prior to actually changing the way medical school teach. Who would do this and how would they go about it? Third, medical schools are filled with teachers that have been teaching in this particular way for decades. So what would you suggest we do, fire the old teachers who didn't teach enough clinically relevant material and hire teachers that will? This is again, easier said than done and seems quite difficult to actually accomplish. About 10 years ago (maybe more) certain medical schools started to teach in a systems based approach and/or problem-based learning and this was different from the stardard way that it was done before. I'm curious if this type of teaching is any better, although I doubt it as there would still be the same amount of "fluff". I don't have the answer as to how to make it better, but I bet that even if you try to change things, it would take at least 10 years to do it.
 
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As M.D.s we are scientists, and as scientists we are benefited by knowing the biochemical/physiological/pathological processes behind a given disease.

No, MDs are not scientists. They are consumers of scientific knowledge, not producers. I agree that they have to understand the relevant science, just like engineers have to understand physics, but that doesn't mean that engineers are physicists.
 
If we did condense down MD/DO training, why even bother having MDs and DOs anymore at all? I mean, PAs are basically MD-lite as it is.
 
No, MDs are not scientists. They are consumers of scientific knowledge, not producers. I agree that they have to understand the relevant science, just like engineers have to understand physics, but that doesn't mean that engineers are physicists.


Well, this is news to me. I must've woken up in bizzaro world.

I mean open up any high impact science journal... you will see TONS of M.D.s (who might or might not have extra degrees, MSc, MPH, PhDs) doing research--basic, clinical, and translational.

Clinical reasoning is the ultimate in hypothesis testing. You generate/gather evidence. Come up with a hypothesis (list of Dx) and use tests (experiments) to test these.

Granted, many people will not "think" that they are doing this. But, essentially on each patient, they are doing 'science".

And what bothers me most about this argument is that, people do not realize how sought after MD input is in research (especially from "translational researchers") because we are able to bridge that gap from the bench to the bedside.

I mean, there are just so many countless examples. Why does infliximab work? Why are patients at risk for reactivation TB? Only an understanding of the basic sciences lets you prescribe these drugs and understand what's going on.

I don't even understand how people feel comfortable ordering a test---say, a PCR, without having any idea what they are actually ordering? (if say, they had no understanding of basic science)

Without an understanding of the basic sciences--you might as well have a a midlevel provider... cause like others said...then, what's the difference?

That's my biggest challenge to RustedFox... we already have these programs. They are called PA-school. Stream-lined basic science (does cover some, but not all as in depth), lots of clinical experience and focus and they seem to move between specialties with relative ease (and are very good at their job). Why not just expand their scope if that's what you looking to do? Just add a residency and ta-da!!!!! (Btw, in no way could I ever support that, but I'd be interested in hearing your argument)

I am very tired of people feeling like we need to "dumb down" the profession to make everyone happy.
 
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Better formulated post to come, with rebuttal to RxnMan (and I acknowledge his good arguments), but for now this will have to do, as I have company coming in tonight.

1. "...because that's the way we've always done it" and "its going to be difficult to do" are not acceptable answers to any problem. It sure was going to be difficult to thread a tiny tube through an aorta and squirt dye into a heart... but we managed to do it.

2. The vast majority of things taught in med-school are critically important, yes - but there's A LOT that just needs to go. Period. Anyone ever make a clinical decision that was dependent on recalling that important TATA-box knowledge, or the structure of a sodium-ion channel? Didn't think so.

3. Condensing MD/DO school will not make us "more like PA's"; it will allow us MORE time to learn MORE clinically relevant items and lock down better patient care. Its good for everyone; happier docs, more capable docs, and (most likely) better patient outcomes and satisfaction measures.

Medical education CAN be done better; just look at the vast majority of responses from student, resident, and attending in this thread. There's a lot of "Yep. That was useless" responses, and the like.
 
One problem is that no one really know what is going to be clinically important 20 or 30 years from now. It looks like a lot of that basic science is going to be more and more important (gene mapping for individualized patient care, using viruses to treat diseases etc.) Imagine if you didn't learn about those kinases and suddenly Gleevac comes on the market, you'd be less prepared to understand how it works.

I became a much bigger supporter of that first year "fluff" when I was on peds and we had a kid with a new onset urea acid cycle defect. Sure I needed to refresh myself but it took much much less time than trying to figure out what the urea acid cycle was or what those enzymes were.
 
3. Condensing MD/DO school will not make us "more like PA's"; it will allow us MORE time to learn MORE clinically relevant items and lock down better patient care. Its good for everyone; happier docs, more capable docs, and (most likely) better patient outcomes and satisfaction measures.

