MS1-MS2 doesn't teach you bread and butter medicine in enough detail

[MedicineZ0Z]

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Just reflecting that in ms1-ms2, I really think that there was excessive emphasis on zebras without enough relative emphasis on day to day medicine. Learning about conditions that are 1 in 1 million really doesn't carry the same value as learning about diabetes. And quite frankly a small chunk of First Aid teaches you virtually useless facts that have literally 0 clinical utility, ever.
The solution is to get rid of that chunk, maybe 10-15% of it. And replace it with high-yield facts that maximize the depth of knowledge on day to day encounters.

What that does is that it prevents MS3s from putting budd chiari on their differential for simple abdominal pain and forgoing the routine common stuff.

 

[OnePunchBiopsy]

Blame the NBME and USMLE, not the schools. Medical schools are just trying to set students up for success.

Unfortunately, success means scoring high on an exam taken 1 day of your life that puts knowing superfluous facts over clinical utility.

 

[ace_inhibitor111]

A few things:

1. In-depth management of diseases like diabetes change over time, and sometimes aren’t clear cut depending on the patient. Pathophysiology and mechanisms/side effects of drugs for diabetes that you learn in M1/M2 don’t change for the most part and provide an essential foundation.
2. Common diseases aren’t really that interesting. Besides you learn about things like viral gastroenteritis, allergic rhinitis, GERD and sleep apnea in M1/M2. They just don’t put as much emphasis on them cause there’s really nothing too complicated about them in the first place.
3. You’re usually never just given something like “abdominal pain” and then forced to think of everything on the differential. That’s why the history and physical exist. You should have enough info from M1/M2 to recognize patterns when you see them which is the point.

 

[MedicineZ0Z]

A few things:

1. In-depth management of diseases like diabetes change over time, and sometimes aren’t clear cut depending on the patient. Pathophysiology and mechanisms/side effects of drugs for diabetes that you learn in M1/M2 don’t change for the most part and provide an essential foundation.
2. Common diseases aren’t really that interesting. Besides you learn about things like viral gastroenteritis, allergic rhinitis, GERD and sleep apnea in M1/M2. They just don’t put as much emphasis on them cause there’s really nothing too complicated about them in the first place.
3. You’re usually never just given something like “abdominal pain” and then forced to think of everything on the differential. That’s why the history and physical exist. You should have enough info from M1/M2 to recognize patterns when you see them which is the point.

There are nuances to common conditions that med students don't learn enough of. Then spend endless hours on biochem and genetics. That's a bit of an issue...

 

[Alkaidius]

I don’t necessarily disagree, but I can understand why it happened. From what I can tell the focus of med schools has changed a great deal in a relatively short period of time. I’ve spoken to so many docs from a few decades back that only applied to 5 or fewer residencies and weren’t even concerned about not matching. 20 years ago, if I remember right, the average USMLE was just over 200. Does that mean that students were dumber then? I sincerely doubt it....What it definitely means is that the curriculum has slowly focused toward murdering the test and away from the more clinical aspects. But with every student applying close to 100 residencies nowadays, I don’t really blame them for desperately looking for an easy way to cut 80% of candidates.

In my opinion, with regard to your original point, though. I think the best way to tackle this change in education would be to actually change the residency culture. The old-school method of putting people through the grinder “cuz that’s how it was done” should stop in favor of more efficient and non-demeaning methods of learning. That way residents can walk into the hospital actually excited to work and learn. You learn better when you’re happy, after all. And you’re less likely to burnout when you’re happy. Win-win. Down with the old guard!

 

[efle]

The moment Step 1 switches to pass/fail like the Bar exam, and students can focus on something other than the flashcard UFAPS bible, this can get attention. Until then, curriculum revision like this is a waste of time at best, and a harm to students' residency prospects at worst.

 

[MedicineZ0Z]

I don’t necessarily disagree, but I can understand why it happened. From what I can tell the focus of med schools has changed a great deal in a relatively short period of time. I’ve spoken to so many docs from a few decades back that only applied to 5 or fewer residencies and weren’t even concerned about not matching. 20 years ago, if I remember right, the average USMLE was just over 200. Does that mean that students were dumber then? I sincerely doubt it....What it definitely means is that the curriculum has slowly focused toward murdering the test and away from the more clinical aspects. But with every student applying close to 100 residencies nowadays, I don’t really blame them for desperately looking for an easy way to cut 80% of candidates.

In my opinion, with regard to your original point, though. I think the best way to tackle this change in education would be to actually change the residency culture. The old-school method of putting people through the grinder “cuz that’s how it was done” should stop in favor of more efficient and non-demeaning methods of learning. That way residents can walk into the hospital actually excited to work and learn. You learn better when you’re happy, after all. And you’re less likely to burnout when you’re happy. Win-win. Down with the old guard!

The moment Step 1 switches to pass/fail like the Bar exam, and students can focus on something other than the flashcard UFAPS bible, this can get attention. Until then, curriculum revision like this is a waste of time at best, and a harm to students' residency prospects at worst.

