Poor grades in med school

[TheSky]

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If I were to make straight C's through the first two years of medical school and have an average Step 1 score, have I screwed up my chances of getting into a residency (maybe something in pediatrics or IM)? This is hypothetical but it might make me feel better about my current grades.

 

[JeffLebowski]

If I were to make straight C's through the first two years of medical school and have an average Step 1 score, have I screwed up my chances of getting into a residency (maybe something in pediatrics or IM)? This is hypothetical but it might make me feel better about my current grades.

No, you'll match somewhere just fine in peds or IM, as long as you have a solid application strategy per http://www.nrmp.org/data/chartingoutcomes2007.pdf. The nice thing about peds and IM is that they're a very large, heterogenous group of programs and applicants. The majority of med students across the country go into IM, and I think peds is 2nd on the list. I like reading these posts. You have goals matched well with your performance and expectations that are realistic and optimistic. It gets annoying when all you see is "help! I've got a 201 and am bottom 1/3 of my class, can I still match neurosurg?!" or "help! I've got a 245, 4.0, MD/PhD, 10 first author publications, can I still match radiology?!" You'll be fine. That said, do your best at every turn as much as you can - and you'll have no regrets about what you did, where you match, how you match, and what that means for your future.

 

[njbmd]

If you graduate, you can get into a residency in Peds or IM. Can you get into a top university program in Peds or IM with average grades and Step I scores? Probably not but you can likely match into a solid program that will train you well as neither of these two specialties are uber competitive if you are a U.S. grad.

 

[Esteban24]

From what I understand, your grades throughout your first two years are the last thing many residencies look for. However, it goes without saying that there are certain competitive residencies who will screen you by your grades. I'm in a similar situation and the way I'm approaching it is by trying to keep the big picture in mind. Pharm, Physio, and Path are the 3 biggest topics on your boards. If you can focus your energy on really understanding those 3 subjects you should do well on the boards (assuming you review the other subjects as well, of course) and more importantly, in understanding medicine.
With the constant testing and studying that we do its easy to forget that we WILL be expected to know and understand a lot of things, in facts lives may depend on it.
While some of us may not excel in book studying, its important to keep in mind the big topics that we'll be expected to know and how they're going to apply to our patients.

That being said... if you just wanted to know which residencies you could still get into I wouldn't really worry about it too much. EM, Peds, Surgery, and IM (which is a window into other specialities like Cardio) are still possible, along with others.

 

[sirus_virus]

If I were to make straight C's through the first two years of medical school and have an average Step 1 score, have I screwed up my chances of getting into a residency (maybe something in pediatrics or IM)? This is hypothetical but it might make me feel better about my current grades.

IM and peds will be more than happy to hear you are interested.

 

[TheSky]

Thanks, I am feeling ever-so-slightly better. All I really want to do is become a doctor and help people (I know, I know, very cliche), in any specialty that I can.

 

[45408]

IM and peds will be more than happy to hear you are interested.

Word. If someone had a bona fide interest in either specialty, it shouldn't be hard for a US grad to land a spot, as long as you're not an ass at your interview.

 

[Droopy Snoopy]

Year 1/2 grades are pretty low on the totem pole of what residency program directors care about when selecting applicants. Of course the more you learn years 1/2 = better StepI = better clinical grades, both of which are quite high on the pole.

 

[docscience]

i think this issue has been talked about ad naseum (perhaps by me), but the general conclusion seems to be that ones grades do not matter especially if the school is designed as an H/P/F or something similar how is a PD going to know how good of a student you are? - USMLE step 1 scores (which can be argued correlate with grades) - 3rd year clinical grades I think these are the top two aspects of an applicants file that PDs look at. Any other opinions?

 

[khadija]

i understand what everyone is saying about MS1 & 2 grades not being that important in the scheme of things. But don't those same grades affect your rank, and isn't rank important?

 

[rmm262002]

i understand what everyone is saying about MS1 & 2 grades not being that important in the scheme of things. But don't those same grades affect your rank, and isn't rank important?

As I unfortunately learned this week, yes

 

[JeffLebowski]

i understand what everyone is saying about MS1 & 2 grades not being that important in the scheme of things. But don't those same grades affect your rank, and isn't rank important?

