Ask the Half M. D.: Why are medical students such assholes?

April 29, 2009 at 11:20 am (Ask the Half MD)

A reader asks, “Why are medical students such assholes? The same people are in charge of EVERYTING. It seems like they’re all licking each other’s asses.”

At my own university, we have about 20 students in my class who run every organization from student government to most of the interest groups to even the choir. These people got elected into positions of power as freshmen while most people were trying to study and then spent the next four years appointing each other to positions so they could pad their resumes in attempts to land an elusive residency spot. Watching them work is like visiting the zoo and watching the monkeys pick nits out of each other’s hair. At the end of each year, they hold self-congratulatory parties in which they circle jerk to let the rest of the student body know how awesome they are for organizing the spring formal and judiciously dispensing student government funds to the registered groups on campus.

While I have no problem with someone wanting to become involved with extracurricular activities on campus, there is certainly a line that people cross when they join organizations for the sake of holding leadership positions. I’m the president of one of my campus’ interest groups. I have a vice president who has never been to a meeting, a secretary who has not returned an e-mail since last July, and a treasurer who has no idea how much money is in our budget. In a sense, I’ve had to run every officer position in the club over the past year and frankly, I’m quite annoyed that other students would run for positions without any intention of following through on their leadership responsibilities.

The other line people cross is mistaking leadership for dictatorship. I know quite a few people who believe that barking orders to others is the only necessary component to leadership. Our last class president was completely ineffective at his job and needed the secretary to plan and organize every event from social functions to the teacher of the year award. He would then gladly take credit for all of the effort put forth by others. While I would like to claim that he is an idiot, his move was actually very smart. If a residency committee were to acknowledge the accomplishments of our student government, he would automatically gain credit simply from his position.

There really is no other way around the situation. You can try to ignore it during your four years in medical school. Some people just need to be in charge and there is nothing you can do to stop them, unless you plan on running against them in the next election.

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Ask the Half M.D.: grading in med school

December 31, 2008 at 12:54 pm (Ask the Half MD)

A reader asks, “I was just curious if grading in Med-school is like high school or college like letter grades or if its more of a pass/fail thing. I’m sure they use scores for rankings and internship and residency selection, but do you feel that they really represent your progress in becoming a doctor?”

There are two questions that need to be answered: 1. How are students tested? 2. How are students graded?

The majority of medical schools employ multiple-choice tests when examining students’ progress. The questions typically take the form of a clinical vignette such as, “a 34-year-old woman presents with upper abdominal pain of one hour’s duration. She stated that it began after eating chili. What is the first step you take?” These tests do a pretty good job of ensuring that students have properly studied the material. Granted, medical students can generally find reasons to complain about a particular exam, claiming that the wording was insufficient, that there were more than one correct answer choice, or that the material was never taught in class. And while I have seen some very poorly written tests, for the most part they do a good job in representing our progress to become doctors.

The difference occurs with the frequency at which tests are given as well as who writes the questions. You’ll find that some schools give exams every Friday. Others might give tests every two weeks on a Monday. While there are some that give exams only at the end of the semester and use it as the sole determining factor of your grade. Further, there seems to be a variety of sources where course coordinators can draw questions. My own university requires professors to submit three exam questions with each lecture they give. Other universities employ the Shelf exams to test students. Shelf exams are written by the National Board of Medical Examiners, the same group that puts out the Medical Licensing Exam. These tests are standardized and are given all across the country. When you apply for medical school, be sure to ask how students are tested, as there is no universal method employed by all universities.

As far as the grading mechanism, there is also much variability between schools. My own university uses a pass/fail system, where we are merely assigned a P or an F on the transcript. The school has set an exam score of 70 as the cutoff for passing. We are then internally ranked where students are placed into quartiles at the end of each year. No one will ever know his/her individual rank, but will be provided with his quartile standing.

Other universities use the old college system with an A-F grading scale. Using this method, students know exactly where they stand. Other universities use an awkward hybrid system with honors, high pass, pass, marginal pass, and fail that eerily resembles the A-F scale. Again, you’re on your own to discover which method is employed by each school.

Finally, almost every medical school as an honor system known as Alpha Omega Alpha (AOA). The students who belong to this group represent the top 12% or so of each graduating class. To claim AOA status is a universal distinction recognized by all residency programs. In short, if you are a member of AOA, you can pretty much write your ticket to any residency.

