31 Comments

I agree with the author that medical education in the United States is in need of reform. The challenges that they have identified are all valid and need to be addressed.

I would like to add a few additional thoughts on these challenges:

Selecting students: I agree that medical school admissions are unfair and select many of the wrong students. The current system relies too heavily on standardized test scores and grades, which do not always correlate with success in medical school or practice. I would like to see a more holistic approach to admissions that takes into account factors such as personal qualities, work experience, and community service.

Educating students: I agree that much of the basic science curriculum is irrelevant to the majority of practicing physicians. I would like to see a more clinically-focused curriculum that prepares students for the real-world practice of medicine. I would also like to see more emphasis on interprofessional education, so that students learn how to work effectively with other healthcare professionals.

Promotion and dismissal: I agree that assessment throughout the continuum of medical education is not done well. I would like to see more frequent and more meaningful assessments of students and residents. I would also like to see a more transparent process for dismissing students and residents who are not meeting expectations.

Education vs free labor: I agree that residents are sometimes used as cheap labor. I would like to see a system that better compensates residents for their time and expertise. I would also like to see more opportunities for residents to gain research experience and develop their skills in leadership and management.

I believe that these reforms would make medical education more fair, effective, and efficient. They would also help to ensure that we are graduating the best possible physicians to care for our patients.

I would like to add my voice to the conversation about reforming medical education. I believe that these are important issues that need to be addressed. I am hopeful that we can work together to make a difference.

Regards- Jennifer

Writer at https://sites.google.com/site/bestessaywritingservicereview/

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Writing as a patient, I would like to see doctors with some knowledge of natural medicine. Perhaps a course could be added, unless Big Pharma “owns” the medical schools.

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I totally agree. There is so much knowledge to master now including parallel areas like nutrition, acupuncture, eastern medicine, and many others. Question is when is it enough? There just isn't enough time to cover all these topics adequately to make most physicians comfortable to use them. Better to teach basics and have a better selection of providers in these area to refer to.

I don't need to know how to do surgery to be a doctor, I need to know when to refer my patient to one. Same thing with cardiology, dermatology, etc. I need to know the most common diseases in the area and when my patient needs more specialized help. Nutrition is something that we don't pay enough attention to, and we need to. True nutritional knowledge requires much more time than currently available. Maybe we need to make it part of the requirements to apply to med school??

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I would add an emphasis on nutrition, epidemiology, bio stats, and prevention as mentioned. Also, medical schools should be free of conflicts of interest from pharmaceutical companies. Textbooks, faculty, funding - it degrades trusts with patients at a critical time in our society.

As far as prospective student evaluations, perhaps a rigorous mental health exam - too many students with borderline sociopathic/homicidal tendencies.

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Maybe the time has come to review the amount of time we teach physicians. I had a big red flag interaction with a top surgical program in a highly rated hospital and residency program. My 87 yr old mother had a subtotal mastectomy for stage 2 adenoCA of the stomach.

Her pain was well controlled with Oxy 5mg po. prn. But due to a number of stupid, 1st yr med student level errors, and failures of the system to recognize or even question a prescription, my mom was prescribed 100mg dose of Oxy. Only I noticed it. Nursing n pharmacy assumed Cancer pt, high dose pain meds. The error was the resident had ordered Oxycodone LIQUID and 5ml of the liquid was =to 100 my!!

Mucho trouble to correct this on a Friday evening to boot!! Meanwhile my mom who just had major surgery gets no pain meds!! When I brought a copy of this script to the head surgeon at our follow up visit and pointed out the significant and lethal error, his response was we don't have enough time to teach them everything they need to know!!

No that isn't the problem. The problem is we have had to put so many safety steps in place that Residents depend on those to pick up and correct their lack of knowledge, so they don't bother on their own. Only when they get out into the real world of independent practice, that backup will not be there.

So do we need to increase the length of training? Or rearrange it like some of these excellent ideas here? And why are we teaching future DRs to "shotgun" w labs n tests, instead of good hx and exam and use their brains instead? In my last 5-6 interactions with physicians as a patient, not one actually touched me, even when they were creating an emergency based on labs, when the patient did not come close to labs!! I had been in the ER for over 8 hrs for severe weakness and inability to stand up balance wise. Suddenly now they want to intubate me bc my pC02 was over 80. Yet the pt is awake, alert, coherent, and maintaining a reasonable pulse ox. But still no DR has touched me as they r trying to convince me, a fellow DR, that I need emerge tubing!!

