Advice for a First Year Medical Student

I recently had quite a long conversation with a college senior that was just accepted into medical school for this coming fall. As a rising fourth year medical student myself, I would like to think that I have navigated the waters of academia and figured out both efficient paths to success and avoidance of roadblocks and setbacks. However, I was quite overwhelmed with the number of questions and concerns that this particular student had. But in retrospect, I can recall my own naivete and fear of the unknown that is medical school.

After answering all of his questions, I realized that many soon-to-be first years may not have the advantage of mentors or advisers. Lacking guidance, students are willing or forced to charge forward and hope for the best. These are the same students that suffer the inevitable fatigue and burnout. But I believe that there is a smart and efficient way to approach medical school. That is not to say there are any shortcuts or cheats. Rather, I wanted to share with you my advice on 5 easy steps to being a better medical student from day 1.

1) Be willing to be selfish

You must be willing to prioritize personal time and to continue to do the unique things that make you who you are. And trust me, the time can be found in any rigorous program. Doctors aren't robots, and you should never plan to train like one. Medical school must be a time for you to continue to develop your hobbies and your personality. These are the individual characteristics that will make your patients love you one day. More importantly, these are the activities that will keep you both sane and free from stress.

2) Get 8 hours of sleep

No debating this one. First the benefits – you will study better, be healthier, and feel happier. There are enough distractions and obstacles built into the medical education that you should not be adding to the list. Sleeping in class, rereading text, and mental sluggishness are not paths to engaging the curriculum. Turn off the light, set your alarm, and keep track of your sleeping schedule. After all – you are training to be a doctor who will one day advise patients on healthy practices. Limit the sacrifices you make in your own health along the way. Healthy eating and regular exercise follow, as well.

3) Subscribe to just one health policy daily email or news blog

Medicine, particularly in the modern world, has much importance beyond the realm of clinical information. As a doctor, you will one day be called to be a leader, and your understanding of health policy and health systems will drive your success. You do not have to understand every sentence, or even read every word. But be open to absorbing what you can so you will be better aware of health care on-goings. The future of medicine is in dynamic health delivery systems. While you're cramming over the Krebs cycle, take a five minute break to review the latest info on real-world medicine issues. ACOs are being built and discussed right now – embrace that change and learn as the systems are being designed. (Feel free to email me for the full list of my daily subscriptions – aaronge@pcom.edu). Read during rounds when your attending is off ranting about something esoteric and his back is turned. Read it while your on the bus or in the bathroom. Again, time can be found if you look for it.

4) Study Smart

There is a difference between studying for a test and studying to be a doctor. While these two goals sometimes coincide, they are often very different in nature. I find that, for some reason, medical students have difficulty wrapping there minds around this concept. Here is what I mean – medical students often look to prepare for exams as if they need to know everything about a given subject. Buying multiple textbooks and review guides is more than common. Gaining this knowledge is the right thing to do, and will make them a better doctor in the long run. But it may distract you from your goal of doing your best on given test – and worse, it may lead to burnout. If an exam has questions that are drawn from lecture, then information outside of lecture is irrelevant for the scope of that test. You need to make a personal decision as to how much supplemental information you need to be successful. I'm not telling you to take any shortcuts in learning medicine, I am telling you to be prepared for what matters. You have at least 7 years to go through medical school and residency, and then a lifetime to practice. You cannot possibly learn everything in a day, month, or year. Don't sweat the details during your first year, anymore than is already forced on you.

5) Smile

As easy as this simple act sounds, this may be the most difficult of my suggestions. But stick with me! I am a firm believer in the power of positivity and confidence. You will get through medical school. That is not in question. But you have a choice as to HOW you get through medical school – to complain, suffer, and grieve through the process.....or to enjoy the ride. I believe that smiling, appreciating the best that you have, and keeping a positive attitude effects you in two ways. In the first, you will have the advantage of internal confidence and lower stress. From a medical standpoint, you will be less rattled on test day and benefit from decreased cortisol - both can go a long way! The second effect of positivity is the external impact you will have on those around you. How do you think nurses respond to medical students that complain or look upset during morning rounds. I know that a genuine smile and greeting has led to nurses and residents that have been willing to go the extra mile to offer me support. How do you think an attending or residency coordinator will respond to the stolid student, versus the upbeat one? The truth is that letting in negativity and suffering through complaint are a means of externally expressing defeat. You do not want to be that kind of medical student. Smile, you are living your dream!

