Sunday, June 19, 2016

Questions to ask When Picking a Medical School if You Want to be a Good Doctor

I graduated medical school this May from the Keck School of Medicine of USC.  And only now can I speak about what I should have cared about when picking a medical school in the first place.  Originally, I had picked USC for a unique medical engineering program called Health, Technology, and Engineering, and because I heard colloquially that it had good clinical training since it had a major county hospital.  I was extremely fortunate that I did so.

Let's start with what factors don't matter.  The format of the first 2 years is almost completely irrelevant, as long as the curriculum is pass/fail.  That last factor removes a large amount of stress, and doesn't materially affect learning.  But problem-based learning vs. traditional lecture, systems-based curriculum vs. traditional discipline based- all of it doesn't matter.  There is a lot of material, and it must be memorized before Step 1, the big test that basically determines the course of every doctor's life.  The small differences between medical schools are minor.  Some schools are better at some things than others- my school had a great anatomy department for example.  But in reality, the modern process of studying for Step 1 which is shared by all medical students largely evens out such differences.  Everyone finds the best way to study, buys access to modern test-prep resources such as Pathoma and uWorld, and does as well on the test as they can.  One factor to consider is how much time students get to study for Step 1 after pre-clinical classes end, since that may impact one's score- but most schools give enough time.  Also, Some schools are moving to a shorter pre-clinical duration- 1.7, or 1.5 year curriculums.  In general, more time on the wards is better, since that means more chances to do away rotations if you are thinking of competitive specialties, and more chances to take useful electives.

I'll briefly touch on prestige, research, and rankings: yes, it is easier to match in competitive specialties coming from a higher ranked medical school.  No it is not impossible to match if you come from a lower ranked one.  Research is harder to find at lower ranked schools, and increasingly is needed to match.  But, this post is about how to become a good clinician- not how to match into what you want.

The differences between medical schools really lie is the clinical experience- specifically, the autonomy given to medical students when they hit the wards.  The reality is that there is a vast dichotomy in medical education today when it comes to medical student responsibilities.  As a medical student at LAC+USC Medical Center, I was the primary clinician seen by my patients on the wards and in various clinics- I would see the patient, write their clinic note, put in orders, and the resident or attending would come in and confirm the salient points before co-signing and approving my work and orders.  (This was allowed because LAC+USC doesn't bill fee-for-service, and thus is not subject to CMS rules which dictate that medical students may only write the ROS, Family History, and Social History components of notes).  Patients remained safe at all times- I was appropriately supervised- but my responsibility for my patients was very real.

Being required to write notes and come up with a plan for all of my patients was immensely beneficial to my education.  In the beginning (and even at the end) my work often had large gaps and problems, necessitating long hours reading and learning.  But by being forced to commit to something on paper, and then being told what I had forgotten to ask and write about in my note and what I had gotten wrong in my plan I learned an incredible amount from every patient.

I was a 4th year student going into General Surgery, but when a patient who was relapsing into membranous nephropathy came into the renal clinic and was randomly assigned to me, guess what?  After seeing the patient, I had to spend 30 minutes reading UpToDate, come up with something approaching a reasonable plan, and present it to the attending.  Once the plan was (heavily) modified and a protocol approved, I then had to figure out the right doses of medications, labs required, follow-ups needed, and then send those orders to that same attending for a counter-sign.  Then, it was me sitting down with the patient and a Spanish translator to answer as many of their questions about their disease and plan that I could.  It was hard, and that day I went home well after most of the residents who staffed the clinic.  But I learned- just as I did when working with the trauma team on patient after patient coming into the trauma bays on Acute Care Surgery, carrying up to 9 patients at a time and taking 24-30 hour call in the SICU, doing countless H+Ps and rounding daily on patients with decompensated cirrhosis on Medicine- and dozens of other experiences that I wouldn't trade for anything.  I had amazing mentors in my residents, who took the time to teach me since what I did made their lives easier.