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Where does the teaching of bedside manner come into education reform? Is bedside manner an individual's approach or manner? Is a future doctor born with this very important approach?

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Bedside manner itself was never specifically taught in med school or in residency. Growing up my father had many interactions with medical system due to traumas from his job as a roofer. He had chronic back pain from the multiple fractures and injuries. I used to go with him and was appalled by the lack of caring by most of the Drs. Our family Dr seemed to be the only one who showed any empathy and kindness.

All thru college I had a number of emergency surgeries and hospitalizations and my OB-GYN truly taught me about proper bedside manner.

I personally tend to treat patients like I would like to be treated. I sit down and talk with them eye to eye. I listen to what they say and ask questions. Usually before I ever lay hands on them, from what they have told me, I have a good idea what is wrong with them. My exam usually confirms this. I then discuss what is wrong and options for treatment. I then ask them if any questions and how do they want to treat. I tended to have very dedicated patients, who stayed with me for a long time.

So to answer your question, you have to look thru a lot of Drs to find the ones with bedside manner and who treat you with respect. Also to find one's who are able to think outside the box and can treat things that are not just similar, straightforward issues.

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It never ceases to amaze that the US pereptuates a brain drain on other countries by importing doctors trained on other countries' dime, often the Third World, while countries like Cuba are exporting doctors. It should be the reverse.

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Sep 21, 2022·edited Sep 21, 2022

re: biochemistry - do physicians need to know any basic science *at all* ?

the practice of medicine seems so far abstracted from technical details. Like, you don't need to know anything at all about the entity known as "insulin" or the entity "diabetes" to run through the care pathway - to recognize clinical symptoms associated with the disorder, order bloodwork, prescribe the drug, etc. It makes no difference that it is a peptide, that it's produced in the pancreas, the cysteine thing is irrelevant - the technical details make absolutely no difference to how care is delivered. It's all pattern matching with (seemingly) very low information content. Most of the care I've received consists of" "let's order a bunch of bloodwork and see what we find!" or "let's get a scan!" At which point it's a simple if/then process. Where is the complexity?

From an outsider's perspective, medicine seems highly constrained - "the Science" is compressed into neat decision trees / guidelines that sum the clinical evidence, reimbursement considerations, and all those technical and scientific details...into flowcharts. Which are at hand in decision support software lol. The actual practical information complexity of practicing medicine is way way lower than it's made out to be. But on paper physicians need to be experts in all aspects of physiology - to atomic precision. Why? (Of course no one "understands" biochemistry or genetics or molecular biology or the liver to any real degree anyway *anyway*)

so what is the hyper-competitive med school selection *for* - is it actually necessary to select for the top 1% of the cognitive and empathy elites because that is *required* for the practice of medicine? Or is it to create a pretext to constrain supply?

We pay way too much and have care shortages because of these assumptions. "I spent 10-15 years in school to become a doctor so I *should* get paid lots".. Uh, why? Most of that time was spent learning "esoterica." You could have learned what you need in 2 years. And "we can't increase quotas because care quality will be compromised". Will it? (no.)

It's a house built on sand. It should be a trade!

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His father, his father before him, and his father before him were doctors of medicine in China, going back five hundred years. However, when the family arrived in the United States, his father was not allowed to practice medicine.

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I would argue that we need to keep all 4 years of medical school and include those items that a physician needs but is not taught. It becomes painfully obvious how important nutrition is to the development and treatment of a disease process. By including actual courses, not just the passing lecture, about nutrition into each of the four years would help that physician apply it to their future specialty. Also, most physicians end up practicing primarily in a non academic setting. Having a basic fund of knowledge taught to the them regarding office management, contract evaluation and negotiation, and all of the financial aspects of a practice will better prepare them for what they will encounter.

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My young son, a health care worker told me I couldn't pay him, enough, to become a doctor.

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I think medical education needs to start at the pre-k level, with play, then onto elementary school for science, middle school for labs, high school for shadowing in the real world, and voilá you have a medical student. This public school training model could level the "playing field"...more opportunity for the least able to afford medical school.