Medical education CAN be done better; just look at the vast majority of responses from student, resident, and attending in this thread. There's a lot of "Yep. That was useless" responses, and the like.

Uh, but that's the point of residency. Your entire argument seems to be based on the idea that freshly minted interns don't have enough practical clinical knowledge. Who cares? Freshly minted attendings do and that's all that matters.

And what's funny is that you seem to think the fact that people are saying elements of their education were useless supports your argument, but it actually refutes it. Because they're all saying DIFFERENT THINGS were useless. That's the price for a broad education, different people in different fields will only use particular parts of it.
 
Uh, but that's the point of residency. Your entire argument seems to be based on the idea that freshly minted interns don't have enough practical clinical knowledge. Who cares? Freshly minted attendings do and that's all that matters.

And what's funny is that you seem to think the fact that people are saying elements of their education were useless supports your argument, but it actually refutes it. Because they're all saying DIFFERENT THINGS were useless. That's the price for a broad education, different people in different fields will only use particular parts of it.

1. So it *wouldn't* be a good idea to have interns be more clinically capable? Seems like it would be good for the interns, the attendings, and the patients.

2. There's a lot that we're highlighting as useless here; and a lot of it is useless... therefore it has to go. If it doesn't, soon - medical school will be eleventeen years long, students will be in 4-5x the debt, and there will be more patients lining up wondering why there aren't enough doctors.
 
1. So it *wouldn't* be a good idea to have interns be more clinically capable? Seems like it would be good for the interns, the attendings, and the patients.

2. There's a lot that we're highlighting as useless here; and a lot of it is useless... therefore it has to go. If it doesn't, soon - medical school will be eleventeen years long, students will be in 4-5x the debt, and there will be more patients lining up wondering why there aren't enough doctors.

so, explain to me please. How this program would be different than a PA-program+residency?

(I hate this argument.... mark my words...our biggest problem is a distribution of physicians more than a lack of... what happened to law is going to happen to medicine without any thought process to pumping out as man doctors as possible (with no incenstives to practice in underserved areas).
 
Anyone ever make a clinical decision that was dependent on recalling that important TATA-box knowledge, or the structure of a sodium-ion channel? Didn't think so.

Be careful what you say in ignorance. I often do make decisions based some of the "fluff" of medical school. I can't count the number of times over the last 3 years, since completing residency, that I wish I had paid more attention in biochem and physiology.

Over the course of a month I will make decisions about patient treatments that rely on an understanding of channel structure and function, secondary messenger cascades, differences on pre vs post synaptic neurons, mixed function oxidases, plus other "fluff" from the basic science years.

Much of that clinical medicine is based in basic science. While you can memorize that patients in heart failure should be on a diuretic, ACEI, Bblocker and maybe spironolactone, understanding the role of catecholamines and the neurohumeral axis in CHF makes it much easier to optimize a difficult to treat patient.

Physicians need to be more than mere technicians. The book doesn't have an answer for all situations. Understanding "the why" behind clinical medicine helps the decision making process when the evidence and the book run out.
 
No, MDs are not scientists. They are consumers of scientific knowledge, not producers. I agree that they have to understand the relevant science, just like engineers have to understand physics, but that doesn't mean that engineers are physicists.

I'm sure the clinical research arm of many of the academic departments at your school will disagree. As will much of the scientific assembly at ACEP.
 
No, MDs are not scientists...
I've found there's a small subset of MD/PhDs (who give the rest a bad name) who think that their degrees grant them a stranglehold on research in medicine. That stance is funny because most of the medical research being done in this country is done by PhDs, many of whom think that anyone who hasn't done a straight PhD with three post-docs is just playing at being a scientist. Reality is, the degree doesn't matter - it's the experience of the researcher and the data they bring to the table. The rest is hot air.

Well, this is news to me. I must've woken up in bizzaro world...
Preach it, brother.

Seriously, I don't expect all MDs to be practicing scientists, but part of our training is to think critically and some of us will be scientists.

1. So it *wouldn't* be a good idea to have interns be more clinically capable? Seems like it would be good for the interns, the attendings, and the patients...
This argument would make sense if the following were true:

A) There were no attendings or senior residents overseeing the interns
B) The point of MD school was to produce fully functioning and independent practitioners

RustedFox - I'm actually more interested in knowing the specifics of your project. I am willing to debate and refine your idea here or offline.
 