Fair points but I'm saying that you should be testing the detailed nuances of common conditions more rather than ultra rare zebras.

 

[Alkaidius]

The moment Step 1 switches to pass/fail like the Bar exam, and students can focus on something other than the flashcard UFAPS bible, this can get attention. Until then, curriculum revision like this is a waste of time at best, and a harm to students' residency prospects at worst.

Would be awesome if this were the case, but wishful thinking for the reasons I mentioned. We’re in an information overload age, and nobody will want to get rid of such an efficient system. It would take an entirely innovative idea to rip the current method from the ground up, ideally one that takes into account more than the ability to cram...but that’s probably decades away if ever.

 

[Med Ed]

Just reflecting that in ms1-ms2, I really think that there was excessive emphasis on zebras without enough relative emphasis on day to day medicine. Learning about conditions that are 1 in 1 million really doesn't carry the same value as learning about diabetes. And quite frankly a small chunk of First Aid teaches you virtually useless facts that have literally 0 clinical utility, ever.
The solution is to get rid of that chunk, maybe 10-15% of it. And replace it with high-yield facts that maximize the depth of knowledge on day to day encounters.

What that does is that it prevents MS3s from putting budd chiari on their differential for simple abdominal pain and forgoing the routine common stuff.

Solution identified: PA school.

 

[Splenda88]

I like the zebras, but I have yet to treat a patient with Acute Intermittent Porphyria or one of the many Porphyrias 😉--disease we studied twice in med school (biochem and pathology)

You just told us something we did not know. Med school is inefficient.

 

[operaman]

Gotta disagree on this one. The first two years don’t teach medicine, they teach the language of medicine. The clinical years and residency are when you learn the nuances. It’s like studying a foreign language for 2 years, learning some grammar and vocabulary you may not use much is regular conversation, but then going to that country for your last two years armed with the tools to take the next steps.

The zebras also have the bonus of teaching their associated pathology and physiology. You may not see AIP much but what a great way to study and internalize that part of biochem and metabolism. More time on diabetes and hypertension outside the clinic is probably not as useful.

 

[wanderingorion]

The moment Step 1 switches to pass/fail like the Bar exam, and students can focus on something other than the flashcard UFAPS bible, this can get attention. Until then, curriculum revision like this is a waste of time at best, and a harm to students' residency prospects at worst.

Then again, your Bar score determines which states you are able to practice in, so there's still plenty of teaching/studying to the test.

 

[Mad Jack]

Just reflecting that in ms1-ms2, I really think that there was excessive emphasis on zebras without enough relative emphasis on day to day medicine. Learning about conditions that are 1 in 1 million really doesn't carry the same value as learning about diabetes. And quite frankly a small chunk of First Aid teaches you virtually useless facts that have literally 0 clinical utility, ever.
The solution is to get rid of that chunk, maybe 10-15% of it. And replace it with high-yield facts that maximize the depth of knowledge on day to day encounters.

What that does is that it prevents MS3s from putting budd chiari on their differential for simple abdominal pain and forgoing the routine common stuff.

Depth is what separates physicians from the rest of the pack. If you don't learn the weird stuff it will never be on your differential. The clinical phase is about learning to target that blunderbuss of knowledge appropriately, and residency is about perfecting its use

 

[Ho0v-man]

Fair points but I'm saying that you should be testing the detailed nuances of common conditions more rather than ultra rare zebras.

This. I’m all for scored board exams, but it’s pretty silly some of the stuff they make us focus on. None of us are ever going to do anything meaningful with knowing what happens when there’s a CGG vs GAA trinucleotide repeat, but everyone reading this knows what that is and it’s pointless.

Ataxic GAAit!

 

[Mad Jack]

This. I’m all for scored board exams, but it’s pretty silly some of the stuff they make us focus on. None of us are ever going to do anything meaningful with knowing what happens when there’s a CGG vs GAA trinucleotide repeat, but everyone reading this knows what that is and it’s pointless.

Ataxic GAAit!

Anyone can learn the bread and butter stuff. It's the esoteric points that save at least a patient or two a month on the inpatient service. You'll see a zebra or two a month on a busy service, and if you never learn these zebras you'll never spot them.

 

[Ho0v-man]

Anyone can learn the bread and butter stuff. It's the esoteric points that save at least a patient or two a month on the inpatient service. You'll see a zebra or two a month on a busy service, and if you never learn these zebras you'll never spot them.

Oh yeah I’m not saying don’t learn about the conditions or their presentations. I’m saying knowing the specific trinucleotide repeat associated with it is pointless. Just like memorizing stop codons.

 

[Ultimax]

Its what distinguish physicians from nurse practitioners/physician assistants. I am a nurse practitioner and one the reasons that I go back to medical school is to learn about rare conditions. You will encounter common health problems daily, but the day when you can recognize a rare disease is the day you will make a difference in patients’ life. Throughout my nursing career, I have heard countless stories of patients who complain that their doctors fail to diagnose their rare and unique conditions, or do not refer to appropriate specialists. Any physicians can treat diabetes, but not every physician can treat rare diseases.

