Medical Education: Toxic?

[Angler]

@Goro

Q&A with Goro

In the above interview, you indicate that Medical Education has become more toxic in the last ten years. Could you briefly elaborate? Do you mean the process of actually getting into Medical School, which is certainly as full of toxicity as a Dig level of 5?

Or during Medical School itself? I've precepted M3 & M4 Medical Students over the years who rotated through my outpatient HMO primary care clinic (not officially affiliated with a Medical School), and they seem very happy and very well prepared. Certainly more prepared than I was at that level, eons ago. I'm biased, but I am far from a toxic teacher.

I also devoted about 1/10th of my working time to outpatient teaching to our Internal Medicine Residents (again this was not a Medical School Residency but at our independent HMO Internal Medicine Residency), and they were similarly happy (and treated more humanely than I was treated 35 years ago during my Internal Medicine Residency). Again, I don't believe I was a toxic teacher.

I'm not disputing your statement at all. Medical Education has a lot of room for improvement (so does Health Care in this country overall).

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[srirachamayonnaise]

@Goro

Q&A with Goro

In the above interview, you indicate that Medical Education has become more toxic in the last ten years. Could you briefly elaborate? Do you mean the process of actually getting into Medical School, which is certainly as full of toxicity as a Dig level of 5?

Or during Medical School itself? I've precepted M3 & M4 Medical Students over the years who rotated through my outpatient HMO primary care clinic (not officially affiliated with a Medical School), and they seem very happy and very well prepared. Certainly more prepared than I was at that level, eons ago. I'm biased, but I am far from a toxic teacher.

I also devoted about 1/10th of my working time to outpatient teaching to our Internal Medicine Residents (again this was not a Medical School Residency but at our independent HMO Internal Medicine Residency), and they were similarly happy (and treated more humanely than I was treated 35 years ago during my Internal Medicine Residency). Again, I don't believe I was a toxic teacher.

I'm not disputing your statement at all. Medical Education has a lot of room for improvement (so does Health Care in this country overall).

Tbh, I don't think Goro is involved in any clinical teaching.(some hints such as industry vs academia in the interview point to the fact that it's not an MD or DO talking. Phd's talk about industry all the time).I don't know where goro got the idea that medical education is toxic. So far, my experience has been quite positive, so have my friends' experiences. We are quite content with pass/fail and low stress environment and furthermore I really enjoy the clinical learning with great clinicians who are really willing to teach. I hate to say that that last question about giving advice to people who want to go into academia doesn't generate an answer that's relevant to academic medicine at all. It's a PhD answering that question...I have no problem with PhD's teaching med students, but they simply don't have any clue how medicine works.

 

[operaman]

Not sure what he means specifically. It definitely wasn’t toxic to me but then again my entire med school and residency and fellowship experience was pretty idyllic all things considered.

I’m not sure if toxicity is the word I would use, but it does seem that students have become less and less of a priority over the last 10 years. Some of this came out of trying to relieve students of scut work and blatant abuse by overworked residents, but also made them less useful to a team in a practical sense. Many hospitals have curtailed what students are allowed to do - ie they have phlebotomy teams getting morning labs whereas that used to be a student job. Many schools restrict students from doing much of anything to a patient.

And then maybe the biggest impact has been the EMR which really locks students out and locks faculty in. There’s a big push for more and more productivity from MDs since they’re the gatekeepers of revenue for big systems, but this incentive structure rewards clinical rvu output far more than teaching. So students become an afterthought.

Rather than toxic, I think the student environment has gone so far the other direction that’s it’s become anemic. For many the clinical years have become a long shadowing experience. I always love the looks from students who rotate with me in the OR - they reach for the suction and retractor which I promptly take out of their hands and hand them a knife and pickup and say “gonna take way too long for you to do this case with a suction!” Ideally those kinds of experience should be the norm, but I think they’re becoming even more rare.

 

[Rapsidy]

Not sure what he means specifically. It definitely wasn’t toxic to me but then again my entire med school and residency and fellowship experience was pretty idyllic all things considered.

I’m not sure if toxicity is the word I would use, but it does seem that students have become less and less of a priority over the last 10 years. Some of this came out of trying to relieve students of scut work and blatant abuse by overworked residents, but also made them less useful to a team in a practical sense. Many hospitals have curtailed what students are allowed to do - ie they have phlebotomy teams getting morning labs whereas that used to be a student job. Many schools restrict students from doing much of anything to a patient.

And then maybe the biggest impact has been the EMR which really locks students out and locks faculty in. There’s a big push for more and more productivity from MDs since they’re the gatekeepers of revenue for big systems, but this incentive structure rewards clinical rvu output far more than teaching. So students become an afterthought.

