Medical School 2020, Year 2 begins

Before starting the publication of Medical School 2020, Year 2 entries, here are some Year 1 wrap-up thoughts from our anonymous insider:

Nearly every answer in medical school spurred another question until finally the answer wasn’t known or wasn’t answerable in the limited time for each subject. I eventually got used to the frustration that the system at-hand was too complex for a simple generalization. The every-two-month exam cycle gives students a sprint mentality, but I came to realize that it was okay to not know everything. Medical school is a marathon, not a sprint.

One year done and I’m more excited about working in healthcare, but disillusioned about the trajectory of American health. Diabetes, drug abuse, premature heart disease, psychosis. These are not typically driven by genetics, but rather symptoms of the society that we’ve built. Americans expect the healthcare system to clean up the mess, but seldom are doctors able to provide a complete cure for these ills of modern society.

I have also become disillusioned about our ability to formulate health care policy. We learned about ongoing clinical trials that pay diabetics to exercise and eat better, similar to the classic “A behavioral approach to achieving initial cocaine abstinence” (Higgins, et al. Am J Psychiatry, 1991), in which patients were given $1,000 to stay clean for 12 weeks rather than being put into rehab ($1,000 per day?). This could be much cheaper than Medicaid and Medicare paying to treat the inevitable complications. Politicians make beautiful speeches taking credit for providing insurance to millions of Americans, but where are these people who have purportedly been helped? Some of the hardest working people I met in the clinic made too much to qualify for Medicaid, but not enough to afford an Obamacare policy. They eventually have to stop work and show up in clinic with a far worse prognosis, e.g., half a foot that needs to be amputated, and the bill is paid by Medicaid or absorbed by the hospital’s charity care fund.

At least in our university-run, mostly Medicaid/Medicare-funded, health care system, I didn’t see obvious examples of what Jack Wennberg, the founder of clinical evaluative sciences, called “supplier-induced demand.” However, my attendings would nearly always refer patients to specialists out of fear of “missing something,” and every stubbed toe got an X-ray. Perhaps Wennberg’s estimate that 30 percent of healthcare expenditures are unnecessary or harmful is correct, but it wasn’t obvious which 30 percent we should have cut.

As a child I associated healthcare with doctors and nurses. One trip to the most popular restaurant across from the hospital campus and Jane and I realized that it was really more about administrators, lawyers, IT, and Human Resources staffers. I’m no longer surprised to see a hospital employee badge reading “business development officer” pinned to a business suit.

Classmates often wonder “Why does medical school cost so much?” Our conclusion is that the enemy may be us. Administrators and deans have proliferated along with LCME requirements in the name of creating an fair and equitable learning environment. Is it helpful to have lectures recorded? Yes, but it requires a huge IT department and expensive software. Our gym was just upgraded, which seems to have been a marketing decision because most classmates didn’t know that we had an in-school gym within the school in addition to the membership at a comprehensive fitness center (with pool!) that is covered by our tuition. The Wellness Committee and the Office of Inclusion and Diversity, led by a Ph.D. psychologist, seem to have unlimited funding to hold seminars on self-defense and microaggressions (I try never to miss one due to the great catering from local restaurants); funding for student-organized events on medical topics, such as a suture workshop, is limited to $2.50 per attendee and can be challenging to obtain. Waste is noted, but seldom criticized, due to the free-flowing Federal spigot of student loan funds.

I conducted an informal survey of classmates towards the end of the year. Some of their responses are below.

What has surprised you?

“The amount of independence. You hear about all these learning environment resources, different subjects, supplemental materials for purchase like Anki and Firecracker. It is pretty overwhelming at first. I eventually realized that if I just study the exact the same way [as in undergraduate courses] then I do well. It is just school.” [Jane]

“That I could actually be interested in surgery.” [Disinterested Dorothy, originally planning to follow her father into internal medicine]

“People like talking about their health problems.” [He obviously hadn’t met my grandfather!]

Is it more or less studying than you expected?  

“Less overall but exam week is brutal. It’s the way it is, not the way it should be.  I regret not being as organized and dedicated as some students. I would study more spread out instead of cramming before.” [Jane]

What did you wish you knew about healthcare that you know now?  

“I always thought doctors were unquestionable. Doctors are human. Ask them questions. If they are not explaining the reason, they are not doing their job right. I now know there are good doctors and bad doctors.” [let’s hope that she doesn’t practice these sorting skills at home; she’s the daughter of a physician]

“Healthcare is challenging but it is more accessible than people would think. I approach healthcare as a field in which if you work hard enough or study long enough you can succeed. Compare this to, for example, computer programming or engineering. No matter how hard I worked at that, I just could not do it.” [she majored in biology as an undergrad]

What do you like about the class and what do you not like about the class?  

