We need to articulate fundamental questions for medical training: what does it take to be a good doctor? What does it mean to be a good academic doctor?
I don’t see this as mutually exclusive skills. Physicians learn to assess H&P (background), compile symptoms and order tests (method), evaluate results of the tests (results), and diagnose and treat (discussion-conclusion). The scientific method should be a natural extension of med students’ learning.
Very thought provoking. I agree with your sentiment and wrote a reply expanding on some of your questions and concerns, and proposed a few potential solutions. Thanks for writing and try to enjoy yourself before intern year!
There are many other experiences that are valuable to medical students, some of which will give them more practical knowledge that they can use when they transition out of academia (which I have to think 90% of them are bound to do).
When I was in college and medical school I worked in an orthopaedic clinic. Most of my time was spent processing insurance claims - hmm, do any of us have to deal with insurance companies and claim denials? Preauthorizations for treatment? Worker's compensation? I spoke with patients and with the carriers to try to resolve payment issues. I also learned about CPT codes and ICD-9 (at that time) codes. I learned how to read medical notes, the format and what was included in each section.
On days when someone called out, I would work at the front desk checking in patients or scheduling appointments. By the time I got to medical school, the physicians knew me well enough that they would let me come in to observe aspirations and injections, help with casting and prep for minor procedures.
I did do academic research later, during my fellowship, and, while I learned a fair amount of how grant submissions are written and medical writing, I'm not sure that I use any of that in my practice today. That other stuff from my early education - put into practice most every day.
We have M2 students rotating through our clinics now on their ambulatory rotations. They are bright and have long resumes, but part of me wonders if some practical experience might not have put them in a better position to succeed and understand more of what really goes on in a medical practice.
Thank you, Jonathan. I was up to my ears in the curriculum as a student, (Albert Einstein, Class of 1974). The modern medical student needs more education in the culture of medicine and the breadth of health beliefs among patients, not a trivial brush with research. I did publish an article in a peer-reviewed publication, which I enjoyed and from which I learned some basics. It was more than 10 years later before I participated in the publication of another manuscript. Students also need to understand how politics impacts clinical medicine - a retrospective review of the deep errors of our profession during the pandemic should be imperative in today's med school curriculum.
Going a notch or two lower on the ladder - I graduated from nursing school at age 60. Within two months of being hired in my first job in a large metropolitan hospital, I was asked to try to help other new nurses deal with the frustration that, even with a BSN, they really didn't know what they were doing. I told them their nursing degree was only a framework on which to hang everything else they were about to be learning for the rest of their career. I realized that I had a tremendous set of advantages: male, as old as their grandparents, experienced patient (aortal bi-fem; semi-laryngectomy, etc.) and earlier exposure to some of the academic silliness being described elsewhere in this chain. BTW, the complaints outlined and solutions being proposed are hardly exclusive to the medical/academic world; they could apply almost anywhere. Like in congress maybe?
This is an important post - resonates a lot with my PhD experience too. Training programs should more heavily weight the skills and abilities of trainees as measures of success. We need systemic change that doesn't accept the harsh "reality" of the current publishing culture but actively pushes back.
Doing research at the medical school level is a joke and a real waste of time. Better would be a course in critical analysis of published research so that the student learns to separate the wheat from the chaff in what passes for medical research these days. Much of the analysis on this website would be useful in that regard. But most of the time should be spent in providing a solid background in cell biology, human physiology, and pathophysiology. Then clinical training will provide the guidance and experience of applying that knowledge to the diagnosis and treatment of disease. Those that are skilled in teaching should do that. They shouldn't be required to publish research in order to follow that path.
It would be so much more educational for medical students to do a deep dive into the life cycle of medical ideas generated by “research”. Bias toward publication of positive results leads to hypotheses likely to generate positive results. Then there’s the joy and hope for the new treatment paradigm; with time, data is generated that provides fodder for comparative studies, which is where negative results can see the light of day. Then and only then, does doubt and realism enter the equation. I can think of many examples, such as gabapentinoids in the perioperative period, where what was once embraced as a game changer is now considered more harmful than beneficial. And yet every surgeon I work with still orders it!
