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...
I agrée with some points. But the critical thinking skills I have are due to the challenges of med school. Meaning the basic science, research and figuring out how to learn despite less than desirable teachers. True medicine is an art. The mcat is a test of a ton of information at once that you have to do your best with. I think it is too highly valued. But I agree with some rights of passage if lives are in your hands. It’s easier to handle frustrated parents when you have dealt with difficult bosses. And I don’t remember every tendon and pathway but if I pull articles on a difficult case I quickly understand it with minimal review. If we are all simply practitioners I fear for the patient with a rare illness or more nuanced problem. The choice to me is great docs or one size fits all. 90 percent can be done faster and easier. But what if you are dying as the 10 percent?
I did medical education outside the United States (Pakistan). Every faculty was PhD level, old school blackboard and discussion-based curriculum. Neuroscience curriculum was done through many chapters of a fat book by Kendal and Schwartz. Physiology book by Schmidt and Thews in addition to 3 others. Thoroughly robust basic and clinical science (not sociology, a big miss).
Indeed, we learnt a plethora of items that I do not use. But, I do think everything else we learnt that we do not always use, is valuable. That is what makes us doctors. It still enables us to think. I am not a vascular surgeon like my spouse, but I was able to understand why an arterial dissection needed heparin based on knowledge of the layers of an arterial wall and the Virchow's triad, not just based on a written recommendation from a consult service.
One can make testing easier for medical student, sure, but teach about the human body like we mean it, both in biology and sociology. The latter needs attention as well. Apparently irrelevant information can still be 'knowledge'. If it helps us think better, it can become wisdom. Better to subspecialize from a broad-based knowledge than handpicked information, even if sub- specializing makes us forget so much.
I find it extremely concerning that the focus of education is on just 'what appears' useful. It is no longer education, it is 'training'.
Having a rigorous medical education should enable building grit to care for patients, not just process them. As we can observe, to climb the ladder of 'success', most 'doctors' do not want to see patients. I will spare my impressions on upcoming role of affiliate practitioners to replace doctors, many positives for sure and some important caveats.
Thank you for this. Given the prevalence of lifestyle diseases in the US, I'm surprised that lack of nutrition training in medical school isn't on this list. In my view, it should be right near the top. The great Dr. Michael Klaper has covered this issue extensively, including traveling to medical schools across North America, Europe and Australia to give the students the information he wishes someone had given him fifty years ago, about how the patient’s diet is key to reversing many of the most feared degenerative diseases known to medicine. Here's his lecture: https://www.youtube.com/watch?v=fobYY3158fM
My perspective comes from the British system, where you go straight from school (with three good science A-levels) into five years of medical school. It was possible at my school (UCL) to take a year in the middle and add a BSc, and I understand this is now mandatory (maybe more for the benefit of the bursar collecting tuition than the average doc). It was very competitive to get in, and based on A-level grades and a successful interview. But once you got in, there was little reason to worry. Only two people dropped out of my year of ~100 students. The first two years of 'pre-clinical' (anatomy, biochemistry, physiology, pharmacology, embryology) were intense, and the amount to be memorised for exams was phenomenal, presumably to weed out the few who couldn't do it. Then three years of clinical (but including three months of pathology in the classroom, and three months elective working away, abroad if possible, which we arranged on our own. I spent it in Canada and ended up moving here.) Then a year of 'housejobs' - working 1 in 2 and trying to kill as few innocent bystanders as possible, three years of family medicine residency (first two as a junior hospital doc, third as a trainee in a practice). At that point I jumped ship and moved to Canada and ended up in a remote rural setting running an office, the ER and a hospital. And even then, nine years of training under my belt, it wasn't much preparation for reality. I can level all sorts of criticism at the training then (I qualified in 1981) but it wasn't that we wasted time on irrelevancies, it was that we were left pretty much to our own devices during the clinical years, trained mostly by working housemen and registrars (interns and residents) and it was up to us to take advantage of it. That could have been better organised as many did the minimum to get by. The Canadian students I met during my elective were rarely seen on the wards, but when they were seen they carried a tiny Boston bag and introduced themselves as 'doctor.' I was not impressed by either, and among my colleagues who were trained in the Canadian system some showed all too well the fact they'd had four years of med school and one of internship before going to the front line. Others were stalwart and excellent at their job.