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Ask the Half M.D.: what is the fourth year of medical school like?

November 5, 2008 at 8:22 am (Ask the Half MD)

Over the past few weeks, several medical students in the first through third-year classes have been asking me what the final year of medical school is like. I’ll be the first to confirm that the fourth year is indeed the promised land of your medical education. After working nearly 80 hours a week as a third-year medical student, you can look forward to the warm light at the end of the tunnel that is your fourth year.

Whenever I encounter residents or attendings and tell them that I’m a fourth year student, they tilt their heads to the side, stare off into space for a few seconds, and release a nostalgic sigh as they remember the joys of their own fourth year. A typical conversation might go something like this:

Senior resident: You’re late. Where have you been?
Me: I’m a fourth-year medical student.
Senior resident: Oh, in that case you don’t even have to be here. Would you like to go home?

The final year for medical school can roughly be divided into two domains: getting into residency and vacation. You’ll certainly have to do some work this year as you will travel the country on externships in an attempt to impress various programs where you might want to enter residency later. During these externships you’ll serve as a star student reliving the 80-hour work weeks that you grew to hate so much during third year. You will study hard, work hard, arrived early, leave late, and introduce yourself to every faculty member in the department in the hopes that you can get a favorable review when the time comes to apply for residency.

Fourth-year is also filled with lots of administrative headaches such as tracking down grades, securing rec letters, meeting with deans, applying through ERAS, setting up interviews, booking flights, and voting in the presidential election. But after your you have finished all of those tasks, you are ready to enjoy the next six months.

Whereas the third years are required to take courses in surgery and obstetrics where they invariably get yelled at for not knowing everything on the first day, fourth years get away with courses such as nuclear medicine and geriatrics. Typically, the day starts at 9:00 a.m. when I come in and meet my resident to obtain his signature on my attendance form. I then go home at 9:05. Thanks to the accreditation board which requires that we attempt to learn something during this glorious year, clerkships hold afternoon lectures which usually revolve around having an attending show up late, tell us how wonderful fourth-year is, give out the answers to the final exam, and then end class early.

That’s not to say that all medical students take fourth-year so lightheartedly. There are a few scabs at could never let go of being a gunner for the previous three years and for some reason, feel the need to study and work away their last year of freedom. These students will take clerkships in the intensive care unit and hematology/oncology service where they will work to the point of exhaustion while the rest of us play drinking games during the presidential debates. As for me, I started brewing my own beer and I’ve been working my way through all of John Grisham’s novels. As far as I’m concerned, those are the only sorts of activities that fourth-year medical students should be involved in.

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Ask the Half M.D.: Is there a best medical school?

October 21, 2008 at 8:17 pm (Ask the Half MD)

A reader posted the following comment on another article:

Hi, I was just wondering how large a factor what medical school plays into getting a residency and job where you want. I realize getting into Harvard Med is a bigger deal than say Oakland University. But when you say apply to as many school as possible, is it simply the money issue that would prevent you from doing that, or is getting into a below average medical school that bad of a thing.

I’ll summarize it by saying, “Is there a best medical school?”

The U.S. News & World Report rankings would have you think that there is a vast difference in the quality of medical schools here in the United States. Pre-meds, parents, and the media play into this frenzy of believing that certain schools are vastly superior to others. I’ve written in an earlier post on my feelings about the ranking methodology. Instead, I will use today to discuss whether or not there is any validity to these rankings.

First, consider performance on the licensing exams. All universities, on average, have a 95% pass rate for their students. That also means that there is, on average, a 5% failure rate. Both Harvard and Drexel each have students perform at the top of the bell curve as well as those who fail outright. While there are differences in the average score, your performance on the test is based solely upon your own preparation, and not any magical instruction given by the school.

Here are the match lists for Johns Hopkins University (currently ranked #2), Brown University (currently ranked #31), and Albert Einstein College of Medicine (not ranked). You will notice that people from all three universities have matched in noncompetitive specialties such as pediatrics as well as competitive specialties such as ophthalmology.

I also found a list of people who have matched into plastic surgery in 2007 and neurosurgery in 2008. Take a moment to go through the names of all of the schools. You’ll notice a variety of universities are listed, including rank and unranked programs.