Yes. Don't let anyone tell you "M1 & M2 grades aren't important". They are important. Just not quite as important as Step I & clinical grades. But yes, it's absolutely important, because: 1) it's another objective measure, 2) it determines AOA status, 3) it determines class rank, 4) it comes across in your Dean's letter, 5) if you're shooting for a competitive specialty or a competitive program, you're competing against people who've "got it all". If you don't, that's a potential reason to ding you down their rank list. That said, it's not as dramatic as all that, by my reckoning. Just do your best, make no mistake that your work and effort is well-spent getting good grades, that they will indeed look good when you're applying for residency, and that you'll have no regrets about what corners you chose to cut because you listened to folks who claimed "who cares". The difference between good and stellar is caring about the stuff other people don't tend to care about. Just try not to go nuts in the meantime.

 

[vtucci]

Class rank is important but third year is often worth first and second year combined. A stellar performance in third year can make up for a multitude of sins in MSI and MSII. You still will need a solid showing on Step I, II, good LORs and a solid Dean's letter no matter what specialty you decide on.

Keep in mind a lot of people change their minds. Some of my classmates came in being set on neurosurg--> now in neuro, OB/GYN. Others were interested in EM--> now interventional radiology. Some family medicine--> ENT surgery. Some internal--> ophthalmology.

The better your stats, the more wiggle room you will have if you change your mind or the more competitive program you can get into in peds or medicine.

 

[docscience]

i understand what everyone is saying about MS1 & 2 grades not being that important in the scheme of things. But don't those same grades affect your rank, and isn't rank important?

As another poster said...it does influence your AOA status...but that is it.

At our school, class rank is only put on the Dean's letter if asked...in actuality, all schools got rid of the "dean's letter" and are writing a medical student performance evaluation (MSPE). It has a tiny paragraph (at least in my school) about how your performed in year 1 and 2...mentioning any honors that you received and/or any classes that you failed.

I still stand by that class rank doesn't really matter at all.
A PD is not going to know if you were 57th in class or 83rd.

 

[SomeDoc]

Yes. Don't let anyone tell you "M1 & M2 grades aren't important". They are important. Just not quite as important as Step I & clinical grades. But yes, it's absolutely important, because: 1) it's another objective measure, 2) it determines AOA status, 3) it determines class rank, 4) it comes across in your Dean's letter, 5) if you're shooting for a competitive specialty or a competitive program, you're competing against people who've "got it all". If you don't, that's a potential reason to ding you down their rank list. That said, it's not as dramatic as all that, by my reckoning. Just do your best, make no mistake that your work and effort is well-spent getting good grades, that they will indeed look good when you're applying for residency, and that you'll have no regrets about what corners you chose to cut because you listened to folks who claimed "who cares". The difference between good and stellar is caring about the stuff other people don't tend to care about. Just try not to go nuts in the meantime.

Not really.

That being said, you want to do your best anyway. Gives more wiggle room as previously stated.

 

[michaelrack]

Psychiatry is also a possibility with mediocre grades.

 

[Law2Doc]

If I were to make straight C's through the first two years of medical school and have an average Step 1 score, have I screwed up my chances of getting into a residency (maybe something in pediatrics or IM)? This is hypothetical but it might make me feel better about my current grades.

The nice thing about going into a profession where there are more residency slots than US allo med school graduates is that if you are a US allo student pass everything, there will be a place for you someplace. Doing better opens more doors, makes you less likely to have to relocate geographically. But you will have a job at the end of the 4 years if you want it, even if you get straight Cs and pass Step 1 with the lowest possible passing score. Enjoy the fact that you definitely working with a safety net, and cannot really fall all that far.

 

[45408]

Just remember that some of this advice can be misleading. If you do very well in your first two years, you'll probably do well on Step 1. The highest score in my class - that I know of - came from someone who honored basically everything.

Likewise, when your attending asks you "What's this nerve?" or "Which of these medications are causing this patient's prolonged QT interval?" it'll be a big help if you know that sort of thing.

 

[SomeDoc]

If you are highly motivated to do well in class, chances are that you are highly motivated to do very well on the boards as well, so there is some self-selection involved. How many students who perform highly on the boards remembered all the details of biochem, a course taken a year ago that they aced, at the start of board prep?

Self-selection a la wikipedia:
Self-selection makes it difficult to determine causation. For example, one might note significantly higher test scores among those who participate in a test preparation course, and credit the course for the difference. However, due to self-selection, there are a number of differences between the people who chose to take the course and those who chose not to. Arguably, those who chose to take the course might have been more hard-working, studious, and dedicated than those who did not, and that difference in dedication may have affected the test scores between the two groups. If that was the case, then it is not meaningful to simply compare the two sets of scores. Due to self-selection, there were other factors affecting the scores than merely the course itself.

http://en.wikipedia.org/wiki/Self-selection

 

[GZA]

Self-selection?