I genuinely want all of you to do well, and to be great and successful doctors. After reading many other medical school advice posts on more tangible or “hard” skills, I wanted to offer a different perspective. As always, you have to do what works best for you, and everyone will find success with different methods. But I do hope that some of my advice gives you a different perspective on how to achieve that success. Good luck!

Bringing It All Back Home

In the scope of history, medicine has a definite tendency towards cyclical trends through generations. Recently, I've been considering the moves to incentivize preventative medicine, as well as those to reduce admissions and lengths of hospital stay. These factors are driving health care out of the hospital, and into the home. But looking though the lens of the past – we've been there before.

For the overwhelming majority of American history, health care delivery was centered around the home. Only recently, with the rise of the hospital system, have we witnessed an explosion of inpatient care. Far from this, the only care done outside the house was in charitable centers for the destitute. Further, physicians rarely maintained private offices. Early American medicine was a diminutive practice, and professional physicians viewed as a whole, were considered inconsistent at best.

Throughout the 18th and 19th centuries, the center of health care delivery was definitively the home. It was considered a familial responsibility to care for the sick of the household, and it was often beyond thought to send an ill family member outside for care. There was great tradition in caring for one's own family and considerable comfort and dignity in dying in one's home. In rare or advanced circumstances, a doctor could be summoned to the house to offer guidance. But, by and large, patients remained in bed and the extent of care was entirely within the confines of the family house.

The rise of the professional hospital system and the association of physician licensing to health facilities did much to initiate the movement of medicine outside of the home. Increased urbanization and longer work hours also limited the ability for families to care for themselves. The final blow was cast by the rise of individual health insurance, and the co-committal necessity to seek professional care. By the 1930s and 1940s, the public perception had shifted and American expectations aligned with hospital and office-based care. Since that time, health care delivery has become overwhelmingly associated with these entities.

Modern medicine is now seeing a rejuvenation in health care in the home, and a movement away from the hospital and office. Equipping patients with home blood pressure cuffs, glucose monitors, and sensitive scales allow regular monitoring of health. Many large health systems have developed integrated patient tracking programs, in which these devices automatically transmit information into the system database for that patient. Red flags are recognized by the system, and a phone call to the patient allows immediate evaluation and intervention. Further, the rise of direct care physicians has seen a sharp return to “house calls”. In the near future, a continued increased emphasis on preventative care will keep patients out of waiting rooms and tele-medicine will allow many to confer with doctors from the comfort of own living rooms.

Looking at the cyclical nature of American health care, I am reminded of the importance of remembering our roots. With the current debates and projections in health reform, perhaps it would be prudent to more fully consider the past as a means of plotting the trajectory of the future?

Another thought, which may be somewhat tangential, is no less important for the future of family medicine. As we move into this increasing technological world of health care delivery, it becomes ever more paramount that we stick tightly to our foundations. We must be resolute in our commitment to our patients and present in our compassion. We must practice a delicate and humanistic bedside manner. For that is the one thing that computers and precision medicine can never replicate – a comforting hand, a warm heart, and the dedication and trust of a life-long family physician.

1. For an extensive and enjoyable review on this subject, I would encourage EVERY medical student to read Paul Starr's The Social Transformation of American Medicine. If we understand where we are coming from, we can better be prepared for where we are going.