My daughter is graduating from a top three university with two degrees (one in biology) this spring, and decided midway through college that she wanted to apply to med school. Her many extracurriculars and leadership fed her personal interests and sociability - so even though she's graduating with a 3.98, the medical school advisor told her to take a year and get hands on clinical experience before applying to med school, otherwise her options might be limited.
She was told that the only kids that go straight through are those that *start* college with the intention of going on to med school and plan their classes and their time off with precision. Aside from the curiosity of expecting 17-18 year olds to know exactly what they want to do with their life, I think it a shame that some kids might miss out on some interesting college sidebars for lack of time to pursue things without obvious career value - a club sport, a social club, theater work, etc. (She did have a summer fellowship working abroad on diabetes research, and was one of many authors of a published medical paper.) My daughter wants to help people, exudes warmth, is cheerful and fun to be around, and boasts a myriad of artistic talents in addition to being a smart cookie with a strong work ethic. I'm glad she didn't know what she wanted to do at 18 and instead has made the most of her undergrad years. And I feel pretty confident she'll be a compassionate, conscientious doctor when that day comes.
It may also be worth thinking about what it means to be an MD in a world that seems to want to rely more on NPs and PAs in the future.
Frankly, most want a good clinician to treat them when sick. The general
public could not care less about their publications or research, many of which wind up in backwater journals that no one has time to read and digest anyway.
It’s time to get back to basics. Reinstate grades and boards scores. Focus on what actually matters in the clinic. Allow for students to do research their fourth year. Return to what medicine actually is and start focusing on mentoring good physicians, instead of mediocre researchers.
I'll share my experience as an M1. From what I've been told by current residents that I've spoken with and some of my faculty mentors, research was never a "must have" until grades and step 1 became pass fail. Once every student's transcript looks the same as the next, residency programs had to start looking for something else as a surrogate for more traditional measures of academic performance, and for better or worse (the latter by far in my opinion), research became that substitute.
Why are we not selecting for those people we think will be good doctors? Do we not want non-academic doctors? Who is going to take care of all the people if all the newly minted docs are busy with research? Or are we just abandoning all the actual care to mid-levels in the future?
Curious why a gap year is a hated term? Is this just a medical field feeling? As a parent to teens and blessed with the ability to provide them with an intentional gap year full of travel and learning, it’s an incredibly important idea in our family, backed with evidence of growth in confidence, happiness, motivation and clarity. We plan to create it for each of our sons after graduation. Why the negativity?
Dan answered perfectly. To me, it’s not a gap year if you’re pursuing your interests, working because you need to, want to, or are trying figure things out, or just need a break. But a gap year just to buff your CV, 😬😬😬
I think it's "hated" in the context of medical school admissions in which terming someone's year(s) of travel, working an actual job (God forbid!), etc., as a gap implies that it is abnormal and of little value in the grand scheme of their career when, in fact, it is very much the opposite.
Ah, thanks for clarifying. I read Sensible Medicine trying to be a sensibly informed patient and caretaker vs working in medicine. So thanks for sharing.
It seemed to me during training that the research year was just an excuse to get a warm body into the lab. The MDs going on to do research had a longer commitment than a year. A far more concerning question is one that has plagued academic medicine since I was a study, almost 50 years ago. What makes a good teacher. Teaching is rewarded only in words, not in time for additional research, not in RVU (the coin of the realm). It takes a special understanding of one's specialty to bring a student along, from a to b to c without underwheming or overburdening them.
I don’t see this as mutually exclusive skills. Physicians learn to assess H&P (background), compile symptoms and order tests (method), evaluate results of the tests (results), and diagnose and treat (discussion-conclusion). The scientific method should be a natural extension of med students’ learning.