Ho, ho, ho! I would probably have tagged this as a correlation caused by a common variable; motivation, so to speak.

You select not to apply to derm because you, well, performed poorly during preclinical years etc.; you self-select, as they say.

You don't select not to study for step 1 because of poor preclinical grades; the same other factor causes it.

 

[Law2Doc]

Self-selection?

Ho, ho, ho! I would probably have tagged this as a correlation caused by a common variable; motivation, so to speak.

You select not to apply to derm because you, well, performed poorly during preclinical years etc.; you self-select, as they say.

You don't select not to study for step 1 because of poor preclinical grades; the same other factor causes it.

Agreed. self selection is not the right concept being applied here, and I think the term is actually misused in that wiki example. There is a correlation, but one's selection isn't really it.

That's the danger of relying on a database where anyone can type something in, whether they are knowledgeable or not. It's why a lot of folks in medicine will get upset with you if you rely on wiki. It's only as good as the person who types stuff in, which isn't always that good 100% of the time. I think this is an example of such.

 

[Jwax]

That's the danger of relying on a database where anyone can type something in, whether they are knowledgeable or not. It's why a lot of folks in medicine will get upset with you if you rely on wiki. It's only as good as the person who types stuff in, which isn't always that good 100% of the time. I think this is an example of such.

For what it's worth, throughout the first semester of med school, I compared what wiki has to say about whatever disease / drug / whatever I come across with what is on our syllabus / texts (that I wanted to look up... which was often). To this point, I have not seen a single thing that is inconsistent. Wiki may lack in some of the finer details, but so far I haven't noticed any blatant inaccuracies. Thus is my defense of my excessive wiki use (I really like "smart doctor" concepts to be dumbed down to layman's terms first before I try to comprehend the doctor babble from our professors.

 

[meister]

I have been told by actual program directors here that pre-clinical grades are not very important at all. We had one PD tell us that they accepted a guy into EM who had failed a couple classes but excelled in a couple rotations in M3 and did very well on step 1.

So don't intentionally sabotage yourself but just do the best you can without being a recluse. That's my approach anyway. Then for the few months before step 1 next year I will be a recluse.

 

[docscience]

just another anecdotal piece of evidence...i know a guy who failed two classes, did decent on step one, did some cool research and is now doing internal med and just landed a cardiology fellowship...

F&*^ the competition and the crazy expectations....work hard, learn medicine and the rest will be all gravy

 

[JeffLebowski]

just another anecdotal piece of evidence...i know a guy who failed two classes, did decent on step one, did some cool research and is now doing internal med and just landed a cardiology fellowship...

F&*^ the competition and the crazy expectations....work hard, learn medicine and the rest will be all gravy

I wouldn't expect to match impressively having failed classes, though. With good reason. I mean come on, this isn't a "everyone's a winner, you're okay I'm okay" situation here.

Edit: and I just want to add that there's a lot of people that think "eh I'll just wing it for now and crush Step 1" which is the wrong attitude. While I agree with the sentiment that we should do our best and match our expectations and measure of success with doing our best, just don't expect it to bring the same results as someone who achieved more.

 

[docscience]

I wouldn't expect to match impressively having failed classes, though. With good reason. I mean come on, this isn't a "everyone's a winner, you're okay I'm okay" situation here.

Edit: and I just want to add that there's a lot of people that think "eh I'll just wing it for now and crush Step 1" which is the wrong attitude. While I agree with the sentiment that we should do our best and match our expectations and measure of success with doing our best, just don't expect it to bring the same results as someone who achieved more.

He did not match at MGH or the Cleveland Clinic, but he matched at USF and he is doing quite well.

And how do you define "someone who achieved more"...does that mean someone who memorized a subtle pathological detail about a bacteria that isn't clincally applicable? For example, does it matter a ton if you know that the virus is ssDNA, RNA negative or positive strand, histones, etc. It is good basic science...and impressive that some are able to remember all that, but academic achievement is different from clinical achievement also, though the two do have a correlation.

All I was trying to say is, work hard, have good intentions of being a competent physician, and be genuinely passionate about all this and things will work out.

 

[Droopy Snoopy]

He did not match at MGH or the Cleveland Clinic, but he matched at USF and he is doing quite well.