The biggest issue for me is how to select students who will make good doctors. Intelligence alone doesn't do the job very well, and picking those who have cynically washed the feet of the poor to aid their application is worse. Selection on DEI grounds is potentially dangerous. I don't have the answer to that puzzle.
You are correct which isn’t good. Let’s just say as someone who just took MCAT, if I didn’t study any of the human organs and their functions, I would not lose a single point. I was ready and still surprised me how little actual biology was tested.
You are spot on. So many issues with education that have become institutionalized. So much emphasis on publishing garbage (case studies are interesting, but rarely useful). Wellness “homework” (seriously??)!! How do we get off this train and back to teaching when it is so derailed? I am heading towards retirement and worried about the direction that medical training is taking and the future of medicine. Am very worried about the influence of politics trumping science. And administration has become the machine that directs it all, at physician and patient expense. It used to be that administration worked to help physicians to take better care of patients. Their role was to get you the things you needed to care for patients. Now, it’s to extract the most money from every resource and advertise to bring in new “clients.” Wish they could spend as much on caring as they do on showing that they care. Thanks for your pursuit of honest medicine and teaching. I will keep teaching, practicing, and advocating. If I’m lucky they won’t fire me before I retire.
“I recently did some sample MCAT questions. One was nominally about biochemistry … 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…. There was a follow-up component … 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.”
I am in the process of completing the NCARB Architectural Registration Examination for professional licensure to practice architecture, and you could categorically adapt, without substantive modification, the essence of the above description of the MCAT to the ARE’s as a test of knowledge & expertise requisite to the professional practice of architecture.
Hundreds of hours of postbaccalaureate (and often postgraduate) exam-preparation, thousands of dollars in fees, several dozens of hours sitting to complete a six-part series of exams that all in all consumes several years of a candidate’s lifetime (the typical timeframe for completing the examinations, because most undertake the process while in fulltime (overtime) employment) — all only to yield ostensible ‘professionals’ whose actual, relevant working knowledge & expertise remains, at the end of it all, at best questionable.
Great post sir. Another thing is the issue of fertility. My daughter would like to be a physician but wants to have children and is frightened of the fact that it would consume her reproductive years. We aren't honest with female students, and so they often put off childbearing until their mid 30s. While I agree that medical school is one year too long (I didn't do much that was useful my 4th year except spend seven weeks on active duty in the Air Force). But maybe it could be a bit longer for women who want to mesh it with starting a family.
At the least, lecturers should be proficient in English or have a translator who is.
Sorry, but thick accents only made your esoteric research even less relevant to my education. (Why did we have to sit through what were essentially reports on unpublished research by PhD post docs in biochem & neuroscience?)
I hope students and residents take advantage of opportunities to learn to teach. As an FP resident,I loved teaching patient exam skills to a 1st year small group.
I think pre-med is about identifying type A high achievers. What’s funny about MDs is the amount of complaining they do in their 30s when their lawyer buddies are making partner and their investment banker buddies are making huge bonuses…and then suddenly the MDs hit 40 and buy a huge house and start sending their kids to private schools and buy a Porsche and the complaining stops.
I agrée with some points. But the critical thinking skills I have are due to the challenges of med school. Meaning the basic science, research and figuring out how to learn despite less than desirable teachers. True medicine is an art. The mcat is a test of a ton of information at once that you have to do your best with. I think it is too highly valued. But I agree with some rights of passage if lives are in your hands. It’s easier to handle frustrated parents when you have dealt with difficult bosses. And I don’t remember every tendon and pathway but if I pull articles on a difficult case I quickly understand it with minimal review. If we are all simply practitioners I fear for the patient with a rare illness or more nuanced problem. The choice to me is great docs or one size fits all. 90 percent can be done faster and easier. But what if you are dying as the 10 percent?