I'm sure the clinical research arm of many of the academic departments at your school will disagree. As will much of the scientific assembly at ACEP.
Well, I am not saying that people with the MD degree don't do research. Obviously some do, but they have generally done this with training done independently or after med school. The MD is a clinical degree and it does not generally include research training. Physicians and scientists are not inherently the same. That's not a slam on either group, just a statement of fact.

EDIT: I don't want people to get carried away with this, I'm just saying there is a difference between learning about science (which all physicians do) and doing science (which relatively few physicians do). Training for the latter is not part of most MD programs.
 
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Reality is, the degree doesn't matter - it's the experience of the researcher and the data they bring to the table. The rest is hot air.
It is strange to me that you imply that clinical curricula and training are very important and worth discussing, and that inferior training (such as PA programs) cannot later be made up for by experience, but that for research, dedicated training is wholly irrelevant. Do you think that research is so much easier than clinical work?
 
It is strange to me that you imply that clinical curricula and training are very important and worth discussing, and that inferior training (such as PA programs) cannot later be made up for by experience, but that for research, dedicated training is wholly irrelevant. Do you think that research is so much easier than clinical work?
It takes talent to erect so many strawmen while backpedaling so quickly.

With respect to healthcare providers, I did not say anyone's training is inferior. I said that a defining difference between MDs and others is that we are trained to think and practice independently. (In retrospect, I should add clinical psychologists and a few others.)

With respect to scientists, I stated that experience and data matter. Going from mentored researcher->independent research = experience, and is path-independent.
 
From the movie Crimson Tide and I think aptly applying here:

Capt. Ramsey: Rickover gave me my command, a checklist, a target, and a button to push. All I had to know was how to push it, and they'd tell me when. They seem to want you know why.

Hunter: I would hope they'd want us all to know why, sir.


The difference between physicians and mid-levels/nurses is that we have to know why. Granted I know a lot of high-functioning, really skilled PAs, but the training is so different. The foundation we struggle through is designed to provide a basis for independent thought later on because you can't generalize every pt and treatment plan. We're not paid for just our knowledge/procedural ability/H&P wizardry, but instead are looked upon for clinical judgement. Everything else + the responsibility of being final and decisive decision makers has, and should continue to set us apart from the mid-levels.

That isn't to say that there isn't a role for NPs/PAs because they are an extremely useful component, but if they want to be doctors, then they're more than welcome to apply for medical school.
 
While you can memorize that patients in heart failure should be on a diuretic, ACEI, Bblocker and maybe spironolactone, understanding the role of catecholamines and the neurohumeral axis in CHF makes it much easier to optimize a difficult to treat patient.

Physicians need to be more than mere technicians. The book doesn't have an answer for all situations. Understanding "the why" behind clinical medicine helps the decision making process when the evidence and the book run out.

CHF is a fantastic example of why the "fluff" in med school is important. While the majority of patients will do well if you just follow a protocol there are some who wont fit into the box you try to put them in, and unless you understand how preload, afterload & stroke volume change cardiac output, the neurohormonal axis, chatecholamine receptor type, function, location, agonists, antagonists, pulmonary physiology, and many other things then good luck managing a hypotensive CHF'er who is in a fib with RVR.
 
Well, I am not saying that people with the MD degree don't do research. Obviously some do, but they have generally done this with training done independently or after med school. The MD is a clinical degree and it does not generally include research training.

The basis of your thinking is simply not true. All residency programs have some sort of "scholarly project" requirement. Many surgical and surgical sub residencies have an additional year or more, on top of the clinical years, for research. You have to walk into residency having clue about about research and the basics that go into it. My medical school had, as part of the cirriculum, some basic intro to research/biostats class.

Besides if you don't have a clue about research, how are you going to know if the paper you are reading is any good?
 
The only relatively useless stuff in med school, so far IMHO as an MS1, has been in anatomy. I mean, really... who the hell cares where the prostatic utricle is? Other than that, I can't imagine practicing medicine without the knowledge / understanding I'm gaining.

Here is my philosophy on life -- an especially life as a physician: if you don't know WHAT you're doing, you SHOULDN'T be doing it! And no, simple cause and effect knowledge is not enough.

I personally think that anybody who finds the foundational sciences of MS1/2 to be fluff is an absolute ***** who probably should be relegated to no higher than a mid-level position.