And how do you define "someone who achieved more"...does that mean someone who memorized a subtle pathological detail about a bacteria that isn't clincally applicable? For example, does it matter a ton if you know that the virus is ssDNA, RNA negative or positive strand, histones, etc. It is good basic science...and impressive that some are able to remember all that, but academic achievement is different from clinical achievement also, though the two do have a correlation.

All I was trying to say is, work hard, have good intentions of being a competent physician, and be genuinely passionate about all this and things will work out.

The OP is seeking real advice for a real issue, not pre-allo cheerleading. He needs to buckle down and work hard, not trust to the stories we all have of friends' friends who failed four classes but matched ortho. In that vein your third paragraph was completely appropriate, the first two were crap.

How exactly does one have the wisdom to know what's 'important' and what's not, as well as the focus to tune it out? The fact is someone who tries to pick out only the 'important' stuff is a fool, because an M1 has no idea what is and is not clinically applicable. This argument is a like a universal defense mechanism for students who don't do so hot. Not that there's anything wrong with that, like you said do your best and whatnot. But don't fool yourself trying to put it off like you're so wise that your 70% encompasses all the important information, the rest was garbage, and that you planned it that way from the beginning. Own it.

 

[Jwax]

How exactly does one have the wisdom to know what's 'important' and what's not, as well as the focus to tune it out? The fact is someone who tries to pick out only the 'important' stuff is a fool, because an M1 has no idea what is and is not clinically applicable. This argument is a like a universal defense mechanism for students who don't do so hot. Not that there's anything wrong with that, like you said do your best and whatnot. But don't fool yourself trying to put it off like you're so wise that your 70% encompasses all the important information, the rest was garbage, and that you planned it that way from the beginning. Own it.

I think that even those who ace the first two years will agree that a large portion of what we learn is crap. That which is important we have pounded into our (thick) skulls. I think that to say 70% of what we learn is clinically relavent seems a bit of a stretch. If 70% wasn't enough for us to be competent physicians, the grades needed to pass med school would require us to get more. I have spoken with many physicians about the importance of learning from M1 & 2 and they have universally advised me that very little of it is of use. I think the importance of M1&2 is so that we can understand what they teach us in our clinical training, kind of like how despite the fact that we don't directly use any of the stuff we learned in O-chem or physics, we needed our UG prep courses so we could understand what we're taught in our BS med school courses.

Personally, I don't have the willpower to put in the time & effort that it takes to ace our classes. Kuddos to those who do. So I will admit that in part the above belief has been formed to validate not putting in the extra effort, but I truly believe that I will be just as capable of a physician as most of those who do put in that effort. Those who slave away will get rewarded with their plastics/derm/ophtho practices and those who don't will be rewarded with their peds/internal med/family practices. We're all going to be equally happy or equally unhappy regardless of how it turns out. I think there was a study awhile back about how only a very small percentage of medical mistakes were made due to lack of knowledge.

So... on that note... go vote!

 

[docscience]

Personally, I don't have the willpower to put in the time & effort that it takes to ace our classes. Kuddos to those who do. So I will admit that in part the above belief has been formed to validate not putting in the extra effort, but I truly believe that I will be just as capable of a physician as most of those who do put in that effort. Those who slave away will get rewarded with their plastics/derm/ophtho practices and those who don't will be rewarded with their peds/internal med/family practices. We're all going to be equally happy or equally unhappy regardless of how it turns out. I think there was a study awhile back about how only a very small percentage of medical mistakes were made due to lack of knowledge.

So... on that note... go vote!

Well said.
One will be or will have to be happy with the consequences of doing "poorly" in medical school...those consequences being not as competitive for certain specialties. But I believe if you have the passion for something, poor preclinical grades will not stop one from achieving that goal.

I hope people won't be using formulas that they learned for the spring constant for the MCAT as physicians. "You might kill someone if you don't know how uranium's outer shell electrons would act in a reaction." I do however think it is important to be well rounded, but intelligence/and or the ability to be a good physician should not be judged on memorizing BS detail about histones. I also do conceded that as MS1 and 2s one probably does not know what is clinically relevant.

I just wish people would remember that as a physician you can fill many positions...clinicians, researchers (who would/should know details), administrators, etc. etc.

Sorry about rambling.

 

[JeffLebowski]

Well said.
One will be or will have to be happy with the consequences of doing "poorly" in medical school...those consequences being not as competitive for certain specialties. But I believe if you have the passion for something, poor preclinical grades will not stop one from achieving that goal.

