Year 2 in review and Now What?

Well, I guess that I am now officially a third year medical student. How the time flies when your head is buried in Robbins for a year. I really mean that it flew by. It feels like just yesterday that I was hanging out in the ER and looking back on first year and getting geared up for second year.

It was a struggle for me at times. Sitting around reading a book, memorizing minutiae of diseases for the sole purpose of regurgitating it on an exam felt like an exercise in futility most of the time. That passive style of learning about as far outside of the context where the knowledge will be used as you can get. I think it's a pretty big oversight in the curriculum design, I'd say 90% of us just memgurgitated through the year without trying to integrate the knowledge into something that is applicable to the wards. But then again, it was better than the integrated Problem-Based format that several schools have initiated. I could see sitting around a conference table with a bunch of unprepared students getting on my nerves pretty quickly. From the rather limited small group stuff that we did do, I can say that the majority of my classmates are F'd when it comes to rounds and pimping. Sure they can regurgitate the 25 different translocations for each type of leukemia, but can they form a differential for someone who has abdominal pain??? NO! I feel completely unprepared for what is coming...thanks over-priced medical education. Way to set me up to be useless next year!

Don't even get me started on Step 1 and the debacle that is. While it was somewhat nice to review everything that I've learned so far in a fairly coherent manner, do you really need to charge me 400 dollars and pin my hopes and dreams and future income on it???
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So now that Step 1 is on the books, I keep asking myself "now what?"

There is a ton of information and misinformation floating around about third year clerkships. We had a few forth years come talk about the clinical sites and they weren't able to come up with any clearly discernible differences between them. Our dean of student affairs talked about the sites as well, and without mincing words said that they are all the same. I even took some initiative and talked to older students to try to get a taste of what's expected at my clinical sites and to be honest, they've given me very little to go on in terms of what the expectations are/who the better attendings are to work with, etc. Thanks guys. I guess I'll just have to figure it out as I go.

I hopped on SDN's clinical forum....which is always a huge mistake. Between the posts talking about shoes, PDA's, resident horror stories, pissing matches and generalized gunner behavior, I decided it was a warped perspective that was better to ignore. So I bought myself a copy of the 250 Biggest Mistakes that 3rd Year Medical Students Make to try to get my head wrapped around what I'm in for in two weeks. The overarching theme of the book is to be a neurotic pain in the ass to everyone in the hospital from housekeeping up to the department chairs!!! It instructs me to make sure that I chase down every evaluator and have them clearly define how they'll be evaluating me, how they want write ups, notes, oral presentations, their coffee and their ass kissing. My complaint is that for every helpful nugget in the book (how to write up a new admission/progress notes, how to present a patient), I had to wade through the waste deep gunner advice ("Here's every question to ask your resident on the day you start") and stupidly obvious advice for those medical students with an IQ of 36 or below (Read your orientation packet before orientation). It came with a free Maxwell's (a $15 value), so I can't complain too much.

Anyway, here's my major concern:
In the span of about a week, I'm going to be tossed in way over my head (during the second week of July no less) onto what is rumored to be one of the more malignant Surgery services in the country. There's a bit of a nagging feeling that the preparation that I've received thus far may have been inadequate for what's expected. While that seems the norm for most medical students...so at least I'm not alone.

But in all seriousness: I've never presented a patient orally, I've done 2 complete physicals, I've written up half a dozen patients, I've stabbed a couple veins and I've spent maybe a total of 6 weeks working in a hospital setting...this is going to be a rough transition.

Oh well, the dude abides I guess...

Reason # 57 why medical school sucks

18-24 inches of light, fluffy, west-coast style powder fell over the Green Mountains of VT in the past 24 hours. I studied CNS pharmacology. I could be spending a weekend (like that guy) with my brother or my girlfriend skiing some of the BEST SNOW CONDITIONS EVER, but instead I'll be chillin in the library with Robbins, Cecil, Golijan and Katzung getting ready for my exams. Stupid priorities...Stupid expensive medical education...Stupid Bostonian for making responsible life decisions.

Medical Education Philosophy Rant

Forest or trees?
Looking back on the last exam block, it seems that there is something inherently wrong with the way that I am being educated. I get the joy of trying to cram 3-500 pages of material into my brain and regurgitating it in the form of trivia questions and little black circles. How many of those circles I bubble in correctly corresponds to my grade, which in the context of the performance of 200 of my peers determines a small portion of where I will be allowed to work in the future and what I will be allowed to specialize in. It's an asinine process where I'm not really retaining a whole lot of material that matters. Instead I'm focusing on memorizing which CD's are expressed in which developmental stages of which WBC cancers...and it will have VERY little to do with the rest of my career from here on out. I'd assume that the forest was more important than the trees, but apparently we're going to examine every cell of every tree in the forest.

