How medical school fails students

I previously discussed how some residents call in "fake sick", but medical schools too often provide a "fake education". Basic science esoterica, squandering time of smart people, and more...

In prior posts, I was critical of the culture among trainees. One essay described the phenomenon of calling in fake sick. Another asked what the balance is between accommodation and the rigors of the job. These essays were about the effort, dedication and professionalism of trainees.

In the next few posts, I want to turn it around. Let me discuss the ways in which medical school fails students. Future posts will be about residency and fellowship, and perhaps even junior faculty. These essays will be about how institutions, particularly academic medical leaders, fail doctors in training. Sit down. I won't pull punches.

1. The pre-medical curriculum is tangential to medicine at best. At worst it's irrelevant. It's abusive to make young people devote years of their life to learn things that have zero impact on the actual job. Companies/ universities that sell postbaccalaureate programs strike me as particularly abusive rent seeking. Organic chemistry, calculus, these have nearly no day-to-day relevance in the practice of medicine.

2. The medical college admission test contains many irrelevant questions that have nothing to do with being a doctor. I recently did some sample MCAT questions. One was nominally about biochemistry, specifically amino acid synthesis, but the question required no understanding of biochemistry to get it correct. It was simply a logic puzzle. You could have replaced the question with a logic puzzle from the LSAT about moving four people across a river in a row boat that can only hold two, with restrictions on who can sit together. There was a follow-up component to the biochemistry question, and it too was a logic puzzle, however, unfortunately it was incorrect. It was logically correct assuming only what was presented in the question stem, but a broader understanding of medicine meant it was incorrect. Sadly, I doubt whoever wrote it has any understanding of medicine.

3. At the same time, some standardized testing is likely needed as a test of cognitive ability and a prediction of the ability to pass future examinations and complete clerkships. But the content of this standardized test has to be either directly applicable to the future job, or, if instead it is merely a test of logic or memorization or hard work or dedication, that can be based in any domain, including history, philosophy, baseball, as long as those questions have been selected for the best predictive value of future performance. Being well versed in domains of history and sports may even have a greater impact in the clinic, as it allows you to bond with many patients. Understanding the PTEN pathway and the downstream mediators is irrelevant even for those of us who prescribe drugs along this pathway (me), and it allows you to bond with nearly no one.

4. Once students get to medical school we make them memorize loads of irrelevant trivia. Memorizing all of the bones and ligaments and muscles of the forearm, something that no one besides a forearm surgeon needs to know, and I'm not even sure how much they need to know as a med student vs learning it later.

5. Students receive no good training in statistics. Recently, I was critiquing a randomized trial that had many biases — inappropriate control arm, double drug run in period, unequal dosing -- I said we needed a confirmatory study. The PI argued that the p value had so many zeros, it was like 4 studies in one. A comment like that means the PI has no understanding of p values nor how to read and interpret RCTs, and I am not surprised because the few students who learn this in medical school are ones who do it in spite of their education.

6. Clerkships are often poorly and thoughtlessly run by people seeking to check a box off the promotion and tenure form and fail to provide a real education. Specific clinic assignments make little sense, or exist for historical reasons. What students need to know and how to teach them that is almost an afterthought.

7. Medical schools charge ridiculous fees for little value. It's hard to believe first year classroom instruction costs or is worth $60,000 — it's just paying for the future lifetime earnings.

8. Schools often promote and retain mediocre faculty who play politics and anoint them ‘educators’. Students get bad teachers often because schools give teaching and advisory positions based on favoritism or politics (including the classic liberal university bias) and adherence to vogue ideas (like wellness) rather than assign these jobs to the absolute best lecturers and thinkers. This is a disservice to students even when they themselves demand that more activist faculty hold these roles.

9. Students seldom receive one on one instruction from faculty. For what they pay, you’d think students get more apprenticeship and coaching but they do not. Largely because universities don't want to pay faculty to do this work. They would rather hire more compliance officers and mid-level administrators.

10. Med schools pass students who should fail, and don't admit student who deserve a shot. Med schools will do better to admit more students, including ones they're uncertain about succeeding, but also dismiss more students who are unwilling or incapable of doing the job. Currently nearly no students are dismissed despite the fact a fraction will not be good doctors.

11. We force students to do fake research. The last 15 years have seen an explosion in publications among medical students. This is almost exclusively low value, irreproducible, unhelpful research. There is an illness in medical schools — the idea that everyone, no matter how disinterested, should do a useless research project. Universities make this happen. Students would be better served doing less research and learning instead how to read clinically relevant research critically.

12. The RVU system incentivizes certain specialties, which are small in number, and may not be the most societally important. This makes medical students chase those few spots, so many are disappointed. Derm and ID are both valuable and interesting medical fields. If they both paid the exact same for each hour worked, I am sure both would be equally competitive. Obviously that's not the case.

13. Efforts to reform medical education are window dressing at best. Problem-based learning, flip the classroom. The big problems (this article) are never discussed.

14. We don't fire bad lecturers. When I attend a lecture given by a bad speaker (aka most lectures), I feel pain in my skull till I escape. I feel profound pity for students when many of their lecturers are awful. There are good science communicators in med school but these people don't give more lectures because see #8. Schools double down and force students to attend bad lectures.

15. Too much of medical students’ time is controlled by interns and residents who have no training or instruction in what they're supposed to do with these students. Minimal contact with the paid faculty members of the university and max contact with a slightly more advanced trainee, who has never received any training or selection for being an educator. This means students often don't see the big picture of medicine, and just learn what it's like to be an intern, over and over.

16. The best university faculty members are the ones who spend the least amount of time with students, because they have been incentivized to do research, expand their clinical practice, and otherwise bring acclaim to the institution. Universities should make teaching competitive, and pay faculty more to teach. The current system too often exposes students to the weaker faculty. (Obviously there are exceptions)

17. Medical school is at least one year longer than it needs to be.

18. The arms race to get into medical school forces students to take year after year off doing useless activities. This results in a loss of career lifetime earnings, and is pointless.

19. Grading students on clerkships is capricious and often based on favoritism. Many have claimed it is also racist -- I have not seen direct evidence of that. Some schools have felt the solution is to have no grades at all. That's absolutely incorrect, and further incentivizes useless research because after all how will dermatology decide who to take? Medical schools have made no effort to develop robust grading systems that predict future performance. We need grades. We need them to actually be useful. No school is properly studying this.

20. Medical schools trick rich old patients into giving them hundreds of millions of dollars so they can make medical school free, and then they lie and say that that is to increase students going into primary care. Of course, there is no evidence it increases primary care. Orthopedics pays way more than pediatrics whether or not your medical school cost you $400,000 or $0. The future incentive is no different. People don't choose lucrative fields because they have debt, but because it offers higher future lifetime earnings. The real goal of free medical school is to get better applicants which will increase US News and World Report rankings, which is why NYU is ranked much higher than it should be.

Overall, I think students are abused by the current system. A greater focus on wellness or work-life balance will solve none of these concerns. Wellness is a misplaced effort to try to appear to be doing something, while not addressing any of the core issues. Students are angry, and rightfully so, but calling in fake sick is not the solution, but a different problem entirely.

We take smart people, make them jump through irrelevant hoops, teach them irrelevant information, grade them by unproven and irrelevant metrics, incentivize fields in a haphazard and illogical ways, force them to do useless research, and then try to make it better by giving them 4 half days a month they can take off for any reason (mental health days).

I can not imagine anything worse. Next up… residency.