I hope people won't be using formulas that they learned for the spring constant for the MCAT as physicians. "You might kill someone if you don't know how uranium's outer shell electrons would act in a reaction." I do however think it is important to be well rounded, but intelligence/and or the ability to be a good physician should not be judged on memorizing BS detail about histones. I also do conceded that as MS1 and 2s one probably does not know what is clinically relevant.

I just wish people would remember that as a physician you can fill many positions...clinicians, researchers (who would/should know details), administrators, etc. etc.

Sorry about rambling.

Yeah, I agree with you.

The only additional thing I'll add is that in my opinion the whole "most of M1 & M2 material is totally irrelevant to being a doctor" is another falsehood perpetuated by people who didn't succeed at a high level during M1/2. The doctors I respect most have an impressive grasp of even basic physiology, anatomy, etc. and have it as part of their intellectual repertoire. Further, the doctors I respect most are science-minded enough to stay up to date on literature. Do you need to know the intracellular signalling cascade of a cytokine to treat cancer? No, but you may need to know it to understand why a new drug works, or why the drug-sponsored research on said drug is questionable, or what laboratory phenomena to expect when treating with said drug. The point is, this is medical school, it's a tough argument to say medical school grades don't mean anything, and it's a tough argument to say medical school coursework doesn't have any bearing on being a medical doctor.

 

[GZA]

Yeah, I agree with you.

The only additional thing I'll add is that in my opinion the whole "most of M1 & M2 material is totally irrelevant to being a doctor" is another falsehood perpetuated by people who didn't succeed at a high level during M1/2. The doctors I respect most have an impressive grasp of even basic physiology, anatomy, etc. and have it as part of their intellectual repertoire. Further, the doctors I respect most are science-minded enough to stay up to date on literature. Do you need to know the intracellular signalling cascade of a cytokine to treat cancer? No, but you may need to know it to understand why a new drug works, or why the drug-sponsored research on said drug is questionable, or what laboratory phenomena to expect when treating with said drug. The point is, this is medical school, it's a tough argument to say medical school grades don't mean anything, and it's a tough argument to say medical school coursework doesn't have any bearing on being a medical doctor.

When stated in extremes such as this, it would be rather stupefying to see anyone taking such a stance.

 

[docscience]

Yeah, I agree with you.

The only additional thing I'll add is that in my opinion the whole "most of M1 & M2 material is totally irrelevant to being a doctor" is another falsehood perpetuated by people who didn't succeed at a high level during M1/2. The doctors I respect most have an impressive grasp of even basic physiology, anatomy, etc. and have it as part of their intellectual repertoire. Further, the doctors I respect most are science-minded enough to stay up to date on literature. Do you need to know the intracellular signalling cascade of a cytokine to treat cancer? No, but you may need to know it to understand why a new drug works, or why the drug-sponsored research on said drug is questionable, or what laboratory phenomena to expect when treating with said drug. The point is, this is medical school, it's a tough argument to say medical school grades don't mean anything, and it's a tough argument to say medical school coursework doesn't have any bearing on being a medical doctor.

No one said grades didn't mean anything...that is why we have a cutoff for passing or failing.

I am impressed by the "intellectual" doctors also...but you can be a great doctor in other aspects. One may not know the signaling cascade for cytokines in a certain cancer treatment, but he/she may know the best approach to controlling a viral outbreak in their community (epidemiology). I think if you are an oncologist, it is very important to know the signaling cascade....but what if you are a neurologist? You better know your neuro pathways a hell of a lot more.

All I am saying is if you go ask an internist who controls diabetes and hypertension in his office about the signaling cascade of cytokines, he/she will only have a working knowledge...probably not specifics. That is why subspecialties exist.
When someone comes into the ER with ketoacidosis, you should probably have a differential that it is probably Type I diabetes, but do you need to know the specific HLA mutations and such? Probably not relevant in an ER setting.

This is medical school and you are here to learn medicine...wether is be epidemiological med, molecular med, genetics, etc. is up to the person's interests.

I think it is just important to try and learn as much as possible, but not to kill yourself if you miss something on an...one isn't going to kill a patient...one probably can't be board certified if he/she is incompetent.

One more point...grades don't define everything...a critical care doc (jon hopkins i think) just put up a checklist in closed ICUs around the countries and cut down certain infections to 1%. Critical thinking and thinking outside of the molecular/signaling cascade box is also necessary for a physician.

P.S. Perhaps we can ask some of the M3s, M4s, interns, residents, attendings, etc.....any of you ever used the info from what the C5 convertase is in the alternate pathway in a clinical setting?