Rather than toxic, I think the student environment has gone so far the other direction that’s it’s become anemic. For many the clinical years have become a long shadowing experience. I always love the looks from students who rotate with me in the OR - they reach for the suction and retractor which I promptly take out of their hands and hand them a knife and pickup and say “gonna take way too long for you to do this case with a suction!” Ideally those kinds of experience should be the norm, but I think they’re becoming even more rare.

I also have a feeling the limiting of what students can do is most correlated to lawyers. Medicine seems so litigious I could easily see someone saying they suffered battery and permanent psychological harm because a hospital irresponsibly!!! let a UNTRAINED student maul me with a needle!!!

 

[operaman]

I also have a feeling the limiting of what students can do is most correlated to lawyers. Medicine seems so litigious I could easily see someone saying they suffered battery and permanent psychological harm because a hospital irresponsibly!!! let a UNTRAINED student maul me with a needle!!!

I think that’s surely part of it. Another part is the propagation of various QI committees. It’s awfully challenging to fix real problems in a complex system like healthcare. It’s much easier to invent a problem that’s not actually a problem and then solve that instead.

I think this is largely what has happened to medical students. There wasn’t some epidemic of student led harm to patients; rather, a committee of nurses and administrators decided to fix a non-problem.

 

[Goro]

Yes on the phD, teaching at the preclinical level. That does not negate my experience at seeing what happens to students, Nor does it make me ignorant of what's going on in the 3rd and 4th years. one does not have to be a chicken to know something about eggs


By toxicity, I mean that medical education has become more stressful. As I like to point out, medical school could break even healthy students. It certainly can hurt those students who have preexisting mental health issues, or who have not fully developed the coping skills


Boards going pass fail is a step in the right direction at helping alleviate some of the stress, As do pass fail curricula



.

 

[srirachamayonnaise]

Yes on the phD, teaching at the preclinical level. That does not negate my experience at seeing what happens to students, Nor does it make me ignorant of what's going on in the 3rd and 4th years. one does not have to be a chicken to know something about eggs


By toxicity, I mean that medical education has become more stressful. As I like to point out, medical school could break even healthy students. It certainly can hurt those students who have preexisting mental health issues, or who have not fully developed the coping skills


Boards going pass fail is a step in the right direction at helping alleviate some of the stress, As do pass fail curricula



.

I don’t endorse second hand statement. It’s not more stressful at all compared to 5 years ago. Everything is more or less pass/fail. And the remediation is a lot more lenient. We have a direct line to the leadership for med student abuse report. The stress associated with matching into a competitive specialty is always there. But that’s not toxicity.

TLDR: Stress =\ toxicity.

 

[Med Ed]

There’s a big push for more and more productivity from MDs since they’re the gatekeepers of revenue for big systems, but this incentive structure rewards clinical rvu output far more than teaching. So students become an afterthought.

The issue is complex (of course), but this is the single biggest factor by a good margin.

Thank way back to the days before DRGs and work hour restrictions. Everyone lived in the hospital, and the margins were solid.

Contrast this to the modern environment of outpatient medicine, ambulatory surgery centers, hospitalists, mergers, RVUs, and ruthless efficiency, all in the face of spiraling costs. There is little space for medical students in any of this. Systems (read HCA) have a strong incentive to build GME programs as physician pipelines, but UME isn't much of a priority, and I'm not sure if/when that will change.

 

[Angler]

By toxicity, I mean that medical education has become more stressful.

This is a "for sure," just in terms of the sheer amount of knowledge one needs to acquire. And much of that knowledge will be wrong, just a few years later. "Half of what you learn in Medical School is wrong. We just don't know which half." It's important to teach problem solving techniques, and also teach WHERE to find the knowledge that you don't know.

Despite the stress, many would do almost anything to subject themselves to the torture...

 

[DarkBluMage]

I don’t endorse second hand statement. It’s not more stressful at all compared to 5 years ago. Everything is more or less pass/fail. And the remediation is a lot more lenient. We have a direct line to the leadership for med student abuse report. The stress associated with matching into a competitive specialty is always there. But that’s not toxicity.

TLDR: Stress =\ toxicity.

Keep in mind that every school is not P/F and not every school has lenient remediation options either.

 

[Angler]

Boards going pass fail is a step in the right direction at helping alleviate some of the stress, As do pass fail curricula

My daughter is currently in the 2022-2023 cycle for Medical School admissions. She thinks that P/F boards makes it more stressful as a premed as one needs to get into the best school (highest ranked), in order to get into a desirable residency program. Once you've matriculated, I would guess that the tension is eased. Fortunately, she's gotten a T30 A (a very good school by the way), but she is anxious about two higher ranked schools that she's interviewed with but not heard from since. I think her anxiety is unreasonable, but she's more stubborn than her parents, which is pretty bad. This is toxicity.

She's a good kid. I'm not throwing her under the bus. She just wants to keep her options open in case she wants to be a heart surgeon, or whatever.