 

[VA Hopeful Dr]

Oh yeah I’m not saying don’t learn about the conditions or their presentations. I’m saying knowing the specific trinucleotide repeat associated with it is pointless. Just like memorizing stop codons.

We need to know why diseases happen. You could certainly argue about how much in depth pathophysiology/biochemistry we need to know (since there is way more detail than we go in to), but I think the way its taught now seems about right.

 

[Ho0v-man]

We need to know why diseases happen. You could certainly argue about how much in depth pathophysiology/biochemistry we need to know (since there is way more detail than we go in to), but I think the way its taught now seems about right.

I’ll respect your seniority in this case and hope I agree with you in the future.

 

[aafisahar]

Learning the bread and butter is for clinical and residency. It's thing you need to see repetitively and there's enough nuance and variation that learning it early is probably worthless.

 

[sloop]

I went into psych, so this is coming from someone for whom the majority of med school is perhaps less “relevant”: I disagree that med school should primarily be teaching about common conditions in the didactic years.

As others have mentioned, those years are for learning how to talk about physiology, disease, and treatment. They also provide the basis for a broad differential diagnosis, which is the hallmark of the physician. Even as a psychiatrist, my responsibility is to get the diagnosis correct and to safely treat the patient. It’s important that I have a background that introduced the zebras so that I’m able to diagnose them in the correct clinical context. In clinical medicine, you will see zebras but perhaps not enough to reinforce your understanding of them. That’s why it’s important to have a background that emphasized them so that at least some knowledge of most topics sticks with you.

The other thing is that probably half or more of common conditions don’t really have nuanced diagnosis or management. Unsurprisingly, many common conditions are also not very serious and are the type of thing that a PCP will just send a patient home for with some supportive recommendations. Do you really think it’s worth spending lots of time on the nuances of styes or whatever? For what it’s worth, I do think that my med school spent considerable time on those common conditions which do have such nuances, such as HIV and diabetes.

Overall, this is one of those things that med students complain about but a lot of the time they don’t have the perspective to understand the utility. I don’t mean disrespect, but an MS2 really just has no idea what type of education has clinical value. You can go ahead and have these conversations with your friends, but understand that it’s just venting about how medical school is hard and does not mean that you have amazing insights into the failings of med school that nobody in power seems to recognize.

 

[GoSpursGo]

What that does is that it prevents MS3s from putting budd chiari on their differential for simple abdominal pain and forgoing the routine common stuff.

I guess I don't see a problem with an MS3 having a zebra on their differential diagnosis. At least that tells me they put THOUGHT into their patient, and even if the result gives me a chuckle the whole point of MS3-4 is that you start learning some of those practical points that gets you ready for residency.

As others have said, MS1-2 is about creating a solid foundation. Sure, a decent amount of it you will never think about after Step 1, but I think you could find that just about all of it is used by SOME specialty out there. For example, as an MS1 I found histology mind-numbingly boring, but it's actually super relevant to me now as a pediatric oncology fellow. The biochemistry helps me understand how the hell the chemo I'm giving my patients works. You don't know where your career is going to take you as an MS1, so you need to gain a broad general understanding so that you at least have the basics down and can expand that knowledge later when it turns out you happen to need it.

 

[jdh71]

I can teach bread and butter to a monkey. Nuance only comes about by experience and can’t be formally taught.

you learn esoteric stuff because you are becoming a doctor. Looks like too many these days don’t actually want to be one.

 

[Chemist0157]

I think it’s mostly okay the way it is now. My 1st year was anatomy then biochem then maybe something else I’m forgetting before starting system based blocks. There are many rare diseases that are taught not because you will necessarily see them during your career but because we have a pretty good understanding of what causes them, and they are helpful to teach principles from the biochemical, genetics, etc blocks. They are also testable principles/facts. You may get 10 different reasonable answers if you present a real world issue of treating diabetes.

We’re not special. It’s not unusual for students to study something in school that may not be readily applicable in their careers. There’s still value to know it “just in case.” The good docs are thorough and have a deep knowledge base.

 

[efle]

All the practicing docs out there should take a look at samples of the USMLE practice forms like Dr. Carmody highlights in this blog post:

What’s on USMLE Step 1?

Recently, I was on The Accad and Koka Report to share my opinions on USMLE Step 1 scoring policy. (If you’re interested, you can listen to the episode on the show website or iTunes.) Most of …

thesheriffofsodium.com

Obviously there are just as many excellent and more relevant questions on Step 1 (and far more on Medicine NBME and Step 2), but huge swaths of the test is questions like this. Students are out here doing >100,000 digital flashcards to memorize every cellular signaling step and protein name, every mutation and chromosome location, every cytokine, whether each virus is positive or negative strand...you get the idea.

I don't think anybody who recently went through MS1-MS2 can defend the opportunity cost involved here, unless they feel preclinical is supposed to just be a proving ground of memorizing trivia to see who deserves to match Derm and Ortho.