 

[DrZeke]

If I were to make straight C's through the first two years of medical school and have an average Step 1 score, have I screwed up my chances of getting into a residency (maybe something in pediatrics or IM)? This is hypothetical but it might make me feel better about my current grades.

I think it matters more WHY you are not doing well. If you are getting C's, because you are lazy and don't work hard, then that's not such a big deal. If you study your ass off and can't ever get above a C and can't figure out why, that is an issue. Most of doing well in medical school can be accomplished by understanding concepts well and learning them to the point where you nearly have them memorized. But people who don't understand things in their first two years, but memorize intricacies and buzz words may also do well, unless your exams in essay format.

If I was doing poorly, while still studying a lot, I would be worried about things like step I. The reason why I started doing better this year is because I realized that step I has a lot to do with the mental games we play with ourselves. I told myself that this year I would set tasks for myself and I would accomplish them. That way I would go into studying for Step I with a positive attitude and that feeling that when I set my mind to something I can do it. If I can't do that, then I need to figure out why that is or how I can rectify that.

No doubt you're probably intelligent. But don't be too proud to investigate why things aren't working out in your favor grade-wise if you are working hard.

Good luck.

 

[JeffLebowski]

No one said grades didn't mean anything...that is why we have a cutoff for passing or failing.

I am impressed by the "intellectual" doctors also...but you can be a great doctor in other aspects. One may not know the signaling cascade for cytokines in a certain cancer treatment, but he/she may know the best approach to controlling a viral outbreak in their community (epidemiology). I think if you are an oncologist, it is very important to know the signaling cascade....but what if you are a neurologist? You better know your neuro pathways a hell of a lot more.

All I am saying is if you go ask an internist who controls diabetes and hypertension in his office about the signaling cascade of cytokines, he/she will only have a working knowledge...probably not specifics. That is why subspecialties exist.
When someone comes into the ER with ketoacidosis, you should probably have a differential that it is probably Type I diabetes, but do you need to know the specific HLA mutations and such? Probably not relevant in an ER setting.

This is medical school and you are here to learn medicine...wether is be epidemiological med, molecular med, genetics, etc. is up to the person's interests.

I think it is just important to try and learn as much as possible, but not to kill yourself if you miss something on an...one isn't going to kill a patient...one probably can't be board certified if he/she is incompetent.

One more point...grades don't define everything...a critical care doc (jon hopkins i think) just put up a checklist in closed ICUs around the countries and cut down certain infections to 1%. Critical thinking and thinking outside of the molecular/signaling cascade box is also necessary for a physician.

P.S. Perhaps we can ask some of the M3s, M4s, interns, residents, attendings, etc.....any of you ever used the info from what the C5 convertase is in the alternate pathway in a clinical setting?

I feel like some folks are missing some key points here.

1) Yes, even minutiae material of medical school is often clinically applicable and like it or not, a patient's life may hinge on someone remembering it. Our job is to draw those applications. Yes, I can think of specific examples in even my own, limited, student experience. Even involving the complement cascade, if you'd like.

2) Of course it's not 100% all relevant at all times to every specialty (as someone earlier stated referring to extreme statements). And some/most of it may not be strictly required to function in your capacity as a doctor. But I can get a machine to follow simple algorithms and protocols and pattern recognition. Being able to clinically correlate medical science with clinical presentation is not a trivial pursuit and I think that's what we should all strive for - knowing as much as possible and using that knowledge and your experience to make clinical judgments. Look at nurses - all the experience in the world, they'll still never understand a large chunk of pathophysiology because their role doesn't require it. That's why nurse practitioners exist. Sure, you don't necessarily need all that med school info to treat case after case of sinusitis or cellulitis, but at some point we have to decide whether we're learning for merely the sake to satisfy a minimum understanding necessary for pattern recognition or whether we'd like to graduate every medical student with the knowledge requisite to draw more profound clinical correlations in the pathophysiology we see in our patients.

3) I would argue setting our collective sights on the bare minimum for becoming board certified is a pretty good way to produce subpar physicians. Personally, I know what it takes just to pass, and I'd be scared ****less if someone who got straight C's, 185's on Step I & II, and 8 years to graduate was taking care of me.

4) Of course grades don't define everything. But they do mean something. Let's not diminish that to the point of trivializing the hard work some students put in to be their best. If your best is B's & C's and a 200 on Step I, fine, and I'm sure you can function well in whatever capacity you choose to fill. But just because I allow that possibility, don't go around saying everyone who did better than you is a schmuck because none of it matters above passing. It does.