 

[DarkBluMage]

My daughter is currently in the 2022-2023 cycle for Medical School admissions. She thinks that P/F boards makes it more stressful as a premed as one needs to get into the best school (highest ranked), in order to get into a desirable residency program. Once you've matriculated, I would guess that the tension is eased. Fortunately, she's gotten a T30 A (a very good school by the way), but she is anxious about two higher ranked schools that she's interviewed with but not heard from since. I think her anxiety is unreasonable, but she's more stubborn than her parents, which is pretty bad. This is toxicity.

She's a good kid. I'm not throwing her under the bus. She just wants to keep her options open in case she wants to be a heart surgeon, or whatever.

I disagree. There’s a lot more that goes into matching that a student can control besides going to a highly ranked medical school. Step 1 going P/F is a net benefit. Not having a good enough score on step 1 essentially locked students out of certain medical specialties. Prepared your entire med school app towards a competitive specialty and then had a bad day on your exam day and did poorly? Oh well, that specialty isn’t a reality for you any longer. Step 1 performance is affected by curriculum, but it’s also more on the student with how well they perform. Going to a high ranked school doesn’t equate to amazing step 1 scores. Going to a high ranked med school does help with residency matching, but it’s ultimately on the student, their performance during med school/interviews, and the decisions they make if they’ll actually match where/what they want or not. Step 1 P/F is much better for students and their prospective career paths.

 

[Dantes]

My experience is that medical education still has toxic elements and a lot of leaders in ivory tower academia are really out of touch, partially due to never having a job outside of medicine. However, compared to the past, it's probably the least toxic it's ever been and keeps getting better. But on the flip side, stress is ever increasing. All specialties getting more competitive due to school expansion, more debt, more hoops to jump through, pay not increasing enough with inflation, etc.

 

[srirachamayonnaise]

My daughter is currently in the 2022-2023 cycle for Medical School admissions. She thinks that P/F boards makes it more stressful as a premed as one needs to get into the best school (highest ranked), in order to get into a desirable residency program. Once you've matriculated, I would guess that the tension is eased. Fortunately, she's gotten a T30 A (a very good school by the way), but she is anxious about two higher ranked schools that she's interviewed with but not heard from since. I think her anxiety is unreasonable, but she's more stubborn than her parents, which is pretty bad. This is toxicity.

She's a good kid. I'm not throwing her under the bus. She just wants to keep her options open in case she wants to be a heart surgeon, or whatever.

tell her cardiothoracic surgery is totally achievable from a t30. Worse comes worst, she just has to go through GS and then sub specialize if she can't get into an integrated program.

 

[srirachamayonnaise]

Keep in mind that every school is not P/F and not every school has lenient remediation options either.

that's more of an exception than the rule nowadays at USMD schools.

 

[operaman]

Yes on the phD, teaching at the preclinical level. That does not negate my experience at seeing what happens to students, Nor does it make me ignorant of what's going on in the 3rd and 4th years. one does not have to be a chicken to know something about eggs


By toxicity, I mean that medical education has become more stressful. As I like to point out, medical school could break even healthy students. It certainly can hurt those students who have preexisting mental health issues, or who have not fully developed the coping skills


Boards going pass fail is a step in the right direction at helping alleviate some of the stress, As do pass fail curricula



.

Not only is it more stressful, it’s a different kind of stress. And that’s been added on the baseline level of stress that comes with a high stakes profession. I obsess and worry about every patient I operate on no matter how small the case. I can’t help it. It’s just a hugely important thing and I can really hurt people. Nothing short of retirement will remove that stress.

I think students today face a number of additional stresses that form the pressure cooker of medical training:

1) residency more competitive. Long gone are the days when you could do anything you wanted with a solid performance in Med school. When the matched and unmatched stats are nearly identical, you know things have gotten tougher. I frequently hear attendings in my field remark how their applications wouldn’t even survive the pre screen nowadays. Even mine that was pretty foolproof 8 years ago is slowly getting closer to average.

2) debt levels higher. Self explanatory, and can make people feel trapped as they get further along.

3) increased diversity. While many med students are affluent children of physicians, more and more are coming from non medical backgrounds and have less support and fewer resources. There have been some great articles about this in recent years - the trouble with bringing so many marginalized voices into medical school without adequate support systems to help them navigate it. Med Ed has always been easier for white guys like me, is getting better for women, but can riddled with challenges for different races, the disabled, etc., and medical training is not good at adapting to new things. Sure the preclinical years may be able to wokeify the curriculum a bit, but that goes right out the window once students hit the wards. And by then they have lots of debt and fewer residency prospects than kids 10 years ago.

4) students more of an afterthought nowadays versus 10-20 years ago as I discussed in a post above.

5) fewer prospects outside of medicine. Despite all the tales of everyone’s college roommate starting off in silicone valley making seven figures, the truth is that medicine is a very unique gateway to a better life for most of the country. Even the lowest ranked med schools can lead to a solid professional income - compare that to bottom tier law and mba schools - and many students rightly feel like medicine is the best and possibly only shot.