 

[Fatalis]

Just reflecting that in ms1-ms2, I really think that there was excessive emphasis on zebras without enough relative emphasis on day to day medicine. Learning about conditions that are 1 in 1 million really doesn't carry the same value as learning about diabetes. And quite frankly a small chunk of First Aid teaches you virtually useless facts that have literally 0 clinical utility, ever.
The solution is to get rid of that chunk, maybe 10-15% of it. And replace it with high-yield facts that maximize the depth of knowledge on day to day encounters.

What that does is that it prevents MS3s from putting budd chiari on their differential for simple abdominal pain and forgoing the routine common stuff.

you do not "learn" medicine until after residency

 

[GoSpursGo]

All the practicing docs out there should take a look at samples of the USMLE practice forms like Dr. Carmody highlights in this blog post:

What’s on USMLE Step 1?

Recently, I was on The Accad and Koka Report to share my opinions on USMLE Step 1 scoring policy. (If you’re interested, you can listen to the episode on the show website or iTunes.) Most of …

thesheriffofsodium.com

Obviously there are just as many excellent and more relevant questions on Step 1 (and far more on Medicine NBME and Step 2), but huge swaths of the test is questions like this. Students are out here doing >100,000 digital flashcards to memorize every cellular signaling step and protein name, every mutation and chromosome location, every cytokine, whether each virus is positive or negative strand...you get the idea.

I don't think anybody who recently went through MS1-MS2 can defend the opportunity cost involved here, unless they feel preclinical is supposed to just be a proving ground of memorizing trivia to see who deserves to match Derm and Ortho.

I mean, even he admits that he cherry-picked a few questions here. I don't think it's accurate to say that "huge swaths" of the test in on minutiae like this, and I still maintain that this information is relevant to some subset of specialties out there so it's totally fair to expect medical students to learn this basic information in the process of getting a degree in general medicine. There are always going to be those tough questions that separate the top 5% of the class.

But even if you think these questions are over-represented, then good news--you'll have a chance to prove you know that stuff that you think is more relevant on steps 2 and 3.

 

[sloop]

All the practicing docs out there should take a look at samples of the USMLE practice forms like Dr. Carmody highlights in this blog post:

What’s on USMLE Step 1?

Recently, I was on The Accad and Koka Report to share my opinions on USMLE Step 1 scoring policy. (If you’re interested, you can listen to the episode on the show website or iTunes.) Most of …

thesheriffofsodium.com

Obviously there are just as many excellent and more relevant questions on Step 1 (and far more on Medicine NBME and Step 2), but huge swaths of the test is questions like this. Students are out here doing >100,000 digital flashcards to memorize every cellular signaling step and protein name, every mutation and chromosome location, every cytokine, whether each virus is positive or negative strand...you get the idea.

I don't think anybody who recently went through MS1-MS2 can defend the opportunity cost involved here, unless they feel preclinical is supposed to just be a proving ground of memorizing trivia to see who deserves to match Derm and Ortho.

All of life is a competitive proving ground. Med school will always be a competitive proving ground. We can't have every doctor practicing the same specialty, so there is a bit of central planning involved here. People will always be trying to distinguish themselves in order to secure the most control over their destiny and the system should give them opportunities to do so. If the discriminant questions were not this kind of esoteric stuff, they would be some other esoteric information. Most medical students can grasp the majority of essential topics in medicine and if we only taught those things, everyone would be scoring within a few points of each other and med students would complain that their lives are being decided on only a handful of harder questions.

Esoteric knowledge, or at least recognition, if not recall, of esoteric knowledge can be an advantage for an expert such as a doctor. If you get into a very specific legal predicament, you would probably want your lawyer to at least remember hearing of a relevant case rather than have this be totally new to them. Same thing here. There is a logistical need to teach discriminant information. At least the discriminant information that gets taught is relevant to medicine in specific or rare cases, rather than completely irrelevant.

Also, I really don't think there's that much opportunity cost here. You have two years to learn the basics of practical medicine. If you want to talk about opportunity cost, we could always approach the issue of fourth year being largely a nonsense series of underwater basket weaving, interviews and vacation, but no med student wants to change that.

 

[Alkaidius]

Looks like too many these days don’t actually want to be one.

Please stop propagating sheep mentality, that’s a far worse fate for anything than being wrong and being corrected *cough* bestwaytoeducate *cough* Literally the attitude we should be burning away in hellfire as a new generation of doctors set foot center stage.

 

[Angus Avagadro]

I don’t necessarily disagree, but I can understand why it happened. From what I can tell the focus of med schools has changed a great deal in a relatively short period of time. I’ve spoken to so many docs from a few decades back that only applied to 5 or fewer residencies and weren’t even concerned about not matching. 20 years ago, if I remember right, the average USMLE was just over 200. Does that mean that students were dumber then? I sincerely doubt it....What it definitely means is that the curriculum has slowly focused toward murdering the test and away from the more clinical aspects. But with every student applying close to 100 residencies nowadays, I don’t really blame them for desperately looking for an easy way to cut 80% of candidates.