Steve Jobs articulated this well: "when I needed medical attention, I was helpless to help myself survive." This is inexcusable in the United States.

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I have an INSTINCT about all medical issues, because I was brought up by two physicians! - Look for children of physicians -.

Medicine is a lot more than just completing med. school. - we have covid pandemic to prove so.

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Sep 20, 2022·edited Sep 20, 2022Liked by Adam Cifu, MD

I am a tenured full professor and have been teaching/practicing for decades. While I would not disagree that updates to curricula and approach are always meritorious (more on that below) I respectfully disagree with major tenets here.

1. I have seldom, going back decades, seen underfinanced students excluded because they "could not afford" medical school. We were among the first schools (in the 1970s) to specifically recruit from HBCUs to make sure that we were not missing students who could otherwise be potentially great physicians but could not pay (I made some of those visits myself). Every school of my acquaintance has plenty of scholarships, loans and grants for those who have trouble paying. Some even cover all tuition for all students. This is just a distractor and often a trope to obscure other matters.

2. As other commentors have noted, there is a social engineering component introduced into medical education over the last five years that is substantially deprecating the quality of applicants and, almost certainly, the quality of the physicians we are putting out. Primarily selecting students by their demographics, how many hours of pushing wheelchairs they did, and their social justice warrior scores and compliance almost guarantees bad physicians. Across the medical schools with which I am involved (either directly or tangentially) student essays and interviews often dwell on how they want to use medicine to cure the world's social ills, rather than taking care of patients. The idea that medicine is fundamentally an interaction between patients and their physicians seems completely foreign to where they want to go. Few want to be the "best doctor providing the best care" they can be as their primary motivation. Rather it seems a well-paid stepping stone to more social justice warrior-ing and this pattern continues through their medical school tenure.

3. Because we are accepting less qualified students, we have all been forced (word deliberately chosen) to remove all of the measurement tools that we used to, at least, note who was learning and how well. So no more grades (might make someone in the class sad and/or demonstrate that some are better than others), no more scores on USMLE Part I...the list of watering down the validation of learning is long and getting longer. The LCME and their effort to change medical education to something barely related to medicine is a major driver of this. The authors above suggest that we should use "coaching to excellence" which returns to the pre-Flexner days of hocus-pocus completely subjective evaluation of students. I am not even going to go down that rat hole. Of course we should coach our students to excellence, but that is in a very, very different category than measuring excellence. I think all of us that went through medical school can remember attendings that loved us no matter how badly we screwed up and those that hated us no matter how good we were. Part of life, but a bad predicate to being our measurement standard.

4. There is a substantial difference between being a physician and being an NP/PA that the authors seem to mostly ignore. Not to take anything away from the support practitioners, but they already get the education mostly being advocated here -- focus on signs and symptoms and quick diagnoses/cures without much focus on the whys and wherefores. There is an important place for this kind of approach -- but it is not for physicians. I am a hematologist and when I lecture about megaloblastic anemia and its many twists and turns I spend considerable time with concepts from biochemistry, microbiology, histology and pathology. I could not possibly include this information de novo in my lectures -- if not grounded in all these areas, the relevant content would not be taught.

One could still become a check off the boxes kind of provider (coached to excellence in checking off boxes, I suppose). That is not the physician's role. SOMEONE needs to be able to understand what they are seeing beyond signs and symptoms. By discarding all of this, you deprecate the physician's role to that of Epic slave...just like many other health care workers.

5. There is no question that even with the above there is too little time spent on learning to be inquisitive and to question everything. The blind acceptance of the AAPs disastrously wrong diktats in support of the governments disastrously wrong diktats vis-à-vis Covid underscores this well, to the greater detriment of thousands of children. The recent passage of the California law that delicenses physicians who disagree with the government diktats ("Oh, they are experts."...BS) and have the temerity to tell their patients that they do is a further example of how obsequious and unquestioning the general physician population has become. If one is not primarily interested in caring for their patients but rather in supporting whatever party is leading in your social justice warrioring irrespective of their patient-immolating diktats (about which Vinay has written often) then patients suffer. In my opinion this is always wrong. Teaching physicians how to read literature and to question what they read should be high on the hit parade as a prerequisite for graduation. Requiring biostatistics and understanding scientific literature should be a preadmission requirement to medical school. You can be sure that the colleges would jump to offer this if required.