I’m sure there are more but these are what first come to mind.

 

[srirachamayonnaise]

Not only is it more stressful, it’s a different kind of stress. And that’s been added on the baseline level of stress that comes with a high stakes profession. I obsess and worry about every patient I operate on no matter how small the case. I can’t help it. It’s just a hugely important thing and I can really hurt people. Nothing short of retirement will remove that stress.

I think students today face a number of additional stresses that form the pressure cooker of medical training:

1) residency more competitive. Long gone are the days when you could do anything you wanted with a solid performance in Med school. When the matched and unmatched stats are nearly identical, you know things have gotten tougher. I frequently hear attendings in my field remark how their applications wouldn’t even survive the pre screen nowadays. Even mine that was pretty foolproof 8 years ago is slowly getting closer to average.

2) debt levels higher. Self explanatory, and can make people feel trapped as they get further along.

3) increased diversity. While many med students are affluent children of physicians, more and more are coming from non medical backgrounds and have less support and fewer resources. There have been some great articles about this in recent years - the trouble with bringing so many marginalized voices into medical school without adequate support systems to help them navigate it. Med Ed has always been easier for white guys like me, is getting better for women, but can riddled with challenges for different races, the disabled, etc., and medical training is not good at adapting to new things. Sure the preclinical years may be able to wokeify the curriculum a bit, but that goes right out the window once students hit the wards. And by then they have lots of debt and fewer residency prospects than kids 10 years ago.

4) students more of an afterthought nowadays versus 10-20 years ago as I discussed in a post above.

5) fewer prospects outside of medicine. Despite all the tales of everyone’s college roommate starting off in silicone valley making seven figures, the truth is that medicine is a very unique gateway to a better life for most of the country. Even the lowest ranked med schools can lead to a solid professional income - compare that to bottom tier law and mba schools - and many students rightly feel like medicine is the best and possibly only shot.

I’m sure there are more but these are what first come to mind.

I agree with all the points except for 5. If you are a surgeon, point 5 is valid. Very few exit strategies for operative fields. But if you do a quick IM and then some sort of medical oncology or whatnot, there are many outlets. For one, big pharma hires MD's all the time with big dollars and nice lifestyle. Heme/onc, ID, and neurology and even pscyh people can do that fairly easily. You may start at a smaller salary but the upside is very very attractive. Secondly, you don't have to be an entrepreneur yourself. Many MD's get on the boards of start-ups and make good money. You just have to be creative and smart about it. That's also why MBA is so popular among MD's nowadays. In short, if you can't make a good living with an MD, you are doing something wrong.

 

[Billiam95]

I disagree. There’s a lot more that goes into matching that a student can control besides going to a highly ranked medical school. Step 1 going P/F is a net benefit. Not having a good enough score on step 1 essentially locked students out of certain medical specialties. Prepared your entire med school app towards a competitive specialty and then had a bad day on your exam day and did poorly? Oh well, that specialty isn’t a reality for you any longer. Step 1 performance is affected by curriculum, but it’s also more on the student with how well they perform. Going to a high ranked school doesn’t equate to amazing step 1 scores. Going to a high ranked med school does help with residency matching, but it’s ultimately on the student, their performance during med school/interviews, and the decisions they make if they’ll actually match where/what they want or not. Step 1 P/F is much better for students and their prospective career paths.

I think one benefit to a scored step1 was that people know how competitive they were at the end of their 2nd year and had time to adjust their expectations/application accordingly. Now, we won't find out how competitive we are until the beginning of our 4th year when home AIs, aways have already been scheduled. What does someone gunning for a surgical sub do if their only 3 digit score is a 230 step2?

 

[DOVinciRobot]

I disagree. There’s a lot more that goes into matching that a student can control besides going to a highly ranked medical school. Step 1 going P/F is a net benefit. Not having a good enough score on step 1 essentially locked students out of certain medical specialties. Prepared your entire med school app towards a competitive specialty and then had a bad day on your exam day and did poorly? Oh well, that specialty isn’t a reality for you any longer. Step 1 performance is affected by curriculum, but it’s also more on the student with how well they perform. Going to a high ranked school doesn’t equate to amazing step 1 scores. Going to a high ranked med school does help with residency matching, but it’s ultimately on the student, their performance during med school/interviews, and the decisions they make if they’ll actually match where/what they want or not. Step 1 P/F is much better for students and their prospective career paths.

This is only true in a world where Step 2 doesn’t exist….

 

[DarkBluMage]

This is only true in a world where Step 2 doesn’t exist….

Not true, I’ve heard first hand of this happening. Step 2 would essentially have to salvage their app but if they only do decent in step 2 and not amazing then nothing changed. Doing poorly on step 1 pretty much was a determinant for if competitive specialties were realistic vs scrambling to prepare an app for another field. At that point students were faced with staying the course and banking on step 2 vs trying to find another speciality to not risk going unmatched.