Multiple guess/Alphabet soup
Loosely thrown into the mix is an attempt to get interaction from members of the class in small group sessions. Unfortunately, these sessions turn into more of a lecture than a discussion/problem solving exercize. My concern comes when I'm actually going to have to make diagnoses and see patients and interact with other physicians. Will I see the patterns, will I know what tests to order, will I even know what to look for when it's not presented in a multiple choice format. It's not as if people are going to present with the choice of ABCD or E with me able to bubble in the correct choice with only the price of my grade on the line. These will be people's lives, and I don't even know how to make a differential diagnosis work or even what should be listed together. But I can tell you the different markers on the different flavors of Non-hodgkins lymphoma...what is more important in your future physician: performance on a multiple-choice exam or knowing how to diagnose a patient??? I saw an article from AAMC that the Step 1 is being re-thought.

I think what has bothered me most about my very expensive education thus far is that I could have learned most of the material with about 6 books and a ticket to Body Worlds at the Museum of Science...

Second year...

I'm not sure if this is how things are at every school, but second year has been a farcical experience to date. Here's you're syllabus, here's the extremely shallow intro lecture that doesn't even scratch the surface of the topics you need for the exam, here's the summary lecture that basically recapitulates the intro lecture, here's the clinical correlations group discussion problems that are far too in depth for you to possibly glean from the reading and thanks for that $40k in tuition.

I know, I know...first I whine that there's too much class, now I'm whining that there's not enough. You're missing my point...effective lecture beats the pathetic excuse that we're asked to sit through any day. What I have a problem with is that the LCME is making all of medicine "self taught" to make us "life-long learners". Wonderful. How is paying an exorbitant amount of money to sit around reading, highlighting, memorizing and rereading hundreds of pages of Robbins going to make me a life long learner? I could buy myself a Kaczynski style hut in the woods of Montana and hole up there with my Robbins, my Lippencot pharm, my Parham immuno and my Clinical micro made rediculously simple books, 500 highlighters and the syllabi and get just as much done without the bothersome distractions of food, electricity or human interaction. I understand that medicine is progressing at an amazingly fast rate, so instead of updating your lecture series, I get the JOY of teaching myself the molecular nuances of every pathological condition that have all been illucidated in the last 10 years. But I digress...

Ok, so I'm expected to teach myself all of pathology, micro and pharm...cool. I've accepted that. So why am I still giving the school $40k for tuition? Well, they need me to come and discuss the readings, facilitated via a case study format, with my classmates. Sounds wonderful in theory, right? In practice, it is basically 20 of us sitting in a room going through a list of questions with either, a) a path resident who covers WAYYYYYYYYYY too much detail or b) a pathologist that they pulled back from the brink of death to moderate our small group. Kind of like the Crypt Keeper from Tale from the Crypt, but better groomed.

The other students in my group just sit there with blank stares hurriedly taking notes on everything that is said and not contributing to the discussion at all because they're afraid to answer a question incorrectly. We sit around for 2 hours, with the better part of an hour consumed by silence...it drives me up a wall. I throw out wrong answer after wrong answer and in the lovely Socratic method, the doctor just keeps telling me I'm wrong and waiting for someone else to answer correctly.

My favorite example: Young lady presenting with granulomatous lesions in her hilar and mediastinal nodes, SOB, the whole 9 yards infering sarcoidosis...what's the differential?

Lets see, you have to rule out EVERYTHING ELSE before you can call it sarcoidosis...so I start listing things and getting shut down. Silence. Something else, shot down. Silence. Look around at one of the girls that I know studies alot and is way up on her stuff and try to drag the answer out of her brain with Jedi mind control power...silence. IT IS DRIVING ME INSANE. One more try...shot down. Meek voice from the smart girl says "Sarcoidosis...?"CORRECT DING, DING, DING, praise showered on her. Excuse me if I am mistaken, but isn't a differential diagnosis a COMPREHENSIVE LIST OF EVERYTHING THAT MIGHT BE WRONG WITH THE PATIENT. Yet I get shot down at everything I mention...it just makes me feel stupid...better get used to it, because third year isn't much better from the stories that I hear.

Anyway I'll bring this tirade to a close with the following thought:
Dearest LCME,
If you want me to become a life long learner, aren't you responsible for building up my strong foundation now so that I can actually pass your classes, get through school and get to the point of having to educate myself??? I'm paying for an education, not to be tossed a 1500 page book to memorize minutae from while I flounder in your mandatory group sessions. Thanks for your consideration, and I look foward to your reply
~Bostonian