2. Quality of care and patient satisfaction seem to be hot topics in medicine at present. Certainly, the importance of a bedside manner cannot be underestimated. However, I find it intriguing that we are still striving for perfection in this area in the 21st century. After all, the basics of bedside manner were outlined 2000 years ago in the works of Hippocrates. Nearly 400 years ago, Thomas Sydenham wrote extensively on the details and the art of patient care. Again, with the cyclical nature of health care – before so eagerly looking toward the future and waiting for new solutions to arise, perhaps we should more often delve into the past.

Future of Family Medicine Match Day Coverage - The 2011 Family Medicine Match Results

Disclaimer: This post will be an evolving post that will change throughout the course of the week as results and statistics are released for the match in regards to family medicine.

Well, medical students - the day is here!  NRMP Match Day - a day that brings us full circle to US Grads matching into residency programs throughout the country.  It all started back in December with the military match, then continued with early match, the Osteopathic match, and now the NRMP match.

Military match stats this year had family medicine listed along with peds, ob, surg, and ortho as the most competitive for medical students participating in the military match.

Osteopathic match: "Primary care specialties of family (medicine) saw a 15% increase and internal medicine saw a 28% increase. Family (medicine) was the largest matched specialty with 373 positions filled."

Last year's family medicine match results: "more U.S. medical students chose family medicine as their specialty.. resulting in a fill rate of 91.4%, the highest percentage for family medicine ever."

This year, 172 more students chose family medicine - 2,576 family medicine positions were filled out of 2,730: a fill rate of 94.4% - impressive when taking into account that 100 more positions were available for family medicine vs. last year. Of the 2,576 candidates who selected family medicine, 1,317 of them are U.S. medical school graduates - this as a result of 133 more US Grads choosing family medicine this year (7.9% of US students chose family medicine last year vs 8.4% this year).

At 1PM EST, the NRMP released exciting results in regards to primary care!

For the second year in a row, more U.S. medical school seniors will train as family medicine residents, according to new data released today by the National Resident Matching Program (NRMP).  The number of U.S. seniors matched to family medicine positions rose by 11 percent over 2010....
  Among primary care specialties, family medicine programs continued to experience the strongest growth in the number of positions filled by U.S. seniors. In this year’s Match, U.S. seniors filled nearly half of the 2,708 family medicine residency slots. Family medicine also offered 100 more positions this year. 

This link will take you to AAFP's perspective on this year's match data.  Here is a summary of discussion:

Although the Match results are encouraging, student interest, however, is still not at the level it needs to be. Although the match rate in family medicine among US medical school graduates has increased, the majority of positions offered and filled in the NRMP, especially among US graduates, continue to be in non-primary care sub-specialties. In its 20th Annual Report “Advancing Primary Care”, the Council on Graduate Medical Education (COGME) affirms that the US physician workforce needs to be made up of "at least 40% primary care physicians" to ensure the nation's health, health care access, health care expenditures and health outcomes for the future.  
COGME projects that to reach this 40%, 63,000 additional primary care physicians are needed. If health reform succeeds in increasing the number of insured individuals, more than 100,000 additional primary care physicians will be needed. 
The number of students entering family medicine is most reflective of the future physicians who will provide primary care for adults in the future. The vast majority of internal medicine residents sub-specialize; only 2% of students entering an internal medicine residency choose to do general primary care after residency graduation in one study.

AAFP President, Dr. Roland Goertz, comments about this year's match results in AAFP's press release: 2011 Match Results Again Spotlight Family Medicine Gains

“This year’s results mark the second consecutive year of increased interest in family medicine,” Goertz said. “Although several factors likely contribute to the increase, we believe an important element is recognition that primary care medicine is absolutely essential if we are to improve the quality of health care and help control its costs. Of course, sustaining this interest will require continuing changes in the way America pays for and delivers health care to patients.” 

“Primary care has become much more visible as a result of the discussion about improving our health care system,” he said. “More people understand that if we’re to have high quality care at a controllable cost, we need to rebalance our system on a foundation of primary medical care.

Add in the heightened awareness through activities of the Family Medicine Interest Groups, and students began to understand that family physicians will be able to practice the kind of medicine they envisioned when they decided to become a doctor.” 

