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

[efle]

I think that has more to do with the effectiveness of Anki/UWorld in remembering information rather than some sort of huge discordance between what your professors teach and what’s tested on Step 1. Active learning, cased-based learning etc. is just more effective than passive learning of broad concepts.

You might argue that if this is the case why not have UWorld and Step 1 be focused on nitty gritty clinical information like the heparin nomogram or the ACS screening recommendations or something. But the fact of the matter is that specific management changes every few years depending on new research. Physicians are the ones that are the change agents in that respect and need to understand scientific data if they are going to make the rules. Any NP/PA can associate VEGF inhibitors with ovarian cancer without truly understanding how they work or applying them to new situations.

Nah there's examples in the literature that the effect is from teaching to the boards. U Missouri I believe is an example that had a few papers about it from around 2010, they were able to launch their average scores from 220s to 240 by redesigning their curriculum around USMLE. Oh and actually I can mention our MS2 neuro unit as a great example. For my year, they had us take the neuro preclinical NBME at the end of our unit, and told us it was going to be scored and part of our grade; we're a Pass/Fail curriculum, and we needed to Pass it. They had to roll that back because so many people failed it.

When you put a bunch of expert clinician professors together and have them design what they think MS1-MS2 ought to know before hitting the wards, the result is VERY different than what's in First Aid.

Again I think there's plenty of baseline Step 2 CK knowledge that's been the same for a decade or more. It wouldn't be hard to put together a crash course.

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[GoSpursGo]

But doesn't it seem a little problematic for an exemplary preclinical student to arrive on Day 1 of their Medicine rotation and know all about the enzymes of hereditary metabolic disorders, and yet be clueless about what imaging or tests to order for all the common presentations? Trying to put together my Assessment&Plans for my patients was an absolute mess, despite having done a good job of learning what the national board says I should have learned. We can do all that learning later but why wait?

Really I don’t find that problematic at all. I know it’s a point of incredible stress for 3rd years that they think they’re clueless, but it’s not like you’re actually responsible for managing those patients—it actually is the job of your attending and residents to teach you how to do that. And nobody really gets “good” at having an assessment and plan until midway through intern year at best.

The basic science stuff may not come up every day in practice, but those first two years are really your only time to learn it. You’ll spend the rest of your career learning how to manage patients.

 

[ace_inhibitor111]

Nah there's examples in the literature that the effect is from teaching to the boards. U Missouri I believe is an example that had a few papers about it from around 2010, they were able to launch their average scores from 220s to 240 by redesigning their curriculum around USMLE. Oh and actually I can mention our MS2 neuro unit as a great example. For my year, they had us take the neuro preclinical NBME at the end of our unit, and told us it was going to be scored and part of our grade; we're a Pass/Fail curriculum, and we needed to Pass it. They had to roll that back because so many people failed it.

When you put a bunch of expert clinician professors together and have them design what they think MS1-MS2 ought to know before hitting the wards, the result is VERY different than what's in First Aid.

Again I think there's plenty of baseline Step 2 CK knowledge that's been the same for a decade or more. It wouldn't be hard to put together a crash course.

I don’t know, my experience has been pretty different. 7 months into 3rd year I don’t see some great divide between clinical medicine and M1/M2. There is a TON of overlap between Step 2 info and Step 1. Most of my classmates who have done well on Step 1 are also rocking the shelves.

 

[Ho0v-man]

Also hinges on what we think it means to be useful in 3rd year. I might be great and diagramming out all the different ways a heart can fail, but when I was asked what I wanted to do about it? Suddenly, it felt like knowing which drugs affect which part of the cardiac action potential was worthless trivia, and knowing actual diagnostic criteria and drug selection guidelines would've been time much better spent.

There’s a lot of merit to your point, but that’s what we’re there to learn. Furthermore, a ton of that was covered in preclinical medicine classes. Not nuanced stuff for specific situations, for sure. But general plans for common situations were definitely covered and it then becomes an exercise in expanding on that. I went to med school to know not just what to do, but why and how too. If I wanted to know “HTN—> ACE-i bc Moa=lower BP” then I’d be an NP.

I like the crash course idea. We should just do that, then take step 2 and then just focus on training clinically after that imo.

 

[efle]

Really I don’t find that problematic at all. I know it’s a point of incredible stress for 3rd years that they think they’re clueless, but it’s not like you’re actually responsible for managing those patients—it actually is the job of your attending and residents to teach you how to do that. And nobody really gets “good” at having an assessment and plan until midway through intern year at best.

The basic science stuff may not come up every day in practice, but those first two years are really your only time to learn it. You’ll spend the rest of your career learning how to manage patients.