 

[DarkBluMage]

I think one benefit to a scored step1 was that people know how competitive they were at the end of their 2nd year and had time to adjust their expectations/application accordingly. Now, we won't find out how competitive we are until the beginning of our 4th year when home AIs, aways have already been scheduled. What does someone gunning for a surgical sub do if their only 3 digit score is a 230 step2?

That’s only under the assumption that all PD’s will only be relying singularly on step 2. None of us know the effect of step 1 being P/F yet in how apps are evaluated by PD’s. It’ll be interesting to see how things change. Makes me wonder if step 2 will eventually be P/F as well. Step 1 being P/F isn’t a perfect thing but I do believe that it’s a net benefit for medical students.

 

[DOVinciRobot]

Not true, I’ve heard first hand of this happening. Step 2 would essentially have to salvage their app but if they only do decent in step 2 and not amazing then nothing changed. Doing poorly on step 1 pretty much was a determinant for if competitive specialties were realistic vs scrambling to prepare an app for another field. At that point students were faced with staying the course and banking on step 2 vs trying to find another speciality to not risk going unmatched.

That’s only under the assumption that all PD’s will only be relying singularly on step 2. None of us know the effect of step 1 being P/F yet in how apps are evaluated by PD’s. It’ll be interesting to see how things change. Makes me wonder if step 2 will eventually be P/F as well. Step 1 being P/F isn’t a perfect thing but I do believe that it’s a net benefit for medical students.

We do know how apps are evaluated…. PDs have openly stated Step 2 is the new bench marker…

This is off topic so I won’t say anything further in this thread, but Step 2 is the new Step 1. PDs are already treating them the same and employing Step 2 filters with just as much gusto.. Doing poorly on Step 2 is just as much a determinant as Step 1 was but changing course after a Step 2 is basically impossible whereas it actually was fairly easy with Step 1. Thinking that isn’t the case is just wishful thinking.

 

[Mr.Smile12]

I had a different seat at this table, but from what I can see, the forces changing medical education and higher education remain the same when it comes to constrained funding, increased load, small application pools, and pressure from midlevels and scope creep. Universities don't make money from medical school yet it is expected that they do break even in the budget. Academia is also turning more to fewer tenure track instructors to cut costs, so across the board, fewer incentives are there to mentor students or junior faculty.

 

[srirachamayonnaise]

I had a different seat at this table, but from what I can see, the forces changing medical education and higher education remain the same when it comes to constrained funding, increased load, small application pools, and pressure from midlevels and scope creep. Universities don't make money from medical school yet it is expected that they do break even in the budget. Academia is also turning more to fewer tenure track instructors to cut costs, so across the board, fewer incentives are there to mentor students or junior faculty.

Again this post shows how little non-MD’s understand the medical field. In academic medicine, there’s no tenure track. Everyone is essentially a contractor. PhD’s in science have always been a very very unattractive career path due to the exploitation from senior faculty and the schools.

I appreciate that non-MD’s sitting on adcom or advising premeds share their experience. But please don’t just don’t impart knowledge of practice of medicine or the economics of medicine from a second hand point of view, or pure speculation.

Most MD schools are part of the health system, so no they are not expected to break even on their own. Faculty members, who are MD’s, generate income for the system already through seeing patients and part of the revenue stream from the health system goes into running the medical school. The only cost center for medical schools are pure PhD’s who teach pre-clinical. Even that, medical schools of large health systems have stopped hiring full time PhD lecturers because the graduate division of the medical system can supply high quality PhD part time.

In short, medical schools of large health system are not run like a typical school. Again, DO schools and low tier MD schools without the backing of a health system heavily rely on PhD instructors to fulfill the teaching duty. But that’s not the majority. And that’s not the place academic physicians are trained. They are run on the vocational school model.

 

[DarkBluMage]

We do know how apps are evaluated…. PDs have openly stated Step 2 is the new bench marker…

This is off topic so I won’t say anything further in this thread, but Step 2 is the new Step 1. PDs are already treating them the same and employing Step 2 filters with just as much gusto.. Doing poorly on Step 2 is just as much a determinant as Step 1 was but changing course after a Step 2 is basically impossible whereas it actually was fairly easy with Step 1. Thinking that isn’t the case is just wishful thinking.

Agree to disagree

 

[Ho0v-man]

We do know how apps are evaluated…. PDs have openly stated Step 2 is the new bench marker…

This is off topic so I won’t say anything further in this thread, but Step 2 is the new Step 1. PDs are already treating them the same and employing Step 2 filters with just as much gusto.. Doing poorly on Step 2 is just as much a determinant as Step 1 was but changing course after a Step 2 is basically impossible whereas it actually was fairly easy with Step 1. Thinking that isn’t the case is just wishful thinking.