.
My favorite parts of Covid:
#79
Privilege.
Let’s talk about privilege.
As I lean back with my feet up.
With those vaccinated left staring at the soles of my handsome shoes.
A privilege well earned.
.
Very thought provoking. I agree with your sentiment and wrote a reply expanding on some of your questions and concerns, and proposed a few potential solutions. Thanks for writing and try to enjoy yourself before intern year!
https://socraticpsychiatrist.substack.com/p/comment-on-sutkowski-re-medical-student
There are many other experiences that are valuable to medical students, some of which will give them more practical knowledge that they can use when they transition out of academia (which I have to think 90% of them are bound to do).
When I was in college and medical school I worked in an orthopaedic clinic. Most of my time was spent processing insurance claims - hmm, do any of us have to deal with insurance companies and claim denials? Preauthorizations for treatment? Worker's compensation? I spoke with patients and with the carriers to try to resolve payment issues. I also learned about CPT codes and ICD-9 (at that time) codes. I learned how to read medical notes, the format and what was included in each section.
On days when someone called out, I would work at the front desk checking in patients or scheduling appointments. By the time I got to medical school, the physicians knew me well enough that they would let me come in to observe aspirations and injections, help with casting and prep for minor procedures.
I did do academic research later, during my fellowship, and, while I learned a fair amount of how grant submissions are written and medical writing, I'm not sure that I use any of that in my practice today. That other stuff from my early education - put into practice most every day.
We have M2 students rotating through our clinics now on their ambulatory rotations. They are bright and have long resumes, but part of me wonders if some practical experience might not have put them in a better position to succeed and understand more of what really goes on in a medical practice.
Thank you, Jonathan. I was up to my ears in the curriculum as a student, (Albert Einstein, Class of 1974). The modern medical student needs more education in the culture of medicine and the breadth of health beliefs among patients, not a trivial brush with research. I did publish an article in a peer-reviewed publication, which I enjoyed and from which I learned some basics. It was more than 10 years later before I participated in the publication of another manuscript. Students also need to understand how politics impacts clinical medicine - a retrospective review of the deep errors of our profession during the pandemic should be imperative in today's med school curriculum.
Going a notch or two lower on the ladder - I graduated from nursing school at age 60. Within two months of being hired in my first job in a large metropolitan hospital, I was asked to try to help other new nurses deal with the frustration that, even with a BSN, they really didn't know what they were doing. I told them their nursing degree was only a framework on which to hang everything else they were about to be learning for the rest of their career. I realized that I had a tremendous set of advantages: male, as old as their grandparents, experienced patient (aortal bi-fem; semi-laryngectomy, etc.) and earlier exposure to some of the academic silliness being described elsewhere in this chain. BTW, the complaints outlined and solutions being proposed are hardly exclusive to the medical/academic world; they could apply almost anywhere. Like in congress maybe?
This is an important post - resonates a lot with my PhD experience too. Training programs should more heavily weight the skills and abilities of trainees as measures of success. We need systemic change that doesn't accept the harsh "reality" of the current publishing culture but actively pushes back.
Well said!!!
Doing research at the medical school level is a joke and a real waste of time. Better would be a course in critical analysis of published research so that the student learns to separate the wheat from the chaff in what passes for medical research these days. Much of the analysis on this website would be useful in that regard. But most of the time should be spent in providing a solid background in cell biology, human physiology, and pathophysiology. Then clinical training will provide the guidance and experience of applying that knowledge to the diagnosis and treatment of disease. Those that are skilled in teaching should do that. They shouldn't be required to publish research in order to follow that path.
It would be so much more educational for medical students to do a deep dive into the life cycle of medical ideas generated by “research”. Bias toward publication of positive results leads to hypotheses likely to generate positive results. Then there’s the joy and hope for the new treatment paradigm; with time, data is generated that provides fodder for comparative studies, which is where negative results can see the light of day. Then and only then, does doubt and realism enter the equation. I can think of many examples, such as gabapentinoids in the perioperative period, where what was once embraced as a game changer is now considered more harmful than beneficial. And yet every surgeon I work with still orders it!