In comparison, many medical students at other schools describe their clinical years basically as glorified shadowing.  They may have "carried" patients, and occasionally written notes for practice and presented patients to attendings/upper levels, but they often felt that little that they did actually mattered.

So pre-medical students, when you are invited to interview and when you are applying, see if you can't find a 3rd or preferably 4th year student at that school, and consider asking them these questions:

  1. (Pre-clinical question) How much time does the school give after pre-clinical classes end and before rotations start to study for and take step 1?  Do you feel like it's enough?  (4 weeks is a bit short, anything more than 5-6 weeks should be more than enough.  If the school has a unit at the end of the pre-clinical curriculum called integrated cases, or clinical prep or something, you are set- that is your Step 1 time).
  2. (Pre-clinical question) How long is your pre-clinical curriculum?  When do you start Wards?  (The traditional start date is July 1st, but the earlier in general the better.  Some schools start medical students on March 1st, some in January.)
  3. Do you ever write notes that count, or do residents and attendings routinely copy-paste and delete your notes written in Word/the EMR to save them time?  Do you feel like your notes and work ROUTINELY count for anything?  (Most every medical student has that story about 'that one time' a resident read their note on a complicated patient.  What matters is the routine- are medical student notes routinely read and copy-pasted into the record, with feedback given?)
  4. Do you feel like residents have an incentive to teach you and make their lives easier?
  5. Would you ever be trusted to talk to a patient alone about their plan and answer their questions?  (Don't ever tell a patient anything about their plan unless you clear it with the resident first and know it really, really well.  But educating patients about what's going on is a pretty standard med student job, and a nice way you can be useful and actually help patients.  Just listening to them is often enough really).
  6. On Ob/Gyn, do medical students ever deliver a baby?  (The national average for medical students is less than one, meaning most medical students don't deliver a single baby on 6 weeks of Ob/Gyn.  In the past, medical students would graduate having done dozens of deliveries.  This question is a good proxy for the amount of autonomy given to medical students.)
  7. Do you generally feel like a valuable part of whatever clinical team you are on?
  8. Is your medical school affiliated primarily with a public county hospital, or VA?  (By and large, schools that are primarily affiliated with county hospitals give significantly more autonomy to both residents and medical students, and VAs give more autonomy as well- though with a vastly restricted patient population.  Famous County hospitals include SF General and Highland (both affiliated with UCSF), LAC+USC (USC), Grady (Emory), Ben Taub (Baylor), Cook County (Rush), Jackson (U Miami), Parkland (UTSW), Harborview (UW-Seattle), Kings County (SUNY Downstate), and Bellevue (NYU). )

Now, I must include some caveats here: just because one goes to medical school without a significant amount of autonomy for medical students does not mean that they can not be a good doctor.  Residency ultimately matters far more than medical school- and there the question of autonomy and gaining skills by repetition matters so much more.  Many doctors even develop their skills through mentorship once in practice- older general and CT surgeons have described to me how new surgeons would learn many practical skills from their older and more experienced partners.  All medical schools in the US are tightly regulated, and while there may be significant differences coming into residency, by and large most medical students from most schools are able to catch up.  

Finally, I would like to close by including some suggestions for how medical schools around the country can improve: make all medical students qualify as medical scribes.  The fact is, human beings are pattern recognition engines.  The more patients seen, the more notes written, the more plans formed, the better the doctors.  How do medical students see more patients and get more feedback?  By making them useful- if it more convenient for residents/attendings to use what medical students think about and write, the residents and attendings will naturally work harder at making those medical students better and thinking and writing.  Of course, every word they write has to be approved and responsibility taken for by their attendings and residents who must confirm the essential elements of the case- but that's how it should be, and how it was just a few decades ago in the era of paper medical records.

It boils down to this: to be a good doctor, you have to do a lot of doctoring.  Schools which have you do more doctoring as a medical student will make you a better doctor.  So, when you are applying to medical school, find out which medical schools let you do more doctoring.  Simple as that.