In my opinion, with regard to your original point, though. I think the best way to tackle this change in education would be to actually change the residency culture. The old-school method of putting people through the grinder “cuz that’s how it was done” should stop in favor of more efficient and non-demeaning methods of learning. That way residents can walk into the hospital actually excited to work and learn. You learn better when you’re happy, after all. And you’re less likely to burnout when you’re happy. Win-win. Down with the old guard!

Going disagree with you here. Board scores were probably lower decades ago when us old guard were taking the exams. Residencies really didnt care about your absolute score, only if you passed them. If anyone starting studying for boards at Thanksgiving, like they do now, we would think they were out of their freaking mind. Things are definitely different now. I would argue with the vast increase in new schools, that matriculants now are not as qualified, as a whole than a couple decades ago. At our school, we teach to the boards and twist ourselves into pretzels to get the bottom third to maintain our pass rate. Since Step is not centered on bread and butter information, we are forced to teach high yield info. It's different. Better? I'm not sure.
Medicine is hard. I would be interest in how to make it easier and maintain the quality of our product. I'm not sure how to take something hard and make it easy.

 

[efle]

I mean, even he admits that he cherry-picked a few questions here. I don't think it's accurate to say that "huge swaths" of the test in on minutiae like this, and I still maintain that this information is relevant to some subset of specialties out there so it's totally fair to expect medical students to learn this basic information in the process of getting a degree in general medicine. There are always going to be those tough questions that separate the top 5% of the class.

But even if you think these questions are over-represented, then good news--you'll have a chance to prove you know that stuff that you think is more relevant on steps 2 and 3.

I think it's a larger chunk than people want to admit.

Put it as a thought experiment - suppose we took a freshly boarded hospitalist from a premiere program like MGH internal med, someone who ought to represent the best and brightest a generalist medical training path full of both bread-and-butter and zebras can produce, and had them sit for the Step 1 tomorrow.

I don't think they'd get only a few questions about cytokines wrong. I think they'd bomb the exam. Too much decay over those 5+ years of never using lots of it.

All of life is a competitive proving ground. Med school will always be a competitive proving ground. We can't have every doctor practicing the same specialty, so there is a bit of central planning involved here. People will always be trying to distinguish themselves in order to secure the most control over their destiny and the system should give them opportunities to do so. If the discriminant questions were not this kind of esoteric stuff, they would be some other esoteric information. Most medical students can grasp the majority of essential topics in medicine and if we only taught those things, everyone would be scoring within a few points of each other and med students would complain that their lives are being decided on only a handful of harder questions.

Esoteric knowledge, or at least recognition, if not recall, of esoteric knowledge can be an advantage for an expert such as a doctor. If you get into a very specific legal predicament, you would probably want your lawyer to at least remember hearing of a relevant case rather than have this be totally new to them. Same thing here. There is a logistical need to teach discriminant information. At least the discriminant information that gets taught is relevant to medicine in specific or rare cases, rather than completely irrelevant.

Also, I really don't think there's that much opportunity cost here. You have two years to learn the basics of practical medicine. If you want to talk about opportunity cost, we could always approach the issue of fourth year being largely a nonsense series of underwater basket weaving, interviews and vacation, but no med student wants to change that.

Think back to the distant, distant past of the 1990s-2000s when the step didn't exist and/or didn't matter at all in residency placement. Was everyone clamoring for the creation of a test that would stratify students by who best memorizes a 30,000 item flashcard deck? There are definitely other areas of improvement too, but this is a big one.

Some other posts of Carmody I find myself agreeing a great deal with:

Step 1 Apologists and the Memorizing Pi Thought Experiment

There are some weak points in some of his critiques but most of those two ring true to me.

 

[efle]

Going disagree with you here. Board scores were probably lower decades ago when us old guard were taking the exams. Residencies really didnt care about your absolute score, only if you passed them. If anyone starting studying for boards at Thanksgiving, like they do now, we would think they were out of their freaking mind. Things are definitely different now. I would argue with the vast increase in new schools, that matriculants now are not as qualified, as a whole than a couple decades ago. At our school, we teach to the boards and twist ourselves into pretzels to get the bottom third to maintain our pass rate. Since Step is not centered on bread and butter information, we are forced to teach high yield info. It's different. Better? I'm not sure.
Medicine is hard. I would be interest in how to make it easier and maintain the quality of our product. I'm not sure how to take something hard and make it easy.

Thanksgiving...of MS2? The new trend is to begin flashcarding a 30,000 card digital deck in the first semester of MS1.

 

[KeikoTanaka]

There are nuances to common conditions that med students don't learn enough of. Then spend endless hours on biochem and genetics. That's a bit of an issue...

Why spend so much time on the nuance when that's the whole point of residency?

Besides, like other posters posted - The actual management of disease processes change from year to year and will be outdated. Rather the foundational knowledge of every disease process is taught and it's up to you to extrapolate out.

This is why clinical experience is so important in the application cycle for med school. I know about a lot of the "nuances" of diseases from scribing in Primary Care for a whole year before school. Now when I learn the foundational pathophysiology I have that light bulb "Oooooh" moment.