Fair enough, I think my lens of MS1-MS2 being preparation for the latter half is why it frustrates me. If I view it more like college, where you learn things that are important in principle and useless in practice, but for the sake of the learning, then there's no issue. Personally I feel like that approach belongs in the 1900s when it was established, and would rather have a modern European system where you cut out YEARS of that process to get to the useful education sooner.

I don’t know, my experience has been pretty different. 7 months into 3rd year I don’t see some great divide between clinical medicine and M1/M2. There is a TON of overlap between Step 2 info and Step 1. Most of my classmates who have done well on Step 1 are also rocking the shelves.

I have always agreed a ton of Step1/first aid material is important. Just nowhere close to all of it, and certainly not the parts that are easiest to distinguish yourself by doing hundreds of thousands of flashcards. You'll notice there's nobody learning actual medicine via flashcards.

There’s a lot of merit to your point, but that’s what we’re there to learn. Furthermore, a ton of that was covered in preclinical medicine classes. Not nuanced stuff for specific situations, for sure. But general plans for common situations were definitely covered and it then becomes an exercise in expanding on that. I went to med school to know not just what to do, but why and how too. If I wanted to know “HTN—> ACE-i bc Moa=lower BP” then I’d be an NP.

I like the crash course idea. We should just do that, then take step 2 and then just focus on training clinically after that imo.

I think I don't buy into the "knowing why just for the sake of that knowledge" philosophy. I had a great time in college and in MS1-MS2, it was dope having my full time responsibility just be to learn cool stuff all day. But it's pretty hard to construct a defense of the system from the perspective of the care we deliver at the end of the day. All the western European nations seem to cut a lot of that out just fine, hell even in USA we have schools cutting out 25-50% of the preclinical time to no apparent detriment!

 

[JoaoMoutinho]

There's enough stable content in OnlineMedEd/Step 2 CK materials. One could easily trim a few months off preclinical and put in a new 12-week unit at the end of MS2 that's essentially A Crash Course in Actually Doing Medicine.

My school actually does have a course similar to that in the last block of M2 before dedicated. People complain about it all the time because they only want to focus on Step prep at that point, but most people seem to be glad to have taken it.

 

[fldoctorgirl]

My school actually does have a course similar to that in the last block of M2 before dedicated. People complain about it all the time because they only want to focus on Step prep at that point, but most people seem to be glad to have taken it.

Same with my school.

 

[efle]

My school actually does have a course similar to that in the last block of M2 before dedicated. People complain about it all the time because they only want to focus on Step prep at that point, but most people seem to be glad to have taken it.

Same with my school.

Glad to hear it. Funny that even the most high yield clinical prep is complained about for not taking a back seat to Step 1.

 

[FindersFee5]

Also hinges on what we think it means to be useful in 3rd year. I might be great and diagramming out all the different ways a heart can fail, but when I was asked what I wanted to do about it? Suddenly, it felt like knowing which drugs affect which part of the cardiac action potential was worthless trivia, and knowing actual diagnostic criteria and drug selection guidelines would've been time much better spent.

I've agreed with a lot of what you've said in this thread, but this I frankly couldn't disagree with this more strongly. Understanding cardiac physiology is like, the OPPOSITE of memorization. All the different types of heart failure are basically just applications of pressure volume loops, the Frank-Starling relationship, and some understanding of renal physiology. When you combine that with good mechanistic pharmaceutical knowledge, it's incredibly powerful.

I may not be able to come up with the answer as quickly as somebody who is just following guidelines, but there were multiple times during my ICU rotation that I proposed treatments based entirely on theoretical understanding of pharmacology and the pathophysiology. Most of my attendings really valued this input and actually tried some of the suggestions, with decent results.

 

[efle]

I've agreed with a lot of what you've said in this thread, but this I frankly couldn't disagree with this more strongly. Understanding cardiac physiology is like, the OPPOSITE of memorization. All the different types of heart failure are basically just applications of pressure volume loops, the Frank-Starling relationship, and some understanding of renal physiology. When you combine that with good mechanistic pharmaceutical knowledge, it's incredibly powerful.

I may not be able to come up with the answer as quickly as somebody who is just following guidelines, but there were multiple times during my ICU rotation that I proposed treatments based entirely on theoretical understanding of pharmacology and the pathophysiology. Most of my attendings really valued this input and actually tried some of the suggestions, with decent results.