Agree 100%. PDs care about these numbers. Even at my rural community prelim year, the committee would rank applicants they liked lower if their scores were low. And we’ve always been conditioned to believe these types of places don’t care about that stuff. For competitive programs, it’s completely shifted to Step 2.

The only thing that makes it potentially easier is that programs need a little time to figure out what a good score on step 2 really is. This is complicated by step 1 being p/f and applicants just not having the same knowledge base/study strategies (work ethic?) that they had before.

The definition of a good step 2 score will probably change a lot the next couple years. The “good” scores the med students at my program are shooting for are laughably low compared to what we were grinding for a couple years ago.

 

[Captain_Falcon]

Agree 100%. PDs care about these numbers. Even at my rural community prelim year, the committee would rank applicants they liked lower if their scores were low. And we’ve always been conditioned to believe these types of places don’t care about that stuff. For competitive programs, it’s completely shifted to Step 2.

The only thing that makes it potentially easier is that programs need a little time to figure out what a good score on step 2 really is. This is complicated by step 1 being p/f and applicants just not having the same knowledge base/study strategies (work ethic?) that they had before.

The definition of a good step 2 score will probably change a lot the next couple years. The “good” scores the med students at my program are shooting for are laughably low compared to what we were grinding for a couple years ago.

I would wager PDs are familiar already with what a good step score is since there are annual percentiles reported for them right?

 

[acapnial]

Agree 100%. PDs care about these numbers. Even at my rural community prelim year, the committee would rank applicants they liked lower if their scores were low. And we’ve always been conditioned to believe these types of places don’t care about that stuff. For competitive programs, it’s completely shifted to Step 2.

The only thing that makes it potentially easier is that programs need a little time to figure out what a good score on step 2 really is. This is complicated by step 1 being p/f and applicants just not having the same knowledge base/study strategies (work ethic?) that they had before.

The definition of a good step 2 score will probably change a lot the next couple years. The “good” scores the med students at my program are shooting for are laughably low compared to what we were grinded for a couple years ago.

Definitely. Toward the end of my residency when step 1 was announced to become P/F I talked to my own PD and the local TY PD and both felt they would have no choice but to emphasize step 2 scores in the same way step 1 used to be. My last year in my program, they got around 5000 applicants for 36 positions if you include prelims. There's really no fair and realistic way to pare down those kinds of numbers without something like a step score cutoff. Even if Step 2 goes P/F programs will probably shift to shelf scores or, or maybe even develop another big standardized test and start requiring it.

 

[Esmolol]

It’s toxic in the sense that as a medical student you’re just a nuisance, a “lesser being” in the hospital. Attendings and residents have this fake “we care about you” and “want you to succeed” approach but really you can tell they just wish we weren’t there. Nursing staff - just plain simply open about not wanting us there. Really the only people I relate to are the door security people and environmental services people.

Great example (one of many) - I’m walking with my gloves and gown, 5 yards from the scrub table, ready to hand them to the scrub tech. They yell at me - “Whoa!” I say - “what?” And they go - “I don’t like the way you’re walking…” I was 5 yards away, not even close to contaminating anything. It almost felt like they just needed a way to assert that they were superior to a med student. Any way would do.

I get the hierarchy - attending > resident >>>>> med student. It's already tough to keep up with that and take the crap day after day but why

I'm in school to learn. I know that I don't know anything. I can't even fake it that I know something.

 

[srirachamayonnaise]

It’s toxic in the sense that as a medical student you’re just a nuisance, a “lesser being” in the hospital. Attendings and residents have this fake “we care about you” and “want you to succeed” approach but really you can tell they just wish we weren’t there. Nursing staff - just plain simply open about not wanting us there. Really the only people I relate to are the door security people and environmental services people.

Great example (one of many) - I’m walking with my gloves and gown, 5 yards from the scrub table, ready to hand them to the scrub tech. They yell at me - “Whoa!” I say - “what?” And they go - “I don’t like the way you’re walking…” I was 5 yards away, not even close to contaminating anything. It almost felt like they just needed a way to assert that they were superior to a med student. Any way would do.

I get the hierarchy - attending > resident >>>>> med student. It's already tough to keep up with that and take the crap day after day but why

I'm in school to learn. I know that I don't know anything. I can't even fake it that I know something.

it's just a year or two at most. who cares. It's kind of ironic if there were no med students, where would they get new doctors? I think people just like to have some ego trip over others. Just think that everyone with an MD has to go through this process, then you will stop caring. The only ones in med school who have a real problem with the setup of a workplace and considering it's toxic are most likely people who went straight through from undergrad who really never worked a day in their life. Anyone who has worked full-time wouldn't be bothered by those little things.

 

[Ho0v-man]

I would wager PDs are familiar already with what a good step score is since there are annual percentiles reported for them right?

I thought percentiles on step 2 were only estimates and NBME didn’t release the real percentiles anymore. Maybe I’m misremembering.