I did medical education outside the United States (Pakistan). Every faculty was PhD level, old school blackboard and discussion-based curriculum. Neuroscience curriculum was done through many chapters of a fat book by Kendal and Schwartz. Physiology book by Schmidt and Thews in addition to 3 others. Thoroughly robust basic and clinical science (not sociology, a big miss).
Indeed, we learnt a plethora of items that I do not use. But, I do think everything else we learnt that we do not always use, is valuable. That is what makes us doctors. It still enables us to think. I am not a vascular surgeon like my spouse, but I was able to understand why an arterial dissection needed heparin based on knowledge of the layers of an arterial wall and the Virchow's triad, not just based on a written recommendation from a consult service.
One can make testing easier for medical student, sure, but teach about the human body like we mean it, both in biology and sociology. The latter needs attention as well. Apparently irrelevant information can still be 'knowledge'. If it helps us think better, it can become wisdom. Better to subspecialize from a broad-based knowledge than handpicked information, even if sub- specializing makes us forget so much.
I find it extremely concerning that the focus of education is on just 'what appears' useful. It is no longer education, it is 'training'.
Having a rigorous medical education should enable building grit to care for patients, not just process them. As we can observe, to climb the ladder of 'success', most 'doctors' do not want to see patients. I will spare my impressions on upcoming role of affiliate practitioners to replace doctors, many positives for sure and some important caveats.
Very nice article. Thank you for sharing.
Given that all of this is true, what can incoming medical students (like myself) do to make the most of a bad education system?
Thank you for this. Given the prevalence of lifestyle diseases in the US, I'm surprised that lack of nutrition training in medical school isn't on this list. In my view, it should be right near the top. The great Dr. Michael Klaper has covered this issue extensively, including traveling to medical schools across North America, Europe and Australia to give the students the information he wishes someone had given him fifty years ago, about how the patient’s diet is key to reversing many of the most feared degenerative diseases known to medicine. Here's his lecture: https://www.youtube.com/watch?v=fobYY3158fM
I am a now expat US trained MD, and US training far exceeds the world. We are trained to ask why, most of the world just teaches what.
My husband Ralph B Lilly was a brilliant clinician (there’s the rub) and became a behavioral neurologist after a TBI in 1980
He practiced at Brown immediately after his neurobehavioral Fellowhip and starting in 1991, at University of Texas Houston.
He understood his patients, had been there done that and his empathy and willingness to listen were legendary
He practiced on his own, as he did not want
Time
Limits on his office visits, but also
Went
To all
The ICUs at the Med Center every day
He asked frequently for a resident or fellow so that he could
Pass
On his knowledge, to no avail, did not fit the rubric
Now he is gone but not forgotten by the thousand of survivors and healers he helped along his own journey
www.readsecondlives.com
For a compelling story of tragedy resilience healing and love
Should be required in medical
School
My perspective comes from the British system, where you go straight from school (with three good science A-levels) into five years of medical school. It was possible at my school (UCL) to take a year in the middle and add a BSc, and I understand this is now mandatory (maybe more for the benefit of the bursar collecting tuition than the average doc). It was very competitive to get in, and based on A-level grades and a successful interview. But once you got in, there was little reason to worry. Only two people dropped out of my year of ~100 students. The first two years of 'pre-clinical' (anatomy, biochemistry, physiology, pharmacology, embryology) were intense, and the amount to be memorised for exams was phenomenal, presumably to weed out the few who couldn't do it. Then three years of clinical (but including three months of pathology in the classroom, and three months elective working away, abroad if possible, which we arranged on our own. I spent it in Canada and ended up moving here.) Then a year of 'housejobs' - working 1 in 2 and trying to kill as few innocent bystanders as possible, three years of family medicine residency (first two as a junior hospital doc, third as a trainee in a practice). At that point I jumped ship and moved to Canada and ended up in a remote rural setting running an office, the ER and a hospital. And even then, nine years of training under my belt, it wasn't much preparation for reality. I can level all sorts of criticism at the training then (I qualified in 1981) but it wasn't that we wasted time on irrelevancies, it was that we were left pretty much to our own devices during the clinical years, trained mostly by working housemen and registrars (interns and residents) and it was up to us to take advantage of it. That could have been better organised as many did the minimum to get by. The Canadian students I met during my elective were rarely seen on the wards, but when they were seen they carried a tiny Boston bag and introduced themselves as 'doctor.' I was not impressed by either, and among my colleagues who were trained in the Canadian system some showed all too well the fact they'd had four years of med school and one of internship before going to the front line. Others were stalwart and excellent at their job.