“I like how our class is fun and likes to hang out with each other. We have a good sense of humor. What do I not like? Our class will complain about anything. They can also be quite disrespectful.” [Jane]

Do you wish you took time off before medical school.  Gap year or no?  

“No stigma either way.  Straight in or five years out doesn’t matter. Once you are here, you are here.” [Youngest classmate]

“It took me three application cycles to get into a school.” [Straight-Shooter Sally]

“I am glad I took a gap year. I don’t think I was intellectually mature enough to go straight through. I think I would have fooled around with all the free time in medical school if I didn’t learn some discipline working in the real world.” [Male classmate who worked for pharmaceutical company]

“I am glad I am here, but certain specialities are off the table for me. I’m too old!” [Upperclassman who started medical school at 35]

What do you think about our teachers?  

Passion is infectious.  When someone is passionate you can’t help but listen to them. M.D.s are more fun than Ph.D.s. Teachers talk about what they know. They know their patients. That’s why we are here.” [undergraduate physicist major known as the class gunner]

“About a third of the instructors are great. I give an instructor one chance. If I don’t like them, I no longer show up for lecture.” [Classmate notoriously late for the few lectures he does attend. If the class gives him the heads up it was worthwhile, he might watch the recorded lecture online.]

What do you think about anatomy?

“I liked MSK (musculocutaneous) dissections. It was satisfying using your hands to isolate muscle and fascia layers. Reproductive was pretty cool too. I literally cut a penis in half and took the fascia layers apart. Not many people can say that! Oh, and that bone saw was sick!” [Disinterested Dorothy]

“I hate anatomy. You cannot see anything in a cadaver. So excited to be done with it.” [Pinterest Penelope apparently has better things to do]

“Anatomy is the best part of medical school. It is the unique topic for medical school. All the other material a lot of us have have been to exposed to in various undergraduate majors. No one gets exposed to anatomy, at least at this level.”

Anatomy Advice for M1?

“Get in there to get over. Thinking about it is bigger issue. I never had issue. Doesn’t feel real because the cadavers are cold.”

“It is pretty rare to have surgeons take time out of their day to spend two hours helping you dissect. Take advantage of it.  You get out what you put in. Be interested in what you are doing. It looks bad when half the class leaves early from lab.” [Jane]

“Buy a pair of scrubs. You look badass and that way you won’t get your normal clothes smelling like the lab.” [Class Orthopod]

What are you excited about?

“Being a doctor allows you to make a decent living wherever you want to live. You don’t have to live in a big city where all the jobs are for young people.” [Classmate from Kansas]

“All my friends and family ask me about their health problems. It is fun to play doctor. We can now understand what is wrong with them. Ask us what to do about it? We are no better than the internet. Patient care comes from experience, not from education. I’m excited to eventually be able to answer their questions with action.”

What is something you would change?

“Administration treats us as kids, not adults. There is a resource for everything.” [Classmate who juggles a newborn and toddler with medical school studies]

“The cost of tuition. The founding of for-profit medical schools tells you all you need to know.” [Classmate with PA-student wife]

“Just tell me what is going to be on Step I. I do not have time nor the brain space for anything else.” [Type-A Anita…]

“Residency match. If you want to do a speciality, it has become so competitive. The Match is in a death spiral.” [Class Orthopod]

Following the curriculum isn’t enough if you want to be a good doctor. Friends at other schools, a few classmates, and a physician mentor agree that the focus of medical school is ensuring that the lowest denominator passes, not challenging each student to reach his or her highest potential. The resources are there for anyone who wants to take the initiative, but peer pressure works in the opposite direction. The most vocal students echo each other’s complaints that the curriculum isn’t sufficiently test-focused.

First year for most students serves a reminder that not all of us are special. Most medical students were near the top of their undergraduate class, but that was partly because their fear of failure (failure = less than an A) was so great they didn’t take challenging courses. Classmates’ first reaction to getting a question wrong may be to assert that the question was unfair, poorly worded, or that the answer was not worth cramming into our already crammed brains. We expect to be the discoverer of a new drug or the manager of a big project. One of my bosses during my gap year said, “What we really need are great employees. Leadership comes afterwards.” The more that I shed the entitlement mentality, the more I was able to focus on my strengths.

One thing that I learned is that medical students don’t relax until a few months prior to graduation. Classmates traded their fear of not getting into their first-choice medical school for three years of anxiety of not doing well enough on Step I (end of second year) and in rotations (third year) to get into their first-choice residency. One of our clerkship directors sent us an article about the surgery residency match process: “This leaves the 163 orthopedic residencies that participate in the Match in the unenviable position of having to sort through 88,169 applications for 717 total positions from just over 1,000 total applicants.” (Scott E. Porter, JAAOS, 2017)  I.e., a typical applicant applied to 88 programs, more than half of the total programs nationwide. Maybe the Web-based Match software will need to be updated with a Select All option…