That’s not to say that where you go to medical school is completely meaningless. Residency program directors certainly take it into consideration. For example, if a senior resident from State University is doing well at a particular residency, the program director is likely to look favorably upon medical students applying from that university. The converse is true. If a resident who is an alum of your university is performing poorly, the program director might unconsciously think that you will struggle as well.

Some research has been performed on the subject as to what program directors are looking for. Several years ago the journal Academic Emergency Medicine published an article ranking the most important factors of an application. They are:

1. Emergency medicine rotation grades
2. Interview
3. Clinical grades
4. Other
5. Recommendations
6. Grades (overall)
7. Elective at the program director’s institution
8. Board scores (overall)
9. USMLE step II
10. Interest expressed
11. USMLE step I
12. Awards/achievements
13. AOA status
14. Medical school attended
15. Extracurricular activities
16. Basic science grades
17. Publications
18. Personal statement

You will notice that “medical school attended” falls behind “other” and “interest expressed.” So maybe it does play a role after all.

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Ask the Half M.D.: what’s the best stethoscope?

July 15, 2008 at 10:47 am (Ask the Half MD)

All around the country premeds everywhere are anxiously awaiting the start of medical school at the beginning of August. They will bring with them many hopes and aspirations as they begin their careers toward becoming future MD’s. They will have many questions such as which organizations to join, whether or not to go to class, and who is going to kill the first patient. But nothing is more anxiety provoking at this time then trying to decide which stethoscope to purchase.

While there are many options to choose from, I would caution fresh medical students to stay away from the electronic stethoscopes. I have never use these devices. While I’m sure that their built-in microphones will help listeners catch even the faintest heart murmur, there is something to be said about learning the physical exam the old fashion way.

First and foremost you must buy a cardiology grade stethoscope. That includes a diaphragm, a bell, and a dual lumen tube. Instantly disqualified are the nursing-grade stethoscopes that your parents got you as a gift when you were accepted to medical school. You should plan to spend at least $100 on a quality model.

Currently, the most popular stethoscope amongst medical students is the Littman Cardiology III. there is no shortage of users willing to sing its praises. It comes in numerous colors, drug companies give away accessory products specifically designed for it, and it has the appeal of being able to say, “I went with the Littman.”

I don’t like it. I haven’t been able to hear as well with it as the marketing propaganda would claim. The fans will instantly cry out, “But it has a tunable diaphragm.” To which I would respond, “Do you even know what a tunable diaphragm is? And furthermore, if you pay any attention to the research that was conducted on stethoscopes beginning over 50 years ago, you’d realize that a tunable diaphragm is the exact feature that a stethoscope should not have.”

I prefer the Welch Allyn Tycos DLX. The sound quality is much, much better compared to the Littman. It has interchangeable ear pieces that come in various varieties of stiffness so that the user can choose based on comfort level. Finally, the diaphragm can be easily changed to a pediatric version. All I have to do is unscrew the adult version and then replace it with a pediatric one to convert my stethoscope into a listening device for the kids.

Take a look at the pictures below:

Adult version

Pedi version

What now bitches? I’d like to see you pull that off with a Littman. Its users will be required to buy two stethoscopes to follow both adult and pediatric patients. I know several people who purchased new stethoscopes just to go through the peds rotation. I took a more sensible approach.

Edit: I just found this exhaustive article that goes into detail about properly using a stethoscope. There is also this article that gives a comparison of multiple scopes.

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Ask the Half MD: is there a best pre-med school?

June 27, 2008 at 8:32 pm (Applying to med school, Ask the Half MD)

A reader asks, “My daughter and I have been reading your blog for a while now.  She will be starting her freshman year at XXXXX College this fall.  She is worried that by attending a less famous university she is at a disadvantage when it comes to applying to medical school.  She is wondering if she should transfer to the University of XXXXX to better her chances of getting in.”

First, no parent should ever write me to ask about a child’s interest in medicine.  If you want to go to medical school and have a question about how to apply or what life as a med student is like, then you need to be the one who writes me.  Don’t let your mommy do your work for you.  As for the question regarding if there is a best pre-med school, the short answer is no. 

Your application to medical school is based upon your GPA, MCAT, letters of recommendation, extracurricular activities, personal statement, interview, and a host of other factors.  Your application—and all of the things that make it up—are solely you’re doing.  Granted, if you go to a university with grade inflation, your GPA will naturally be higher than other students'; however, you still must work hard to become a competitive applicant.