I loved learning cardiac physio and pharma for that reason. But if I ever tried to justify an Assessment and Plan off of an action potential diagram and whether I thought their sodium vs potassium channels needed drugging, I'd hope my attending would laugh at me and tell me to look up the data/study outcomes to select the safest and most effective drugs instead

Edit: And if that particular example offends, there are plenty others to be had. Take my GABAergic drug example from earlier instead. You need to pick something to prevent seizures in the alcoholic going through withdrawals, are you going to reason it out based on whether their channels need to open with more frequency or more duration? Of course not. That'd be dumb. You're gonna go with whatever benzo your hospital likes for its half life and dosing profile.

And tying up our identity as better than midlevels because we know the frequency vs duration factoid just seems dangerous. We ought to be defending ourselves for the better experiential learning like what drugs to select because we saw a patient like that before. Not patting ourselves on the back for spending extra years on basic science mechanisms, that most providers prescribing those drugs don't even remember.

 

[Matthew9Thirtyfive]

There's enough stable content in OnlineMedEd/Step 2 CK materials. One could easily trim a few months off preclinical and put in a new 12-week unit at the end of MS2 that's essentially A Crash Course in Actually Doing Medicine.

Our school does something similar to this. We have a 16-month preclinical curriculum. Then there's a week-long intro to clerkships course followed by a year of core clerkships. After that we have 3 weeks of leave for winter break followed by 6 weeks of dedicated for Step 1. Then we have a 2-month course called Bench to Bedside and Beyond, followed by our final year and some change of electives.

 

[aldol16]

Each school does things differently. Some schools may emphasize memorizing random facts that help you do well on Step 1 but don't really help you reason clinically which is what the clinical years are about. Some schools emphasize both. But the main difficulty that I see is with how education typically works. Usually the lecturer lectures to the room. They're talking at you about some topic. So you get a ton of information about a specific topic in each lecture. This is basically how undergraduate education works as well. Same story.

The problem lies with how practicing medicine works. You don't start with a clinical condition and think about its epidemiology, symptoms, diagnosis, and treatment in isolation. You start with a symptom or collection of symptoms and have to come up with a differential diagnosis that might include three or twenty different diagnoses. Then you have to think about which tests to use that would separate them. That process is entirely different. In a way, it's going backwards, from symptom(s) to diagnosis instead of the other way around.

Some schools have re-designed their curriculum to help address this. For better or worse, some schools have tried the "flipped classroom" technique, where you can have students learn the lecture-type material beforehand and then use classroom time to walk through cases starting with a patient and how he or she presents.

 

[libertyyne]

IMO our education is designed to allow us to utilize a deep fund of knowledge and apply it to situations where no protocols or best practices even exist. These situations are not hard to find, every patient on my IM floor had multiple interacting co-morbidities that made standard management not necessarily the optimal course. So having to think about the basic pathophysiology was necessary. The price you pay for all of this is having to have a broad exposure to basic sciences and rare conditions.
True clinical Acumen is not the ability to regurgitate a protocol, that is going to be outdated by the time you have the opportunity to apply it, rather the ability to know when application of the protocol does not make sense and a different course of action is necessary. I think the art of medicine is usually relegated to the humanistic portion of medicine, but there is a good chunk of it to be found in the application of the sciences itself. Midlevels even with experience would have a difficult time replicating that sort of thinking.

 

[ExplodingUlcers]

IMO our education is designed to allow us to utilize a deep fund of knowledge and apply it to situations where no protocols or best practices even exist. These situations are not hard to find, every patient on my IM floor had multiple interacting co-morbidities that made standard management not necessarily the optimal course. So having to think about the basic pathophysiology was necessary. The price you pay for all of this is having to have a broad exposure to basic sciences and rare conditions.
True clinical Acumen is not the ability to regurgitate a protocol, that is going to be outdated by the time you have the opportunity to apply it, rather the ability to know when application of the protocol does not make sense and a different course of action is necessary. I think the art of medicine is usually relegated to the humanistic portion of medicine, but there is a good chunk of it to be found in the application of the sciences itself. Midlevels even with experience would have a difficult time replicating that sort of thinking.

Facts. I think this the post that can finally put the mid-level doom and gloom to rest.

Sent from my SM-G955U using SDN mobile

 

[efle]

Facts. I think this the post that can finally put the mid-level doom and gloom to rest.

Sent from my SM-G955U using SDN mobile

I mean, the hospitalist MDs managing complex inpatients have never been the ones scared of NPs taking their job. It's the people who spend all day managing outpatient HTN, DM, etc who are already being replaced by unsupervised midlevel practice in the Midwest and South. They have good reason to be worried, them and the specialty outpatient clinics that are very over-trained for a lot of their bread-and-butter work (looking at you, Derm).