MedPage Today joins in on the mix and offers their perspective on primary care in an article titled "Primary Care Again a Top Choice on Match Day."

"This is good news for internal medicine and adult patient care in the U.S.," J. Fred Ralston Jr. MD, president of the American College of Physicians (ACP), said in a statement.
The organization appeared guarded, however, adding that the primary care work force still has "a long way to go" to meet the needs of an aging population with various chronic diseases.
"We're cautiously optimistic and hope that the positive trend continues, but the U.S. still has to overcome a generational shift that resulted in decreased numbers of students choosing primary care as a career," Steven Weinberger, MD, executive vice president and CEO of the ACP, said in the statement

While we continue to compile data, we invite you to visit Mike Sevilla, MD's Family Medicine Rocks! Podcast recorded earlier today on BlogTalkRadio - info about this podcast can be found at his new site, http://www.familymedicinerocks.com.

Reconsidering Reimbursement

The image and role of the family physician in American medicine has shifted from the house-calling doctor with a black handbag to the integrated coordinator of patient care. Despite this, reimbursement remains largely unchanged, with fee-for-service the dominating payment structure. The modern health care climate demands a robust health policy strategy that restructures these outdated reimbursement schemes. Realigning appropriate payment would address issues with ongoing care for patients with chronic conditions and continuity of treatment. Further, restructuring reimbursement would have an effect to revitalize interest and incentive for medical students to enter the field.

Primary care physicians (PCPs) are recognized as family physicians, general internal medicine practitioners, general pediatricians, and obstetrician/gynecologists. As a group, PCPs are often the first point of physician contact for patients with new health issues. PCPs typically serve as coordinators of comprehensive care, and as mediators between specialists. Studies show that one-fourth of Medicare beneficiaries sees an average of 13 physicians each year, and fills 50 prescriptions in that time. PCPs are the primary point for consistent medical contact for these patients – the proverbial glue that holds the pieces together. These are the doctors that are at the front lines of medicine, but who also work in the trenches of prevention and management of chronic care.

While new models for health care are continually considered, such as the Accountable Care Organization (ACO) and the Patient-Centered Medical Home (PCMH), the common theme among all is the central role of the primary care physician. The fundamental key lies in placing the PCP as the coordinator for a patient within a system of care. This is particularly important in rural or underserved areas. PCPs are called not only to treat patients at point-of-care, but also to manage and facilitate physician extenders.

One of the foundational problems in fee-for-service is that it essentially encourages payment for sickness. Through the course of a year, a diabetic patient may see a PCP for a total of two hours. Yet that same patient has to manage their disease for 8,765 hours in that year. The PCP is reimbursed for the sum of two to three visits of point-of-service care, but the disease is ongoing. This would be akin to having a leaky kitchen faucet and asking a plumber to come look at it twice a year, paying for those two visits, but never having the leak quite fixed. While it remains impossible to completely “fix” a diabetic patient, reimbursement must be restructured to account for ongoing and chronic care. The existing plan provides compensation for volume of care. This model must be updated to consider compensation for counseling, diagnosis, and continuity. Moving away from fee-for-service would shift the perspective of reimbursement from one that pays for sickness to one that encourages payment for healthiness.

Finally, shortages in primary care medicine, long considered the gatekeeper of health care, are now threatening national access to care. Studies show that over 60 million Americans, or nearly one in five, lack access to primary care due to shortage in their communities. Meanwhile, only 8% of the nation's medical school graduates enter family medicine. This compares to 14% of the same graduates in 2000. Restructuring reimbursement would have a profound impact on the incentive for students to enter the field of primary care medicine.

It is often said that an ounce of prevention is worth a pound of cure. This analogy certainly has profound implications for our modern health care system. Primary care physicians, the vanguards of preventative medicine and caretakers of chronic disease, should be reimbursed for the broad level of responsibilities they conduct. Our nation must undertake a sincere evaluation of our reimbursement models and engage in the development of a more robust payment scheme for primary care physicians.