My daughter is graduating from a top three university with two degrees (one in biology) this spring, and decided midway through college that she wanted to apply to med school. Her many extracurriculars and leadership fed her personal interests and sociability - so even though she's graduating with a 3.98, the medical school advisor told her to take a year and get hands on clinical experience before applying to med school, otherwise her options might be limited.
She was told that the only kids that go straight through are those that *start* college with the intention of going on to med school and plan their classes and their time off with precision. Aside from the curiosity of expecting 17-18 year olds to know exactly what they want to do with their life, I think it a shame that some kids might miss out on some interesting college sidebars for lack of time to pursue things without obvious career value - a club sport, a social club, theater work, etc. (She did have a summer fellowship working abroad on diabetes research, and was one of many authors of a published medical paper.) My daughter wants to help people, exudes warmth, is cheerful and fun to be around, and boasts a myriad of artistic talents in addition to being a smart cookie with a strong work ethic. I'm glad she didn't know what she wanted to do at 18 and instead has made the most of her undergrad years. And I feel pretty confident she'll be a compassionate, conscientious doctor when that day comes.
Frustrating.
(Though I do also imagine you have some bias in your assessments here. 😉🙂)
It may also be worth thinking about what it means to be an MD in a world that seems to want to rely more on NPs and PAs in the future.
Frankly, most want a good clinician to treat them when sick. The general
public could not care less about their publications or research, many of which wind up in backwater journals that no one has time to read and digest anyway.
It’s time to get back to basics. Reinstate grades and boards scores. Focus on what actually matters in the clinic. Allow for students to do research their fourth year. Return to what medicine actually is and start focusing on mentoring good physicians, instead of mediocre researchers.
Great piece! Definitely look us for a Fellowship and job in Pulm/Crit Care.
I'll share my experience as an M1. From what I've been told by current residents that I've spoken with and some of my faculty mentors, research was never a "must have" until grades and step 1 became pass fail. Once every student's transcript looks the same as the next, residency programs had to start looking for something else as a surrogate for more traditional measures of academic performance, and for better or worse (the latter by far in my opinion), research became that substitute.
Why are we not selecting for those people we think will be good doctors? Do we not want non-academic doctors? Who is going to take care of all the people if all the newly minted docs are busy with research? Or are we just abandoning all the actual care to mid-levels in the future?
Curious why a gap year is a hated term? Is this just a medical field feeling? As a parent to teens and blessed with the ability to provide them with an intentional gap year full of travel and learning, it’s an incredibly important idea in our family, backed with evidence of growth in confidence, happiness, motivation and clarity. We plan to create it for each of our sons after graduation. Why the negativity?
Dan answered perfectly. To me, it’s not a gap year if you’re pursuing your interests, working because you need to, want to, or are trying figure things out, or just need a break. But a gap year just to buff your CV, 😬😬😬
I think it's "hated" in the context of medical school admissions in which terming someone's year(s) of travel, working an actual job (God forbid!), etc., as a gap implies that it is abnormal and of little value in the grand scheme of their career when, in fact, it is very much the opposite.
Ah, thanks for clarifying. I read Sensible Medicine trying to be a sensibly informed patient and caretaker vs working in medicine. So thanks for sharing.
It seemed to me during training that the research year was just an excuse to get a warm body into the lab. The MDs going on to do research had a longer commitment than a year. A far more concerning question is one that has plagued academic medicine since I was a study, almost 50 years ago. What makes a good teacher. Teaching is rewarded only in words, not in time for additional research, not in RVU (the coin of the realm). It takes a special understanding of one's specialty to bring a student along, from a to b to c without underwheming or overburdening them.