Also my school does a terrific job at stressing "Clinical Systems" which they admit does not help us for the boards but will be vital for our 3rd and 4th year rotations and beyond.

 

[Angus Avagadro]

Thanksgiving...of MS2? The new trend is to begin flashcarding a 30,000 card digital deck in the first semester of MS1.

So true!

 

[Alkaidius]

Going disagree with you here. Board scores were probably lower decades ago when us old guard were taking the exams. Residencies really didnt care about your absolute score, only if you passed them. If anyone starting studying for boards at Thanksgiving, like they do now, we would think they were out of their freaking mind. Things are definitely different now. I would argue with the vast increase in new schools, that matriculants now are not as qualified, as a whole than a couple decades ago. At our school, we teach to the boards and twist ourselves into pretzels to get the bottom third to maintain our pass rate. Since Step is not centered on bread and butter information, we are forced to teach high yield info. It's different. Better? I'm not sure.
Medicine is hard. I would be interest in how to make it easier and maintain the quality of our product. I'm not sure how to take something hard and make it easy.

That’s sort of what I was getting at. The sheer breadth being stuffed into our heads is much broader in exchange for more practical skills immediately on graduation. We’re probably “less qualified” the second we set foot out the door, but unless there’s data that shows we’re actually killing more people than “the old guard” by the end of residency it sorta balances out. We can mitigate this by ensuring that residency culture is as efficient at teaching as it can be, minimizing worthless busywork, stress, and burnout. No one said med-schools are the only institutions that should be scrutinized.

 

[GoSpursGo]

I think it's a larger chunk than people want to admit.

Put it as a thought experiment - suppose we took a freshly boarded hospitalist from a premiere program like MGH internal med, someone who ought to represent the best and brightest a generalist medical training path full of both bread-and-butter and zebras can produce, and had them sit for the Step 1 tomorrow.

I don't think they'd get only a few questions about cytokines wrong. I think they'd bomb the exam. Too much decay over those 5+ years of never using lots of it.

I don't think your analogy holds. Having a broad fund of knowledge doesn't mean you could regurgitate that information cold tomorrow on an exam. But if you found yourself in a situation where you needed to think about those cytokines for the first time in 10 years, that person would still be able to just refresh that information as opposed to having to learn it from the bottom up.

I *know* I complained loudly about how useless the stuff I had to learn for step 1 was when I was learning it in med school years ago, so I do feel your pain. But that knowledge of minutiae or at least being able to recall bits and pieces of it really are what differentiate doctors from PAs and NPs, and I'm glad I have it now.

 

[sloop]

Think back to the distant, distant past of the 1990s-2000s when the step didn't exist and/or didn't matter at all in residency placement. Was everyone clamoring for the creation of a test that would stratify students by who best memorizes a 30,000 item flashcard deck? There are definitely other areas of improvement too, but this is a big one.

Look, med school is a long slog and it's understandable that med students are tired of the constant competitive pressure already by the time they matriculate. Still, this isn't really about Step or esoteric discriminant questions. Med students complain about every aspect of this process where they are pressured to perform and compared to their peers. Clinical evaluations are much more arbitrary than performance on tests, and students (rightly, I think) protest this. Med students protest preclinical exams as testing esoteric details and sometimes even reject the whole idea of competing on this field to "focus on Step 1." Then they complain that Step 1 tests too much esoteric information. They get upset when they learn that it's much easier to honor preclinical classes or rotations at other schools than theirs.

Is the medical education system perfect? No, of course not. That said, it's structured the way it is because it has to provide an essential foundation while also providing meritocratic opportunities for distinction.

Honestly, I just think that a lot of this comes down to med students being frustrated that med school is difficult and competitive.

 

[Mad Jack]

All the practicing docs out there should take a look at samples of the USMLE practice forms like Dr. Carmody highlights in this blog post:

What’s on USMLE Step 1?

Recently, I was on The Accad and Koka Report to share my opinions on USMLE Step 1 scoring policy. (If you’re interested, you can listen to the episode on the show website or iTunes.) Most of …

thesheriffofsodium.com

Obviously there are just as many excellent and more relevant questions on Step 1 (and far more on Medicine NBME and Step 2), but huge swaths of the test is questions like this. Students are out here doing >100,000 digital flashcards to memorize every cellular signaling step and protein name, every mutation and chromosome location, every cytokine, whether each virus is positive or negative strand...you get the idea.

I don't think anybody who recently went through MS1-MS2 can defend the opportunity cost involved here, unless they feel preclinical is supposed to just be a proving ground of memorizing trivia to see who deserves to match Derm and Ortho.

I mean I took Step 1 what, 3.5 years ago and it's the same stuff that was on my test. The purpose of knowing all of this is so that you can understand basic research. We have to be able to understand the language and methods of the science that underpins our field to understand whether certain studies have merit and validity and apply those studies to our patients.

I have to pour through basic research for some obscure nonsense at least once a month, and the degree to which this esoterica applies is going to be highly dependent upon your field. An allergist without knowledge of the complement cascade would be an idiot in the guise of a healer. A geneticist without the knowledge of the different forms of trinucleotide repeats would be in a similar boat. And a pathologist that doesn't understand the basics of how different proteins would look when they run a gel? God help them. And don't even get me started on oncology...

