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!

Is There an Underlying Specialty-Bias in Medical Schools?

A multitude of factors drive students towards, or away from, the path of family medicine. Much has been made recently of reimbursement schemes that incentivize specialty practice. Certainly, medical students strapped with debt are showing preference to more lucrative fields for residency. But is there more to this choice beyond the surface of financial incentive? What about the very environment that cultivates the growth and decision-making of our medical students? Does an underlying, or perhaps hidden, bias to specialty care exist within the modern academic community and curriculum?

First, consider the structure of the academic course itself. The systems-based approach to medical education remains the predominant curricular modality. Under this structure, organ systems are taught by specialists who are invited to profess the proceedings of their specialty. This leaves students with cardiologists teaching cardiology, pulmonologists teaching pulmonology, and family doctors, often, on the sidelines. Certainly, every school employs faculty to a differing degree. In fact, my medical school chooses to bring in primary care providers to approach a 1-2 hour discussion on the broad implications of each system. However, these brief family medicine lectures are all ultimately followed with 2-3 weeks of intensive specialist-driven lecture. This leaves the overwhelming prevalence of educators to be drawn from the specialty fields.

I understand and appreciate the necessity of this approach, but one cannot deny the potential effect on students. How does specialty-driven, systems-based curriculum effect student perception of medicine? Does this leave a dearth of primary care role models at the frontlines of our classrooms?

Next, consider the content and focus of standardized examinations, such as “shelf” exams and USMLE step exams. Exam passages often tell a story, starting with something along the lines of,

“Mr. Smith is a 76 year old male who was referred by his family doctor for difficulty swallowing. He presents to your office today with…”

In my experience, I have rarely come across questions that highlight the role and duties of the family physician. The implication is reasonable – test-writers hope to hone in on minute details of pathology or physiologic consequences of disease. However, in doing so, is their an unintentional belittling or underplay on the value of the family doctor? Does this continued focus on the details and complexities of disease have the effect of placing an unintentional bias towards specialty care in medicine?

Further, consider a medical student’s experience in clinical rotations. Take myself for example – I am now a full ten months into my third year of medical school. Meanwhile, I have spent approximately nine of those months working on inpatient wards or in the operating room. Like most of my colleagues, I have reached the point in academic career in which I must make a decision on my residency path. Yet, is it reasonable for me to do so with 4-6 weeks of total outpatient family medicine exposure? Certainly, I would never argue with the necessity for medical student exposure to the fullest array of clinical experiences. However, does a built-in bias towards inpatient, hospital, and specialty medicine exist within this process?

Certainly, in my experience, specialists do not necessarily paint the best picture of family physicians. Far too often, I hear comments such as, “Oh boy, would you look at what their PCP did? I guess we’ll have to clean up the mess”. These sort of comments are rarely balanced by accolades or praise for general practitioner care or referral. I often found the family physician to be portrayed as a guy on the outside looking in. Ultimately, does the prevailing impression of the inpatient experience in clinical rotations generate a bias towards specialty care?

An article published in the New England Journal of Medicine on February 10th addressed the importance of the involvement of medical schools in the encouragement of primary care selection. The paramount responsibility that was implicated was that the school should place primary care physicians in leadership roles within the administration and deans offices1. This further emphasizes the importance of the medical school curriculum and environment in the process of supporting and advancing the mission of primary care.

I have asked many questions in the preceding paragraphs – this was purposeful. I believe these are all questions that remain to be answered, or questions that could be answered differently depending on the academic institution or environment. Certainly, the modern world of academic medicine provides for limitless variation. I am confident that many medical schools exist that take a balanced approach to exposure and encouragement of residency choice.

The sentiments that I have expressed are drawn from my experience, as well as discussions with my peers. I encourage you to help me answer some of these questions and contribute to a robust discussion below. At the very least, keep these considerations in your mind as you move through your training, or think about the training of others. Does this underlying bias towards specialty training exist in academic medicine?

1. Smith, Stephen R. “A Recipe for Medical Schools to Produce Primary Care Physicians”. New England Journal of Medicine, Feb. 10 2011. Vol. 364;pg 496-497.

The social responsibilities of family physicians - the case of Wisconsin family doctors

Earlier this week, 4 family physicians donned in white coats and stethoscopes were observed handing out sick notes to teachers and other public employees who were rallying outside Wisconsin's state capitol. At this point, the protestors have been rallying for almost 2 weeks straight. These 4 doctors were handing out sick notes to any one who needed them so that they could call in sick while continuing to protest.

At stake for teachers and other public employees was the benefits, wages and the right to protest as the Wisconsin state government tried to rein in their budget and limit public employees' labor rights.

At stake for doctors...?

Multiple media sources labeled the sick notes as fraud. They claimed that the doctors were giving these notes when:

• the doctors were not the regular providers for the protestors
• the doctors were not taking histories or examining before handing out the sick notes
• the protestors were not actually sick!

Here is a YouTube video based on an interview of several of physicians.

One way to approach this is to debate what constitutes as "fraud." Another way, the one I am going to take, is looking at what social and policy responsibilities of a physician. As a future family physician, I believe that we need to look at a broader definition of health and its improvement. If workers' rights are taken away and wages are decreased, do these affect their psychological health... often resulting in physical health implications? I would argue that physicians should not stick to the medical issues to the isolation of political issues. When we do so, we risk leaving the determination of policies and laws to others who may not have the improvement of health in their interests. I personally think physicians stand to gain a lot when we bring our personal narratives about our medical experiences into the realm of politics and policy making. Policy makers, and the general public shy away from statistics and scientific studies and are much more convinced and drawn to personal stories.

However, while I agree that physicians need to be active in policy and politics, I question the mode in which these Wisconsin physicians (all affiliated with UW Madison's family medicine department) engaged in policy making. While physicians need to be engaged citizenry, the professional role (writing sick notes) should not be mixed directly with the advocacy role.

Another thought I had: what is a sick note? Why do doctors write sick notes? In America (and in many countries), patients choose their physicians. I haven't seen statistics on this, but I would say only rarely does a physician refuse to write a sick note when requested by a patient. If a physician did refuse, the patient only need go to another doctor. So, what does the "sick note," so often requested by employers, really signify, if anything? Why are doctors even involved in this play between between employers and their employees?

Thoughts? On either sick notes or physicians' social and advocacy roles?

Media coverage of Wisconsin doctors writing sick notes for protestors:

http://www.theatlantic.com/national/archive/2011/02/wisconsins-real-doctors-and-their-fake-sick-notes-for-protesters/71500/

http://www.foxnews.com/politics/2011/02/19/saturdays-protests-wisconsin-expected-biggest/

http://blogs.wsj.com/health/2011/02/22/doctors-notes-for-wisconsin-protestors-spark-controversy/?mod=google_news_blog