I’m sure a lot are. But a lot think step 1 and 2’s estimated percentiles are similar/the same and they’re not. My percentile went down on step 2, but the number was higher so it was still considered good.

But step 2 scores meaning might become a bit of a black box for a little while. Scores could go down because people aren’t grinding as hard in preclinical. But they could go up because the test actually matters now.

 

[throwaway123342]

I disagree. There’s a lot more that goes into matching that a student can control besides going to a highly ranked medical school. Step 1 going P/F is a net benefit. Not having a good enough score on step 1 essentially locked students out of certain medical specialties. Prepared your entire med school app towards a competitive specialty and then had a bad day on your exam day and did poorly? Oh well, that specialty isn’t a reality for you any longer. Step 1 performance is affected by curriculum, but it’s also more on the student with how well they perform. Going to a high ranked school doesn’t equate to amazing step 1 scores. Going to a high ranked med school does help with residency matching, but it’s ultimately on the student, their performance during med school/interviews, and the decisions they make if they’ll actually match where/what they want or not. Step 1 P/F is much better for students and their prospective career paths.

???

Now your application boils down to a step 2 score lmao.

 

[DarkBluMage]

???

Now your application boils down to a step 2 score lmao.

Lmbo maybe you didn’t read or comprehend my comment where I said “agree to disagree”.

 

[bGMx]

The only ones in med school who have a real problem with the setup of a workplace and considering it's toxic are most likely people who went straight through from undergrad who really never worked a day in their life. Anyone who has worked full-time wouldn't be bothered by those little things.

This isn't the case. I worked and have had a tough life outside of medicine; medicine is out of touch with the real world. Nobody gives two ****s about how you spend your weekend if you work a job; in fact, they will probably invite you to the pub afterward. As a medical student, you're a liability and someone to be shaped into a "professional"; if I say something just mildly different than my "boss" or what the common sentiment is, I will get an evaluation that states I need to improve in some arbitrary way. Sometimes I feel like I'm 13 again.

I think the stress that comes from being a medical student is the rat race to "be somebody" when in fact we already are. More research, more posters, more studying, more wellness, more accolades; I was already very satisfied with who I was before medicine and becoming a physician was just going to add to that. I feel as though medical school has made me regress in multiple ways which is unfortunate, because I think most medical students have so much to offer medicine which will make healthcare way better. Yes work me 80 hours a week, let me perfect the art of medicine under your guidance... there is no need to turn students into subjects and silence their learned wisdom. The applications of some of these incoming medical students are more applaudable than the CVs of some attendings.

And that is the toxicity of medical school; the quest for "more" instead of "this is enough." A fisherman hasn't wasted his day if he hadn't caught any fish. Just my two cents.

 

[srirachamayonnaise]

This isn't the case. I worked and have had a tough life outside of medicine; medicine is out of touch with the real world. Nobody gives two ****s about how you spend your weekend if you work a job; in fact, they will probably invite you to the pub afterward. As a medical student, you're a liability and someone to be shaped into a "professional"; if I say something just mildly different than my "boss" or what the common sentiment is, I will get an evaluation that states I need to improve in some arbitrary way. Sometimes I feel like I'm 13 again.

I think the stress that comes from being a medical student is the rat race to "be somebody" when in fact we already are. More research, more posters, more studying, more wellness, more accolades; I was already very satisfied with who I was before medicine and becoming a physician was just going to add to that. I feel as though medical school has made me regress in multiple ways which is unfortunate, because I think most medical students have so much to offer medicine which will make healthcare way better. Yes work me 80 hours a week, let me perfect the art of medicine under your guidance... there is no need to turn students into subjects and silence their learned wisdom. The applications of some of these incoming medical students are more applaudable than the CVs of some attendings.

And that is the toxicity of medical school; the quest for "more" instead of "this is enough." A fisherman hasn't wasted his day if he hadn't caught any fish. Just my two cents.

oh yeah, definitely there's this kindergarten element in it. It's the constant feedback loop. I don't think it's that they think you are totally useless. It's just this culture that everyone needs to give everyone else feedback all the time. I basically tune off when that happens. I do what I do and go home and have a good time with my spouse.

 

[operaman]

oh yeah, definitely there's this kindergarten element in it. It's the constant feedback loop. I don't think it's that they think you are totally useless. It's just this culture that everyone needs to give everyone else feedback all the time. I basically tune off when that happens. I do what I do and go home and have a good time with my spouse.

My sense is that the whole feedback thing is trying to replace great teaching that’s been killed off by the productivity and other demands on clinicians.

Like when I take a student through a case, and especially if it’s an easier one where I can let them do most of it, I’m giving feedback constantly. Maybe too much, but I have all my attendings’ voices in my head now so they get to have my voice in their head someday. But the point is that I teach and offer constant feedback in the moment so they learn and grow and then usually do a quick debrief at the end often with a brief reading “assignment” for that night relevant to the case.