The purpose of MS1 and MS2 is to give you a foundation that will allow you to excel in ANY field of medicine, and to be an effective researcher, professor, clinician, or any mix of the above. With the right basic tools you can hop right into the lab, the clinic, or the halls of academia and be competent with far less effort than those with more mundane backgrounds. I say this as someone who understands what it was like to be a clinician who had a very narrow scope prior to entering medicine- I could read research and teach students within my field, but throw an oncology paper at me and it may as well have been Latin. But after MS2? Give me five minutes to rattle off the cobwebs and I can still tackle immunology without issue, despite it being quite distant from my field of choice.

 

[jdh71]

Please stop propagating sheep mentality, that’s a far worse fate for anything than being wrong and being corrected *cough* bestwaytoeducate *cough* Literally the attitude we should be burning away in hellfire as a new generation of doctors set foot center stage.

yes being educated to be a doctor with knowledge is a “sheep mentality”

 

[Alkaidius]

yes being educated to be a doctor with knowledge is a “sheep mentality”


View attachment 293548

Cute, but you missed my point. That’s also fine, I guess. Please carry on with your memes and snark~

 

[jdh71]

Cute, but you missed my point. That’s also fine, I guess. Please carry on with your memes and snark~

Make your point very clear then if you can and if I missed it.

 

[Alkaidius]

Make your point very clear then if you can and if I missed it.

I meant that it should be encouraged to question the way a system is set up as the OP does, even if we have nothing better as of this moment. All man-made systems are inherently imperfect and could stand to improve. The USMLE isn’t an exam that descended from the heavens. It was written by people belonging to an institution with an agenda that isn’t necessarily there to benefit patients requiring care. And propagating a “just shut up and get behind the system or you’re lazy” mentality is faulty. It’s a natural law to take the path of least resistance, but let’s be real here, med school is not that. I can’t accuse any med student I met of being lazy, even if they try to find corners to cut every now and then because it’s more efficient.

 

[Goro]

Just reflecting that in ms1-ms2, I really think that there was excessive emphasis on zebras without enough relative emphasis on day to day medicine. Learning about conditions that are 1 in 1 million really doesn't carry the same value as learning about diabetes. And quite frankly a small chunk of First Aid teaches you virtually useless facts that have literally 0 clinical utility, ever.
The solution is to get rid of that chunk, maybe 10-15% of it. And replace it with high-yield facts that maximize the depth of knowledge on day to day encounters.

What that does is that it prevents MS3s from putting budd chiari on their differential for simple abdominal pain and forgoing the routine common stuff.

Every one of my clinical faculty colleagues firmly believes that we should be teaching you about the commonplace and the dangerous.

What you are also learning is the building blocks that form the foundation of the craft you'll learn in residency. You're learning how ot learn and even more importantly, how to be a life-long learner. (LCME and COCA required competency there.)

And I hope you're sitting down for this, because I may shock you into unconsciousness....................ready? Right now you are learning for both Boards AND wards.

And amazingly, you actually are going to have to explain to patients and their families why dad is dying of that rare cancer and nothing can be done.

Thanksgiving...of MS2? The new trend is to begin flashcarding a 30,000 card digital deck in the first semester of MS1.

Truth. I have some kids who start obsessing about Boards during Orientation Week!

 

[Type2Fiber]

Thanksgiving...of MS2? The new trend is to begin flashcarding a 30,000 card digital deck in the first semester of MS1.

As opposed to what else though? I'm 27k through the 30k deck you're talking about and the only reason is because I'm going after a competitive specialty. Medical school is a means to an end - the residency I want. I'm not here for anything else, so whatever metric students need to compete on to get the residency they want is what will be prioritized. Make the metric the highest bench press and I'll go full Ronnie Coleman by the end of MS4

Honestly, I could study so much less if it were P/F. I'd watch BnB a few days before a test, maybe flip through powerpoints, and be done with it. I'd probably spend way more time pounding out marginally useful research but I don't think that would make me a better doctor either

Fwiw, I agree the focus on step is all-consuming at this point. But I just think that reflects a culture change in medical school more than anything else. I would have the same level of tunnel vision on what ever other metric was devised to replace step 1 if it didn't exist

 

[jdh71]

I meant that it should be encouraged to question the way a system is set up as the OP does, even if we have nothing better as of this moment. All man-made systems are inherently imperfect and could stand to improve. The USMLE isn’t an exam that descended from the heavens. It was written by people belonging to an institution with an agenda that isn’t necessarily there to benefit patients requiring care. And propagating a “just shut up and get behind the system or you’re lazy” mentality is faulty. It’s a natural law to take the path of least resistance, but let’s be real here, med school is not that. I can’t accuse any med student I met of being lazy, even if they try to find corners to cut every now and then because it’s more efficient.

what does learning about all manners of disease and disease process have to do with the USMLE??

you don’t learn these things BECAUSE of the usmle. You learn these things because you want to be a doctor.

question whatever you want. Sometimes people ask stupid questions and sometimes they are just wrong. OP is just wrong. There isn’t some kind of implicit correctness that get granted to the asking or the questions.