The biggest issue for me is how to select students who will make good doctors. Intelligence alone doesn't do the job very well, and picking those who have cynically washed the feet of the poor to aid their application is worse. Selection on DEI grounds is potentially dangerous. I don't have the answer to that puzzle.
You are correct which isn’t good. Let’s just say as someone who just took MCAT, if I didn’t study any of the human organs and their functions, I would not lose a single point. I was ready and still surprised me how little actual biology was tested.
You are spot on. So many issues with education that have become institutionalized. So much emphasis on publishing garbage (case studies are interesting, but rarely useful). Wellness “homework” (seriously??)!! How do we get off this train and back to teaching when it is so derailed? I am heading towards retirement and worried about the direction that medical training is taking and the future of medicine. Am very worried about the influence of politics trumping science. And administration has become the machine that directs it all, at physician and patient expense. It used to be that administration worked to help physicians to take better care of patients. Their role was to get you the things you needed to care for patients. Now, it’s to extract the most money from every resource and advertise to bring in new “clients.” Wish they could spend as much on caring as they do on showing that they care. Thanks for your pursuit of honest medicine and teaching. I will keep teaching, practicing, and advocating. If I’m lucky they won’t fire me before I retire.
Orgo could be relevant to modern medicine, it would have to be a very different class. I think it could be done.
“I recently did some sample MCAT questions. One was nominally about biochemistry … 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…. There was a follow-up component … 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.”
I am in the process of completing the NCARB Architectural Registration Examination for professional licensure to practice architecture, and you could categorically adapt, without substantive modification, the essence of the above description of the MCAT to the ARE’s as a test of knowledge & expertise requisite to the professional practice of architecture.
Hundreds of hours of postbaccalaureate (and often postgraduate) exam-preparation, thousands of dollars in fees, several dozens of hours sitting to complete a six-part series of exams that all in all consumes several years of a candidate’s lifetime (the typical timeframe for completing the examinations, because most undertake the process while in fulltime (overtime) employment) — all only to yield ostensible ‘professionals’ whose actual, relevant working knowledge & expertise remains, at the end of it all, at best questionable.
Agree with all except the organic chemistry. Organic chemistry is an everyday life skill, applying even to what we eat.
Great post sir. Another thing is the issue of fertility. My daughter would like to be a physician but wants to have children and is frightened of the fact that it would consume her reproductive years. We aren't honest with female students, and so they often put off childbearing until their mid 30s. While I agree that medical school is one year too long (I didn't do much that was useful my 4th year except spend seven weeks on active duty in the Air Force). But maybe it could be a bit longer for women who want to mesh it with starting a family.
One more thing: anatomy should be taught by radiologists. Every medical student should have a working command of imaging.
At the least, lecturers should be proficient in English or have a translator who is.
Sorry, but thick accents only made your esoteric research even less relevant to my education. (Why did we have to sit through what were essentially reports on unpublished research by PhD post docs in biochem & neuroscience?)
I hope students and residents take advantage of opportunities to learn to teach. As an FP resident,I loved teaching patient exam skills to a 1st year small group.
I think pre-med is about identifying type A high achievers. What’s funny about MDs is the amount of complaining they do in their 30s when their lawyer buddies are making partner and their investment banker buddies are making huge bonuses…and then suddenly the MDs hit 40 and buy a huge house and start sending their kids to private schools and buy a Porsche and the complaining stops.