Having said that, I do have to HIGHLY agree that, at least my school (and I'm assuming many, many more) do us a disservice by having us learn from PhD's who can't tell the difference between clinically useful knowledge and useless garbage. I've had ridiculous professors ask me to parrot the names of researchers who developed certain experimental models which prove some clinically important physiologic mechanism. Now, the mechanism was important but knowing the name of the guy who did it is abso-freakin-lutely ridiculous and I felt like giving the guy a flying Liu Kang kick to the nuts and an austin powers judo chop to the penis from the 5th row during the exam when I read that stupid question. / rant
 
Perhaps the root of the problem is that teaching and preparing lectures is not as well reimbursed as the practice of medicine. It would be ideal for all core courses to be taught by a bench-side researcher/clinician team, who could maximize the clinical relevance, while providing a core understanding of how some of these concepts were discovered in the lab.

For example, wouldn't it be incredible to have a surgeon teaching groin anatomy and to have them point out the importance of the landmarks in placing central lines? At the same time, wouldn't the input of a bench-side researcher who DOES PCR be important in discussing genetics? (ideally, with the input of a clinical geneticist.)
Really, all we need is this: textbooks tailored to medical students looking to pass step 1. Then, have any low-level grad student lecture on the textbook material.

The textbooks that I've used which are geared toward Step 1 are amazing, far better than anything I've ever had prepped by any professor. And, once the foundation is laid (i.e. chapters, content, etc), it should be pretty damn easy for someone to teach/answer questions.
 
Really, all we need is this: textbooks tailored to medical students looking to pass step 1. Then, have any low-level grad student lecture on the textbook material.

Just wrong.

This job is immensely technical and requires very rapid decision making. Some of the patients I see require very little more than a protocol based decision rubric. The complex, very sick patient with aortic stenosis, ESRD, AIDS and advanced rectal cancer presenting with tachypnea and hypotension cannot be well served by reading a flow diagram you have printed from from uptodate. They will die before you find the "you are here" point & try to move on. The more you understand, the faster you can anticipate and act instead of haphazardly reacting. It really does matter.
Studying oriented to pass/ace step1/2/3 is at best misguided. They are a bare minimum standard for advancing through your medical education. The point of the medical education is to have a very broad based foundation. If you want to learn different things in medical school you have ample time in your 1st,2nd and 4th years to do so. If you want to learn less, strongly reconsider you career choice.
 
Studying oriented to pass/ace step1/2/3 is at best misguided. They are a bare minimum standard for advancing through your medical education.

Actually, the Steps are hardly a bare minimum, they are the most important things in medical school. You may disagree with that, but obviously the medical education establishment disagrees with you. Doing poorly will affect the trajectory of your entire career, and not passing means an end to your career.

Not specifically directing your study effort towards them is a really stupid move.
 
Just wrong.

This job is immensely technical and requires very rapid decision making. Some of the patients I see require very little more than a protocol based decision rubric. The complex, very sick patient with aortic stenosis, ESRD, AIDS and advanced rectal cancer presenting with tachypnea and hypotension cannot be well served by reading a flow diagram you have printed from from uptodate. They will die before you find the "you are here" point & try to move on. The more you understand, the faster you can anticipate and act instead of haphazardly reacting. It really does matter.

Studying oriented to pass/ace step1/2/3 is at best misguided. They are a bare minimum standard for advancing through your medical education. The point of the medical education is to have a very broad based foundation. If you want to learn different things in medical school you have ample time in your 1st,2nd and 4th years to do so. If you want to learn less, strongly reconsider you career choice.
What about studying in order to pass Step 1 doesn't involve learning the material? Much like the MCAT, I'd say that learning to answer board questions involves a MUCH greater understanding of the material than simply regurgitating old test material from some PhD who likes to ask questions on clinically erroneous trivia. The question-writers will not test you on detail, but they make sure you can connect dots and come to logical conclusions. In fact, I'd say that the step material is "technical and requires very rapid decision making". Sure, there are some people who crack under pressure, but I'm positive that, at least step one, does a great job sorting people out by their level of understanding and ability to make quick, logical decisions.

And, just for the sake of completeness, I'll repeat my experience so far after having been taught my basic science medical education by somewhere in the realm of 40 PhD's: Despite the fact that many of them are brilliant and do amazing work, their questions are usually thoughtless, highly recycled (and therefore memorized by students), and often ridiculously trivial.
 
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Actually, the Steps are hardly a bare minimum, they are the most important things in medical school. You may disagree with that, but obviously the medical education establishment disagrees with you. Doing poorly will affect the trajectory of your entire career, and not passing means an end to your career.

Not specifically directing your study effort towards them is a really stupid move.

You have got to get some perspective on this. Medical school is not a means to more school & higher test scores, it is basic training to prepare your for a job.