 

[Alkaidius]

what does learning about all manners of disease and disease process have to do with the USMLE??

you don’t learn these things BECAUSE of the usmle. You learn these things because you want to be a doctor.

question whatever you want. Sometimes people ask stupid questions and sometimes they are just wrong. OP is just wrong. There isn’t some kind of implicit correctness that get granted to the asking or the questions.

Black and white for you then, that’s cool. Agree to disagree.

 

[efle]

As opposed to what else though? I'm 27k through the 30k deck you're talking about and the only reason is because I'm going after a competitive specialty. Medical school is a means to an end - the residency I want. I'm not here for anything else, so whatever metric students need to compete on to get the residency they want is what will be prioritized. Make the metric the highest bench press and I'll go full Ronnie Coleman by the end of MS4

Honestly, I could study so much less if it were P/F. I'd watch BnB a few days before a test, maybe flip through powerpoints, and be done with it. I'd probably spend way more time pounding out marginally useful research but I don't think that would make me a better doctor either

Fwiw, I agree the focus on step is all-consuming at this point. But I just think that reflects a culture change in medical school more than anything else. I would have the same level of tunnel vision on what ever other metric was devised to replace step 1 if it didn't exist

Imagine its the year 2000 and your route to your desired residency spot was the same (impress on the wards, do research, get good letters) except that during preclinical you could learn from clinician professors about what they felt an MS3 should know, instead of pounding through tens of thousands of flashcards. Does that really not sound like a better tailored way to educate us?

 

[efle]

I was shocked when I took Step 1 and found that around 90% of questions tested basic concepts/facts (it may be hard to understand the question and sort through the vignette to figure out what is being asked, but the fundamental concept they want you to know isn't crazy). The memorizing esoteric material is only to net those 10% of questions that make a difference between 240 vs 260. Those 10% of questions can completely make or break our careers (which is an issue), but the vast majority of the test was about fundamental concepts.

Any graduating resident worth their salt would understand the basic pathophysiology behind the conditions they treat and would be able to pass Step 1. As physicians, we should know the mechanisms behind the meds we give and the diseases we treat.

I was shocked by the opposite, after my MS2 they had us take a CBSE and it put me in the 210s. I did nothing but rote memorize as much esoteric factoids as I could stuff into my head during dedicated and went up 40 points into the 250s. I didnt get any smarter or better at reasoning in those months, just committed table after table of things I've never used since then into my short term memory, and it moved me from bottom quartile to top decile.

I honestly felt blindsided because I had spent all my effort during preclinical on learning the principles, and scoffed at my friends who were banging away at flashcards 24/7, but they were right and I was wrong. This style of prep caught on like wildfire for a reason. The step is not a test of who can best apply univerally learned fundamentals or reason through novel information. Or at least, that may be true of what you need to pass the exam, but it sure as hell isnt what gets you a 250+.

 

[Type2Fiber]

Imagine its the year 2000 and your route to your desired residency spot was the same (impress on the wards, do research, get good letters) except that during preclinical you could learn from clinician professors about what they felt an MS3 should know, instead of pounding through tens of thousands of flashcards. Does that really not sound like a better tailored way to educate us?

I understand the spirit of what you're saying, but no, at least at my school the clinical lectures are not helpful right now. I think BnB really does teach preclinical far more efficiently than any school lecturer could. If the purpose of the first two years is to build a basic science foundation, BnB/Sketchy/Pathoma are better than the vast majority of school instructors. I feel for the instructors who have to teach to empty classrooms, most do a good job, but the fact of the matter is that the outside resources just do a better job

The situation as is seems like a basic prisoner's dilemma. The ideal outcome might be something besides pounding STEP1 for two years, but I can't afford not to because someone else definitely will. Removing STEP doesn't change the underlying level of competition and I think that is the fundamental difference between now and 2000

 

[efle]

I understand the spirit of what you're saying, but no, at least at my school the clinical lectures are not helpful right now. I think BnB really does teach preclinical far more efficiently than any school lecturer could. If the purpose of the first two years is to build a basic science foundation, BnB/Sketchy/Pathoma are better than the vast majority of school instructors. I feel for the instructors who have to teach to empty classrooms, most do a good job, but the fact of the matter is that the outside resources just do a better job

The situation as is seems like a basic prisoner's dilemma. The ideal outcome might be something besides pounding STEP1 for two years, but I can't afford not to because someone else definitely will. Removing STEP doesn't change the underlying level of competition and I think that is the fundamental difference between now and 2000

I agree Dr Ryan and Sattar teach the material far better than most preclinical lecturers. My issue is with the content rather than the route of delivery. I'm fine with people sitting at home in their underwear watching a streamed lecture package, but I'd rather it be about stuff I may actually use as a clerk on the wards, instead of the significant proportion of stuff that we will only encounter again if we get a PhD in a related area or go into pathology, immuno, etc.