6. The idea of having competence-based progression through school is sound; some do learn faster/better than others. I have also seen the flip side of this -- students who were still there taking resources literally seven years later, still failing to meet the minimum standards. And no one should get out of school after six months because they can memorize things quickly. So this needs some deep thinking to do effectively.

Medical education is inherently difficult and is supposed to be -- one is taking others' lives into one's hands and there are few greater responsibilities. Flexner started the move toward making the selection of those for this profession more objective and more based on understanding health and health care, patient by patient. Recent deprecations of this are not good for the profession or, more importantly, for patients.

There are large numbers of current medical school graduates that I would not let care for me. Enough said.

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Before getting to the subject, one must first raise the question why hasn't there been a significant increase in the number of American (and other) schools training doctors and therefore increasing the number of doctors over the last 25 years? We knew the need was coming, yet it was ignored!! Your answer is likely as cynical as mine. :(

Dr. K starts an interesting conversation.

In the essays I thought I saw woke-like thinking. So I'll I'll offer for discussion the acceptance discussion and use of the MCAT at my local University, a generally very good school.

In these essays it seems to me a critical issue has been avoided.

University of Minnesota MCAT, Association of American Medical Colleges.

https://www.aamc.org/system/files/2022-062023%20MCAT%20Data%20Selection%20Guide%20Online.pdf

Lots interesting information.

IMO, much of it is used to justify White male discrimination. Some White males (and females?) with higher scores are simply excluded from medical schools. If they had been accepted the data and chart trendlines would have likely shifted higher.

One would have to return to an earlier period, non-woke, to see the scoring difference from today. Please keep in mind the high esteem American medical doctors earned in the past probably does not hold today.

Also what the AAMC failed to reveal was the results by nation of student. The same testing applied in foreign lands would be interesting.

The U of MN is discriminating and accepting less qualified candidates but the average is good. The U of MN medical school's 2022 applicant class has an average MCAT and GPA of 512 and 3.7 with ranges of 490-525 and 2.7-4.0.

Fig 3: the school encourages those with lower scores; over those with higher scores.

Fig 4: It appears White males are discriminated against; White's in general are discriminated against. All those Asians? This statement should explain it: "Research suggests the differences in MCAT scores for examinees from groups underrepresented in medicine based on race/ethnicity and other background characteristics reflect societal inequalities in income, education, and other factors rather than test bias."

Fig 7: White males rated higher, Asians higher.

Below Table 1:

"In addition to applicants’ academic data, admissions officers examine applicants’ experiences and demographic and personal attributes." "For example, 80% of admissions officers rated other criteria just as or more important in making acceptance offers."

This could be an example. Seeing the photos and short bios on the wall a while ago, I saw that my local clinic has 12 family practice physicians. 2 are male, 10 women and 6 of those were from foreign lands. I recently tried to see the current information photos. They had removed them.

Interesting, p16, Table 2. acceptances by MCAT and Undergraduate GPA.

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This model is currently circulating in the United States, in many other fields, too.

Through intimidation, or bullying the underclass gains the respect they crave, which they have not acquired through schooling.

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Sep 20, 2022Liked by Adam Cifu, MD

As a non academic surgeon who works internationally in a developing country medical education should include nutrition and public health. It’s construct should be system based where students learn about let’s say: the GI system from anatomy, histology, pathology, pharmacology and to prevention. We put way too much emphasis on illness and disease treatment and not enough on disease prevention.

I hope physicians who are not working in academic institutions weigh in here.

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The greatest problem with medical education is admissions practices that deny the profession many of the most talented and hardworking students. Meritocratic measures like the MCAT and GPA have been supplanted by affirmative action, political tests, and prolific histories of sheetfolding and pushing wheelchairs.

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Sep 20, 2022Liked by Adam Cifu, MD

It wasn't until my MPH (several years after DO), where I better learned and applied epi/biostats, that I was able to appropriately synthesize the latest evidence/science to better apply it to clinical practice. I definitely support the advocacy for teaching/mastering these skills in medical school. Much more useful than much of "the esoterica." Love Dr. Cifu's proposal on preclinical assessment and Dr. Prasad's pitch to add flexibility and debt-forgiveness to medical students/residents.

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