I agree, doing poorly will affect your career - it should. It means you couldn't even get it together enough to meet a minimum standard. Failure on anything in medical school raises a huge red flag about a your maturity level, flakeyness, time management, intelligence, life situation, etc. This isn't a pyramidal system anymore, it is designed for you to learn & pass through successfully.

You are missing the point that the M1 and M2 years are designed and standardized to teach you the basic knowledge that is tested on Step 1. You really shouldn't have to put much more effort in. If you do you just aren't learning what you are supposed to be.

As someone who has been through this already scores are just plain overhyped. Especially in this forum of all places.
 
You have got to get some perspective on this. Medical school is not a means to more school & higher test scores, it is basic training to prepare your for a job.

I agree, doing poorly will affect your career - it should. It means you couldn't even get it together enough to meet a minimum standard. Failure on anything in medical school raises a huge red flag about a your maturity level, flakeyness, time management, intelligence, life situation, etc. This isn't a pyramidal system anymore, it is designed for you to learn & pass through successfully.

You are missing the point that the M1 and M2 years are designed and standardized to teach you the basic knowledge that is tested on Step 1. You really shouldn't have to put much more effort in. If you do you just aren't learning what you are supposed to be.

As someone who has been through this already scores are just plain overhyped. Especially in this forum of all places.

Look, I hear what you're saying. But you need to get some perspective on your past. It's easy to wax eloquent on challenges you've already successfully tackled. But to those who haven't yet passed these hurdles, all this talk is academic. Step 1 is their very livelihood. No flowery language changes that fact.
 
Look, I hear what you're saying. But you need to get some perspective on your past. It's easy to wax eloquent on challenges you've already successfully tackled. But to those who haven't yet passed these hurdles, all this talk is academic. Step 1 is their very livelihood. No flowery language changes that fact.

OK fine, have all the angst you want about it. It still isn't worth it.
 
Actually, the Steps are hardly a bare minimum, they are the most important things in medical school. You may disagree with that, but obviously the medical education establishment disagrees with you. Doing poorly will affect the trajectory of your entire career, and not passing means an end to your career.

Not specifically directing your study effort towards them is a really stupid move.

You have got to get some perspective on this. Medical school is not a means to more school & higher test scores, it is basic training to prepare your for a job.

I agree, doing poorly will affect your career - it should. It means you couldn't even get it together enough to meet a minimum standard. Failure on anything in medical school raises a huge red flag about a your maturity level, flakeyness, time management, intelligence, life situation, etc. This isn't a pyramidal system anymore, it is designed for you to learn & pass through successfully.

You are missing the point that the M1 and M2 years are designed and standardized to teach you the basic knowledge that is tested on Step 1. You really shouldn't have to put much more effort in. If you do you just aren't learning what you are supposed to be.

As someone who has been through this already scores are just plain overhyped. Especially in this forum of all places.

Look, I hear what you're saying. But you need to get some perspective on your past. It's easy to wax eloquent on challenges you've already successfully tackled. But to those who haven't yet passed these hurdles, all this talk is academic. Step 1 is their very livelihood. No flowery language changes that fact.

It's actually kind of interesting how MS-1's and MS-2's are speaking about what part of their education IS and what ISN'T "clinically relevant" and what IS "fluff" as they have NO idea how to answer that and will not until they actually get in a clinical setting and see it first hand. I am a 2nd year resident and I am still figuring out what IS and IS NOT relevant out of what I learned in 1st 2 year of medical school. This is something one learns from experience and after making hard and quick decisions regarding patient care and not just answering a few well-made STEP 1 questions.

I agree that STEP 1 (along with STEP 2) is important, but not because it tests your "minimum ability and knowledge." It's important because the medical establishment made it important by deciding to weed out residency applicants based on the results (along with other factors). Don't get me wrong, I think it's a hard exam and you need to know a lot to do well, but scoring well on some standardized test doesn't mean that you will know what to do when the crap hits the fan and you're standing in front of a patient who you're incharge of and that patient is crashing. I've seen many residents that had amazing USMLE scores, had absolutely ZERO common sense and made horrible mistakes (knowledge based mistakes) regarding patient care that medical students should know. I've also seen doctors who had average and barely passing scores on these exams that were great physicians and knew what to do and how to treat their patient.

In the end, it's ultimately up to the person to make sure that they learn what they should know so that they don't hurt their future patients. This is not just for medical school, but goes for residency and practice. It's a continuous process and we never stop learning. Yes, when you are a resident and/or attending you'll realize that a lot of things that you were taught in med school was "fluff", but as long as you learn what's important (you'll know what this is later in the process), you'll be OK.
 
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