 

[docscience]

I feel like some folks are missing some key points here.

1) Yes, even minutiae material of medical school is often clinically applicable and like it or not, a patient's life may hinge on someone remembering it. Our job is to draw those applications. Yes, I can think of specific examples in even my own, limited, student experience. Even involving the complement cascade, if you'd like.

2) Of course it's not 100% all relevant at all times to every specialty (as someone earlier stated referring to extreme statements). And some/most of it may not be strictly required to function in your capacity as a doctor. But I can get a machine to follow simple algorithms and protocols and pattern recognition. Being able to clinically correlate medical science with clinical presentation is not a trivial pursuit and I think that's what we should all strive for - knowing as much as possible and using that knowledge and your experience to make clinical judgments. Look at nurses - all the experience in the world, they'll still never understand a large chunk of pathophysiology because their role doesn't require it. That's why nurse practitioners exist. Sure, you don't necessarily need all that med school info to treat case after case of sinusitis or cellulitis, but at some point we have to decide whether we're learning for merely the sake to satisfy a minimum understanding necessary for pattern recognition or whether we'd like to graduate every medical student with the knowledge requisite to draw more profound clinical correlations in the pathophysiology we see in our patients.

3) I would argue setting our collective sights on the bare minimum for becoming board certified is a pretty good way to produce subpar physicians. Personally, I know what it takes just to pass, and I'd be scared ****less if someone who got straight C's, 185's on Step I & II, and 8 years to graduate was taking care of me.

4) Of course grades don't define everything. But they do mean something. Let's not diminish that to the point of trivializing the hard work some students put in to be their best. If your best is B's & C's and a 200 on Step I, fine, and I'm sure you can function well in whatever capacity you choose to fill. But just because I allow that possibility, don't go around saying everyone who did better than you is a schmuck because none of it matters above passing. It does.

No one said that those who do well are "schmucks." I just wanted people to realize that grades are not everything...ever think of that 35 year old student with 3 kids and a wife? He probably isn't going to be acing every exam.

Being able to correlate medical science in the clinic IS the job of a doctor, I agree, however, this is what third year and fourth year are for...and residency. For some it is easier to remember pathophysiology of emphysema when they see someone struggling to breath out...at times just reading about it is not enough.

Also, I reiterate the point that some internists can't analyze pathological slides and come up with a diagnosis...that is why they send them to pathologists. But I am sure the internist took pathology and looked at many slides during his educational experience.

I really am not being a smart ass, just really curious...what clinical situation did you use the complement cascade in? In an allergic reaction type setting? Blood transfusion? Infection?

 

[JeffLebowski]

No one said that those who do well are "schmucks." I just wanted people to realize that grades are not everything...ever think of that 35 year old student with 3 kids and a wife? He probably isn't going to be acing every exam.

Being able to correlate medical science in the clinic IS the job of a doctor, I agree, however, this is what third year and fourth year are for...and residency. For some it is easier to remember pathophysiology of emphysema when they see someone struggling to breath out...at times just reading about it is not enough.

Also, I reiterate the point that some internists can't analyze pathological slides and come up with a diagnosis...that is why they send them to pathologists. But I am sure the internist took pathology and looked at many slides during his educational experience.

I really am not being a smart ass, just really curious...what clinical situation did you use the complement cascade in? In an allergic reaction type setting? Blood transfusion? Infection?

Had a patient in the ER with enalapril angioedema, in talking through the DDx we were talking about hereditary angioedema, which is due to a C1 esterase inhibitor deficiency. Also we had a conversation about the infection risk of a patient S/P splenectomy and related it back to opsonin production in the spleen (including C3b), which accounts for the increased susceptibility to encapsulated organism infection. For the record, I didn't catch either of those things until I'd had it explained/reminded to me. Was pretty interesting, actually. I like stuff like that.

One thing I will admit is that I've been surprised by how much of medicine is just unknown. Like, we know kind of what's going on, but don't have a sophisticated enough understanding even with all the research and literature out there to really understand it. It's so multifactorial and variable and complex that really, we only have a pretty superficial understanding of what's going on in our patients at any given time, I'm learning. And a shockingly high percentage of our treatment options exist not to cure the disease, not to even treat anything specific, but rather because we've just observed that it works, and we'd therefore be remiss if we didn't offer it to patients, even though we don't know why it works. Steroids. We give ****ing steroids to everyone and their mother. Definitely don't know why it helps. Why? Because it's the treatment. Lots of times, the only treatment. Why does it work in all those autoimmune diseases? Eh...you can kind of cobble together an "immunosuppression plus blah blah blah" answer, but really we have no idea. And "evidence-based medicine" is not at all referring to understanding the mechanism of disease in our patients, it's just referring to being knowledgeable about what tests are more sensitive, specific, cost/benefit efficient, and what treatments have statistics to compel us to pursue them even if we don't know what we're doing or why it works.