 

[VA Hopeful Dr]

I mean, the hospitalist MDs managing complex inpatients have never been the ones scared of NPs taking their job. It's the people who spend all day managing outpatient HTN, DM, etc who are already being replaced by unsupervised midlevel practice in the Midwest and South. They have good reason to be worried, them and the specialty outpatient clinics that are very over-trained for a lot of their bread-and-butter work (looking at you, Derm).

No we don't

 

[efle]

No we don't

Really, this kind of thing shouldn't raise eyebrows for current med students considering outpatient primary care?

 

[VA Hopeful Dr]

Really, this kind of thing shouldn't raise eyebrows for current med students considering outpatient primary care?

Nope

 

[MedicineZ0Z]

Really, this kind of thing shouldn't raise eyebrows for current med students considering outpatient primary care?

You can do primary care and do minimal referrals and workup/manage things yourself. Or just do inpatient...

 

[efle]

Nope

Huh, thoughts on why the prevailing view seems to be the opposite on these boards? There's some pretty crazy numbers of yearly NP grads, their lobbies are def pushing for more states to turn green on that map, and even in the places I've lived where supervision is required, I've been seeing more setups where 1 MD in the back room supervises many NPs doing the actual visits.

Projecting out over 10-20 years where's their logic going wrong when they say it's going to be bad news for the PCP MD market?

 

[Dr. Anonymouss]

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.

what will be the determining factor towards specialties then? Pre-clinical grades aren’t a strong enough determinant as schools vary on curriculum and difficulty of exams. Not disagreeing with you, only trying to open dialogue towards alternatives and how I see it being too difficult to differentiate candidates

 

[efle]

what will be the determining factor towards specialties then? Pre-clinical grades aren’t a strong enough determinant as schools vary on curriculum and difficulty of exams. Not disagreeing with you, only trying to open dialogue towards alternatives and how I see it being too difficult to differentiate candidates

Well, what was it in the year 2000?

 

[VA Hopeful Dr]

Huh, thoughts on why the prevailing view seems to be the opposite on these boards? There's some pretty crazy numbers of yearly NP grads, their lobbies are def pushing for more states to turn green on that map, and even in the places I've lived where supervision is required, I've been seeing more setups where 1 MD in the back room supervises many NPs doing the actual visits.

Projecting out over 10-20 years where's their logic going wrong when they say it's going to be bad news for the PCP MD market?

It seems like every 4-6 months I have to write this exact same post, so everyone pay attention.

First, the sky has always been falling in medicine. Ask any of the older doctors: its always something that's going to ruin the field for us all. SDN is worse about that than the general population and has been since I joined in 2004.

Second, if you look at NP/PA recent graduates they are increasingly going into things other than primary care.

Third, patients are learning the difference and starting to care. Even our own @Goro was, until recently, very pro-midlevel. Then a midlevel screwed up something with a family member and he's come around. We're getting even more of this with the rise of high deductible plans. If you're paying $10 per office visit, you'll accept a midlevel without too much complaint. When you're paying the full $150 for an appointment all of a sudden it matters. When I had my DPC practice, I'd get at least 1-2 new patients per week who were happy to pay cash to me knowing that they would see a doctor every time they came in. Lots of hospitals are realizing this as well. If you look, most places have way more job postings for PCP MD/DOs than they do for PCP NP/PAs.

Fourth, the rapidly increasing NP graduation rates combined with the lax standards of many of the schools has really screwed up their job market. One of the NPs in my office just turned in her notice and is going back to being a regular RN because the pay is about the same. The hospital can do that because there are way more NPs than there are jobs for them so they can really low ball them.

Fifth, there are way more jobs in primary care than there are people to fill them. I live in SC which is right in the middle of the pack, population wise. There are currently over 50 FM jobs posted throughout the state. That number is actually low as many of the listings actually have multiple openings. For example, my hospital has 1 listing on PracticeLink but 6 open FM jobs. This also doesn't include jobs that are available but not posted. I know of 3 like that in my corner of the state so I expect there are more I just don't know about.

Sixth, in the next 5-10 years all of the baby boomer physicians are going to retire. In FM in 2017 25% of our doctors are over 60 years old. So, conservatively, in 10 years we're going to lose 1/4th of the FPs in the country.

As for offices where 1 doctor is supervising lots of midlevels while they don't actually see patients - that's becoming increasingly uncommon. Hospital systems aren't going to allow it, its mainly older PP doctors and they are retiring.

 

[AnatomyGrey12]

Funny thing about rare diseases: while they are individually rare, lump them all together and you end up with something fairly common. All practitioners see rare diseases on a regular basis. They just can't predict which ones they will come across. The only case I alpha 1-antitrypsin deficiency I have ever seen was in a rural primary care office.