When I get sent the formal feedback form three weeks later, I’m just putting down “does great. Keep reading” because the time for teaching is at the bedside. And all the feedback in the world won’t make up for teaching.

 

[voxveritatisetlucis]

Medical school is probably becoming more toxic due to school expansion. Back even 10 years ago, an average MD student could probably match at least general surgery, radiology, or anesthesiology. Now that these fields are becoming more competitive, some average to slightly below average MD students are facing the real possibility of having to do something they’re not interested in. In order to try to avoid this, they feel pressure to do a lot of research, get leadership, volunteering as well as try to get the grades needed for AOA

 

[i-doctor]

Medical school is probably becoming more toxic due to school expansion. Back even 10 years ago, an average MD student could probably match at least general surgery, radiology, or anesthesiology. Now that these fields are becoming more competitive, some average to slightly below average MD students are facing the real possibility of having to do something they’re not interested in. In order to try to avoid this, they feel pressure to do a lot of research, get leadership, volunteering as well as try to get the grades needed for AOA

Well, we need more primary care. This forces more people into it, even if by gun point.

 

[Ho0v-man]

Well, we need more primary care. This forces more people into it, even if by gun point.

The primary care residency slots still filled after soap/scramble tho. We’re not making more primary care physicians with school expansion. We only do that with more residencies.

 

[DOVinciRobot]

Well, we need more primary care. This forces more people into it, even if by gun point.

The number of PCPs generated every year is not linked to school expansion.

 

[i-doctor]

The number of PCPs generated every year is not linked to school expansion.

Yes, but the net effect is nearly all the PCP residency positions are filled by U.S. medical students (some of whom are spill-over from being unmatched elsewhere), which has basically shut out most FMG’s and Caribbean-trained medical students.

 

[srirachamayonnaise]

Yes, but the net effect is nearly all the PCP residency positions are filled by U.S. medical students (some of whom are spill-over from being unmatched elsewhere), which has basically shut out most FMG’s and Caribbean-trained medical students.

I don't think your interpretation is accurate. I think a lot of PCP residency positions are filled by FMG's and IMG's. They are shut out because there are not enough slots to accommodate them.

 

[Goro]

Medical school is probably becoming more toxic due to school expansion. Back even 10 years ago, an average MD student could probably match at least general surgery, radiology, or anesthesiology. Now that these fields are becoming more competitive, some average to slightly below average MD students are facing the real possibility of having to do something they’re not interested in. In order to try to avoid this, they feel pressure to do a lot of research, get leadership, volunteering as well as try to get the grades needed for AOA

Fields that becoming more competitive, especially those that are more lucrative, are so because of rising tuitions and previous UG debt. This is a vicious cycle that has been long noted in medical education. Finding a solution is not easy, other than reducing tuition, but good luck with telling higher education that.

Although it hasn't happened yet, school expansion, epically in the DO world will eventually exhaust the pool of people who can handle medical schools. Then you're going to see a large increase in attrition and hopefully that will force COCA to take notice. In the MD world, schools, even new ones (at least as far that I have seen) at least have teaching hospitals and their own residency pools. Interestingly, we're also seeing a paradigm shift where hospitals are opening their own medical schools!

Yes, but the net effect is nearly all the PCP residency positions are filled by U.S. medical students (some of whom are spill-over from being unmatched elsewhere), which has basically shut out most FMG’s and Caribbean-trained medical students.

Not yet, but we're getting there.

 

[srirachamayonnaise]

Medical school is probably becoming more toxic due to school expansion. Back even 10 years ago, an average MD student could probably match at least general surgery, radiology, or anesthesiology. Now that these fields are becoming more competitive, some average to slightly below average MD students are facing the real possibility of having to do something they’re not interested in. In order to try to avoid this, they feel pressure to do a lot of research, get leadership, volunteering as well as try to get the grades needed for AOA

What we are seeing is the striking similarity between law and medicine, albeit this happened in law about 30 years prior. Lower-tier MD students will face a lot more uncertainty and competitions.

 

[Billiam95]

What we are seeing is the striking similarity between law and medicine, albeit this happened in law about 30 years prior. Lower-tier MD students will face a lot more uncertainty and competitions.

Will only get worse when step2 inevitably goes p/f.

 

[Goro]

Will only get worse when step2 inevitably goes p/f.

Luckily, there is no evidence of this happening yet, and it took a long time to even get to Step I going P/F!

 

[Med Ed]

Medical school is probably becoming more toxic due to school expansion. Back even 10 years ago, an average MD student could probably match at least general surgery, radiology, or anesthesiology.

You may be surprised to learn that the difficulty of matching into various fields has fluctuated over time.

 

[Hzreio]

Med school education is toxic bc most people don’t realize it’s just a game. It prioritizes playing the game over true learning. It doesn’t reward the people who are most sincere, but those who know how to get the gold stars.

It’s similar to life in that regard, but it’s much more amped up in medicine and the stakes are higher.