But at the end of the day, I want to understand the things I can. And it's kind of a special feeling when you tie something together based on your knowledge to a patient, because it's so rare. So often we're just following the algorithm. And frankly, I find comfort in that just as much as the next guy, especially as a student, whose job it is to learn those algorithms. But the reason I want to learn those algorithms & recognize the patterns is not because I want to be faster or more confident at following the recipe, but because I want to be better than the recipe. I want to be able to deliver care that integrates all those factors that make every patient different, in a sophisticated way that relies on clinical judgement that you can't teach in school or train into anyone who passes rotations, I want to be an individual as well with a unique thought process on each patient, and the best I can offer. I know I'll never get there without the best knowledge I could possibly glean from when they tried to infuse all that info into us M1/M2. I know I'll never get there without learning the algorithms and clinical patterns and basics of patient management I can M3/M4. And I know I'll never get there without the attitude that I do want to attain a better understanding of my patients and their disease to do right by them. I don't flatter myself that I'm going to get as far as all that, but man, that'd be a good doctor, no?

 

[docscience]

Had a patient in the ER with enalapril angioedema, in talking through the DDx we were talking about hereditary angioedema, which is due to a C1 esterase inhibitor deficiency. Also we had a conversation about the infection risk of a patient S/P splenectomy and related it back to opsonin production in the spleen (including C3b), which accounts for the increased susceptibility to encapsulated organism infection. For the record, I didn't catch either of those things until I'd had it explained/reminded to me. Was pretty interesting, actually. I like stuff like that.

One thing I will admit is that I've been surprised by how much of medicine is just unknown. Like, we know kind of what's going on, but don't have a sophisticated enough understanding even with all the research and literature out there to really understand it. It's so multifactorial and variable and complex that really, we only have a pretty superficial understanding of what's going on in our patients at any given time, I'm learning. And a shockingly high percentage of our treatment options exist not to cure the disease, not to even treat anything specific, but rather because we've just observed that it works, and we'd therefore be remiss if we didn't offer it to patients, even though we don't know why it works. Steroids. We give ****ing steroids to everyone and their mother. Definitely don't know why it helps. Why? Because it's the treatment. Lots of times, the only treatment. Why does it work in all those autoimmune diseases? Eh...you can kind of cobble together an "immunosuppression plus blah blah blah" answer, but really we have no idea. And "evidence-based medicine" is not at all referring to understanding the mechanism of disease in our patients, it's just referring to being knowledgeable about what tests are more sensitive, specific, cost/benefit efficient, and what treatments have statistics to compel us to pursue them even if we don't know what we're doing or why it works.

But at the end of the day, I want to understand the things I can. And it's kind of a special feeling when you tie something together based on your knowledge to a patient, because it's so rare. So often we're just following the algorithm. And frankly, I find comfort in that just as much as the next guy, especially as a student, whose job it is to learn those algorithms. But the reason I want to learn those algorithms & recognize the patterns is not because I want to be faster or more confident at following the recipe, but because I want to be better than the recipe. I want to be able to deliver care that integrates all those factors that make every patient different, in a sophisticated way that relies on clinical judgement that you can't teach in school or train into anyone who passes rotations, I want to be an individual as well with a unique thought process on each patient, and the best I can offer. I know I'll never get there without the best knowledge I could possibly glean from when they tried to infuse all that info into us M1/M2. I know I'll never get there without learning the algorithms and clinical patterns and basics of patient management I can M3/M4. And I know I'll never get there without the attitude that I do want to attain a better understanding of my patients and their disease to do right by them. I don't flatter myself that I'm going to get as far as all that, but man, that'd be a good doctor, no?

Thanks for your awesome response...the reason why I like SDN...a good bouncing of ideas.

I remember talking about hereditary angioedema when studying the cascade and thought it would be good to remember (not only for the exam).

Enlightening post...thanks again.

 

[GoLakers310]

Are you being sarcastic?

 

[docscience]

absolutely not being sarcastic...sorry if it came off that way

 

[youthinasia]

Family medicine @ Harvard FTW 😎