Our school produces a lot of primary care physicians for the state and we have been told numerous times that every PC in the state will average at least 1 very rare disease each year exactly for this reason. Rare disease are rare when considered individually, but there are a lot of rare diseases and when considered in aggregate they are more common than you would think.

Also hinges on what we think it means to be useful in 3rd year. I might be great and diagramming out all the different ways a heart can fail, but when I was asked what I wanted to do about it? Suddenly, it felt like knowing which drugs affect which part of the cardiac action potential was worthless trivia, and knowing actual diagnostic criteria and drug selection guidelines would've been time much better spent.

This is literally the point of 3rd year.... to take the knowledge we learned in the first 2 years and learn how to apply it to clinical situations.

 

[Chemist0157]

It seems like every 4-6 months I have to write this exact same post, so everyone pay attention.

First, the sky has always been falling in medicine. Ask any of the older doctors: its always something that's going to ruin the field for us all. SDN is worse about that than the general population and has been since I joined in 2004.

Second, if you look at NP/PA recent graduates they are increasingly going into things other than primary care.

Third, patients are learning the difference and starting to care. Even our own @Goro was, until recently, very pro-midlevel. Then a midlevel screwed up something with a family member and he's come around. We're getting even more of this with the rise of high deductible plans. If you're paying $10 per office visit, you'll accept a midlevel without too much complaint. When you're paying the full $150 for an appointment all of a sudden it matters. When I had my DPC practice, I'd get at least 1-2 new patients per week who were happy to pay cash to me knowing that they would see a doctor every time they came in. Lots of hospitals are realizing this as well. If you look, most places have way more job postings for PCP MD/DOs than they do for PCP NP/PAs.

Fourth, the rapidly increasing NP graduation rates combined with the lax standards of many of the schools has really screwed up their job market. One of the NPs in my office just turned in her notice and is going back to being a regular RN because the pay is about the same. The hospital can do that because there are way more NPs than there are jobs for them so they can really low ball them.

Fifth, there are way more jobs in primary care than there are people to fill them. I live in SC which is right in the middle of the pack, population wise. There are currently over 50 FM jobs posted throughout the state. That number is actually low as many of the listings actually have multiple openings. For example, my hospital has 1 listing on PracticeLink but 6 open FM jobs. This also doesn't include jobs that are available but not posted. I know of 3 like that in my corner of the state so I expect there are more I just don't know about.

Sixth, in the next 5-10 years all of the baby boomer physicians are going to retire. In FM in 2017 25% of our doctors are over 60 years old. So, conservatively, in 10 years we're going to lose 1/4th of the FPs in the country.

As for offices where 1 doctor is supervising lots of midlevels while they don't actually see patients - that's becoming increasingly uncommon. Hospital systems aren't going to allow it, its mainly older PP doctors and they are retiring.

Yeah, but, they’re taking all our jerbs.

 

[efle]

It seems like every 4-6 months I have to write this exact same post, so everyone pay attention.

First, the sky has always been falling in medicine. Ask any of the older doctors: its always something that's going to ruin the field for us all. SDN is worse about that than the general population and has been since I joined in 2004.

Second, if you look at NP/PA recent graduates they are increasingly going into things other than primary care.

Third, patients are learning the difference and starting to care. Even our own @Goro was, until recently, very pro-midlevel. Then a midlevel screwed up something with a family member and he's come around. We're getting even more of this with the rise of high deductible plans. If you're paying $10 per office visit, you'll accept a midlevel without too much complaint. When you're paying the full $150 for an appointment all of a sudden it matters. When I had my DPC practice, I'd get at least 1-2 new patients per week who were happy to pay cash to me knowing that they would see a doctor every time they came in. Lots of hospitals are realizing this as well. If you look, most places have way more job postings for PCP MD/DOs than they do for PCP NP/PAs.

Fourth, the rapidly increasing NP graduation rates combined with the lax standards of many of the schools has really screwed up their job market. One of the NPs in my office just turned in her notice and is going back to being a regular RN because the pay is about the same. The hospital can do that because there are way more NPs than there are jobs for them so they can really low ball them.

Fifth, there are way more jobs in primary care than there are people to fill them. I live in SC which is right in the middle of the pack, population wise. There are currently over 50 FM jobs posted throughout the state. That number is actually low as many of the listings actually have multiple openings. For example, my hospital has 1 listing on PracticeLink but 6 open FM jobs. This also doesn't include jobs that are available but not posted. I know of 3 like that in my corner of the state so I expect there are more I just don't know about.

Sixth, in the next 5-10 years all of the baby boomer physicians are going to retire. In FM in 2017 25% of our doctors are over 60 years old. So, conservatively, in 10 years we're going to lose 1/4th of the FPs in the country.

As for offices where 1 doctor is supervising lots of midlevels while they don't actually see patients - that's becoming increasingly uncommon. Hospital systems aren't going to allow it, its mainly older PP doctors and they are retiring.

Much appreciate the perspective! I didn't realize employers were passing over NPs and willing to pay far more for MD/DO

 

[libertyyne]

Much appreciate the perspective! I didn't realize employers were passing over NPs and willing to pay far more for MD/DO

SC is also a restricted practice state for NPs.

At the rate NPs have been expanding it will only be some time before everyone in america who isnt a Physician will be an NP.
Previous analyses I have seen where NPs were given full practice rights physician compensation in those states did not decrease, rather increased.
I am unsure what the future holds, But this is a political problem and requires a political solution. That and stop training NPs when you are in a position to refuse to do so.

 

[efle]

SC is also a restricted practice state for NPs.

At the rate NPs have been expanding it will only be some time before everyone in america who isnt a Physician will be an NP.
Previous analyses I have seen where NPs were given full practice rights physician compensation in those states did not decrease, rather increased.
I am unsure what the future holds, But this is a political problem and requires a political solution. That and stop training NPs when you are in a position to refuse to do so.

Fair point, it probably depends on ton on your state. There's some wild **** out there - for example Oregon and Washington allow Naturopathic docs to practice with the ability to order pharmaceuticals and perform minor procedures. No issues for an NP that wants to set up primary care gig there, at all.

 

[MedicineZ0Z]

Huh, thoughts on why the prevailing view seems to be the opposite on these boards? There's some pretty crazy numbers of yearly NP grads, their lobbies are def pushing for more states to turn green on that map, and even in the places I've lived where supervision is required, I've been seeing more setups where 1 MD in the back room supervises many NPs doing the actual visits.

Projecting out over 10-20 years where's their logic going wrong when they say it's going to be bad news for the PCP MD market?

Lol go to a GI clinic then. GI doc is doing scopes while army of midlevels sees his consults. Or just go to any specialty clinic nowadays... It is NOT a PCP issue at all. They're in every field dude. Even things like a pediatric stroke specialist has an NP in it. NICU is over run by NPs. PAs all over ICUs. EP has **** tons of NPs. Code stroke has a midlevel come running down to give tpa. It's in every field...

 

[efle]

Lol go to a GI clinic then. GI doc is doing scopes while army of midlevels sees his consults. Or just go to any specialty clinic nowadays... It is NOT a PCP issue at all. They're in every field dude. Even things like a pediatric stroke specialist has an NP in it. NICU is over run by NPs. PAs all over ICUs. EP has **** tons of NPs. Code stroke has a midlevel come running down to give tpa. It's in every field...

I thought PCP would get hit the hardest in the places where an NP can practice unsupervised. Then it's a direct competitor for your practice. If I'm a GI and I'm using midlevels to let me spend more of my time scoping, that seems like less of a threat to other MDs, unless there's not enough colonoscopies to go around. As far as I've seen the GI style setup is still booked solid even in large cities.

 

[MedicineZ0Z]

I thought PCP would get hit the hardest in the places where an NP can practice unsupervised. Then it's a direct competitor for your practice. If I'm a GI and I'm using midlevels to let me spend more of my time scoping, that seems like less of a threat to other MDs, unless there's not enough colonoscopies to go around. As far as I've seen the GI style setup is still booked solid even in large cities.

You missed the point. You can offload workload to midlevels and lower job demand.

 

[efle]

You missed the point. You can offload workload to midlevels and lower job demand.

Sure, if there's not enough colonoscopies to go around. But if business is booming, which it was at the GI center I worked in before med school, it makes everyone more efficient without any MDs having unfilled slots on their schedules.

 

[MedicineZ0Z]

Sure, if there's not enough colonoscopies to go around. But if business is booming, which it was at the GI center I worked in before med school, it makes everyone more efficient without any MDs having unfilled slots on their schedules.

Again, you're referencing isolated examples. What happens when our colon cancer screening technology improves and reimbursement drops?

 

[efle]

Again, you're referencing isolated examples. What happens when our colon cancer screening technology improves and reimbursement drops?

I mean, seems a little unfair to blame midlevels for the effects of tech advancements or fee schedules. What's the alternative, we intentionally keep our GIs working at lower efficiency over these hypothetical boogeymen? I guess we also ought to be intentionally training too few GIs to meet the current demand, just in case?

 

[MedicineZ0Z]

I mean, seems a little unfair to blame midlevels for the effects of tech advancements or fee schedules. What's the alternative, we intentionally keep our GIs working at lower efficiency over these hypothetical boogeymen? I guess we also ought to be intentionally training too few GIs to meet the current demand, just in case?

The real issue is midlevels taking over all "simple" consults.

 

[Chemist0157]

We have Godwin's law. Is there a "law" at this point for threads to be derailed by NP/PA discussions?

 

[Chemist0157]

Chemist0157's law - "As an SDN thread grows longer, the probability of derailment by a PA/NP discussion approaches 1."

Mine!!!

 

[Goro]

Chemist0157's law - "As an SDN thread grows longer, the probability of derailment by a PA/NP discussion approaches 1."

Mine!!!

And there, folks, we have a new SDN paradigm!

Don't forget that we also have Burnett's Law: The longer a thread, the greater the likelihood that someone's ability to be a good doctor will be doubted.

 

[Splenda88]

Also hinges on what we think it means to be useful in 3rd year. I might be great and diagramming out all the different ways a heart can fail, but when I was asked what I wanted to do about it? Suddenly, it felt like knowing which drugs affect which part of the cardiac action potential was worthless trivia, and knowing actual diagnostic criteria and drug selection guidelines would've been time much better spent.

You will know these stuffs for step2/3. But I agree with your overall point about step1 arms race.

 

[mehc012]

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 just think that those students are wasting their time. You don't need to know every cellular signalling step and protein name, etc. to do well in the current system. Much of it can be done with the sort of learning that everyone on here is advocating for. It's just that people would rather skip that (it's hard for someone to market a 'system' for learning how the concepts work and interlace) and do Anki instead. Which is fine, but they don't then get to complain about the system 'making' them Anki. UFAPS is a shortcut in that it increases the brute force work and decreases the thought/nuance necessary to get the scores. Studying that way is a choice.
My medical school didn't even DO multiple choice exams and our Step average is just fine. They focused on patient cases, thinking through them, and connecting concepts. If they hadn't, I'd have definitely gone the UFAPS route, and I'm glad they didn't. I got to do perfectly well on Step 1 and Step 2 without ever reading through all of FA, doing any Zanki/Bros, and not even completing UW once.

 

[efle]

I just think that those students are wasting their time. You don't need to know every cellular signalling step and protein name, etc. to do well in the current system. Much of it can be done with the sort of learning that everyone on here is advocating for. It's just that people would rather skip that (it's hard for someone to market a 'system' for learning how the concepts work and interlace) and do Anki instead. Which is fine, but they don't then get to complain about the system 'making' them Anki. UFAPS is a shortcut in that it increases the brute force work and decreases the thought/nuance necessary to get the scores. Studying that way is a choice.
My medical school didn't even DO multiple choice exams and our Step average is just fine. They focused on patient cases, thinking through them, and connecting concepts. If they hadn't, I'd have definitely gone the UFAPS route, and I'm glad they didn't. I got to do perfectly well on Step 1 and Step 2 without ever reading through all of FA, doing any Zanki/Bros, and not even completing UW once.

Suppose you would've hit a 270 if you did mature zanki instead. Then take it a step further and suppose instead of going 250s to 270, itd be the difference from 230s to 250. Might change your take on things especially if you wanted to match a surgical subspecialty!

 

[Chemist0157]

And there, folks, we have a new SDN paradigm!

Don't forget that we also have Burnett's Law: The longer a thread, the greater the likelihood that someone's ability to be a good doctor will be doubted.

That was the other one I could not remember off hand.

 

[MedicineZ0Z]

Suppose you would've hit a 270 if you did mature zanki instead. Then take it a step further and suppose instead of going 250s to 270, itd be the difference from 230s to 250. Might change your take on things especially if you wanted to match a surgical subspecialty!

Instead of spending 2 years to excel at your career, you spend 2 years learning irrelevant facts to get into your future career. Silly and a waste of time, especially following that logic.

 

[ace_inhibitor111]

Instead of spending 2 years to excel at your career, you spend 2 years learning irrelevant facts to get into your future career. Silly and a waste of time, especially following that logic.

The medical school curriculum is built for general medicine/surgery. If you’re planning to subspecialize into ophthalmology, orthopedics, ENT, or even psychiatry, then most of third and fourth year are also a waste of time.

 

[efle]

Instead of spending 2 years to excel at your career, you spend 2 years learning irrelevant facts to get into your future career. Silly and a waste of time, especially following that logic.

Cant excel at my intended career if I can't match my intended career

 

[mehc012]

Suppose you would've hit a 270 if you did mature zanki instead. Then take it a step further and suppose instead of going 250s to 270, itd be the difference from 230s to 250. Might change your take on things especially if you wanted to match a surgical subspecialty!

That's not my point...I did study, I just studied differently. It's not a question of "do nothing or do Zanki, and Zanki will improve your score". It's a question of "study in a concept based way, or study with Zanki...either one will get you a good score." Obviously doing both would be even better.

I've finally realized, after a lot of time spent being disappointed in myself for never managing to stick to the 'right' study methods (aka Zanki, UFAPS) and 'coasting' on smarts, that I was in fact studying, just in a less brute-force-memorization way and more of a understand-concepts-extrapolate-and-anchor-memory way. The downside is, it's not as easy to ensure thoroughness, so it feels inherently risky, and it's harder to guide someone into doing.

I honestly don't know what the 'right' answer is. I think both methods get you to the finish line. I think that those who advocate for a less memorization-heavy, more conceptual learning style in medical school don't always sit back and think of what that would mean for med school exams (multiple choice would be a poor medium for it), etc.

 

[efle]

That's not my point...I did study, I just studied differently. It's not a question of "do nothing or do Zanki, and Zanki will improve your score". It's a question of "study in a concept based way, or study with Zanki...either one will get you a good score." Obviously doing both would be even better.

I've finally realized, after a lot of time spent being disappointed in myself for never managing to stick to the 'right' study methods (aka Zanki, UFAPS) and 'coasting' on smarts, that I was in fact studying, just in a less brute-force-memorization way and more of a understand-concepts-extrapolate-and-anchor-memory way. The downside is, it's not as easy to ensure thoroughness, so it feels inherently risky, and it's harder to guide someone into doing.

I honestly don't know what the 'right' answer is. I think both methods get you to the finish line. I think that those who advocate for a less memorization-heavy, more conceptual learning style in medical school don't always sit back and think of what that would mean for med school exams (multiple choice would be a poor medium for it), etc.

Religiously flashcarding UFAPS content into your brain will improve your score over the more thoughtful school curriculum, that's the unfortunate truth that was so frustrating for me to realize. I've watched it move an entire student body up by nearly a full standard deviation. You're an elite college grad with a 40+ MCAT, your performance even while half-assing or cramming the best resources will still be comfortable, but if you were an Average Joe test-taker interested in a surgical subspecialty and you tried your approach, you'd be putting yourself in a very bad spot.

Philosophically I'm on the same page as you about what it should be like to learn in medical school, I just disagree about whether they really both get a randomly picked person to the same finish line.

 

[ooh a bean]

Religiously flashcarding UFAPS content into your brain will improve your score over the more thoughtful school curriculum, that's the unfortunate truth that was so frustrating for me to realize. I've watched it move an entire student body up by nearly a full standard deviation. You're an elite college grad with a 40+ MCAT, your performance even while half-assing or cramming the best resources will still be comfortable, but if you were an Average Joe test-taker interested in a surgical subspecialty and you tried your approach, you'd be putting yourself in a very bad spot.

Philosophically I'm on the same page as you about what it should be like to learn in medical school, I just disagree about whether they really both get a randomly picked person to the same finish line.

Anecdotally, my med school class took a CBSE a couple of months ago, and out of my friend group of 10 people in the class (in a <100 person class), all 10 of us do Zanki religiously, and all 10 of us scored 10 to 40 pts above the class average on the exam. I had done <50 practice questions to that point and still was able to score above the class average.

 

[mehc012]

Religiously flashcarding UFAPS content into your brain will improve your score over the more thoughtful school curriculum, that's the unfortunate truth that was so frustrating for me to realize. I've watched it move an entire student body up by nearly a full standard deviation. You're an elite college grad with a 40+ MCAT, your performance even while half-assing or cramming the best resources will still be comfortable, but if you were an Average Joe test-taker interested in a surgical subspecialty and you tried your approach, you'd be putting yourself in a very bad spot.

Philosophically I'm on the same page as you about what it should be like to learn in medical school, I just disagree about whether they really both get a randomly picked person to the same finish line.

What are you even comparing to, there? I'm not saying that anyone who studies from their med school curriculum will do well, I'm saying that people who focus on learning the concepts in a really fundamental, concrete way will do well. Most curricula don't do that, and it's not 'sold' because it's not something you can really explain to someone how to do or package conveniently for them.

 

[efle]

What are you even comparing to, there? I'm not saying that anyone who studies from their med school curriculum will do well, I'm saying that people who focus on learning the concepts in a really fundamental, concrete way will do well. Most curricula don't do that, and it's not 'sold' because it's not something you can really explain to someone how to do or package conveniently for them.

I'm comparing learning concepts, as in what expert clinicians want us to get out of small group sessions with them, against sitting at home in your PJs memorizing tens of thousands of flashcards. And I'm saying that in the current climate, it's only exam-crushing outliers who can get scores that leave all doors open without the latter.