That said, we should not discount undergraduate institutions entirely.  The American Association of Medical Colleges keeps a list of which undergraduate universities applicants attended the year that they applied for medical school.  According to their data, the five universities responsible for having the most applicants in the United States are:

1. University of California at Los Angeles
2. University of California at Berkeley
3. University of Texas at Austin
4. University of Michigan at Ann Arbor
5. University of Florida

In a way, these programs send so many students to medical school every year that their pre-med offices are very familiar with the application process.  If nothing else, going to one of these universities—or to any place that is affiliated with a medical school—can help a person in so far as preparing him/her for the road ahead.  Many of these programs have staff that are very experienced with the cumbersome medical school application process.  Going to a small liberal arts college might very well make you the only pre-med on campus.

That’s not to say that if you are a high school student you should base your decision on where to go to college solely upon the number of pre-med applicants getting churned out every year.  You should certainly attend the school that is the perfect fit for you, whether it be a large state university with tens of thousands of students or a smaller location where all of the professors and deans know your name.  But if you are utterly lost and looking for ideas of where to apply, this list can serve as a good starting point.

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Ask the Half MD: Are there any jobs for M.D.’s that don’t want to practice medicine?

November 11, 2007 at 11:29 pm (Ask the Half MD)

Every year about this time, medical students at all levels of their training begin questioning if they’ve made the right decision in life by pursuing an M.D. Whether this issue arises as a result of the first bad grade received on an exam or it comes from looming uncertainty of becoming a clinician for 20+ years, many students will eventually wonder if they can pursue careers outside of medicine.

Unfortunately, I can’t imagine many reasons for employers to seek physicians on any other grounds other than their medical acumen. While the C.I.A. is looking for health analysts, similar jobs are hard to come by. By its very nature, medical school is designed to give professional training for a occupation with a narrow focus. If it trained any more broadly, we’d call it business school and give everyone an M.B.A.

Sure, we can point to famous physicians such as Sanjay Gupta, Michael Crichton, and Howard Dean, but none of them really needed a medical degree to pursue their current careers. Gupta is merely a reporter; Crichton is a science fiction writer; and Dean long gave up anything remotely related to health or science. If anything, these men took on needless amounts of debt and schooling only to keep someone else from that spot in the applicant pool from becoming a real clinician.

Some readers will bring up the idea of health managers—hospital and health plan directors who don’t see patients, but still need some amount of medical knowledge before setting up shop. My answer to this objection is to look at the ages and resumes of these administrators. Many of the M.D.’s started off in practice and gained experience before transitioning over to leadership roles. Further, the field is full of managers with no firsthand healthcare skills. Duke University offers a degree in health sector management without any requirements of prior medical training. You don’t necessarily need to be a doctor to know how to lead other physicians. And given how poorly medical schools and residency programs are already run, I’m glad that others realize that having doctors in charge is a bad idea.

I realize that the thought of seeing sick patients for the rest of your life can seem unflattering. I also realize that there are warrant fears of getting sued, getting sick, or losing out on family time. However, anyone thinking of applying to medical school needs to understand what this life entails. The blogosphere is full of horror stories of medical training and practice simply because many of the things we experience are so painful. If you’re still in the pre-med phase, take a while to evaluate what an M.D. really means to you. You can certainly find other ways to gain money and respect without taking this route. If you’re already in medical school or residency, things get trickier. While Hoover was willing to leave, others may not be willing to make the same move so early. I’ve already seen so many classmates regret the choices they made in coming to medical school. Getting accepted is difficult enough; being able to admit to such a mistake is even harder.

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Ask the Half MD: Do Med Students Date?

April 12, 2007 at 11:28 pm (Ask the Half MD)

A pre-med asked me earlier this week about the social lives of medical students.  She particularly wanted to know if we have the time to date.  While you’ll do a lot of studying in medical school, you’ll certainly have free time for going out like you did in college.  One trend I’ve always thought peculiar is that students—after spending 8 hours a day with each other—then want to spend their nights and weekends together.  Since many of us came here without knowing anyone before school started, we usually don’t have friends outside of our classmates.  We usually don’t branch out to meet others.  Hence, we also end up dating each other, too.

You’ll hear lots of warnings about dating classmates such as, “Just remember that things are going to get awkward in the anatomy lab once you break up.”  I’ve also heard the colorful advice, “Don’t shit where you eat.”  While I imagine that there’s some truth to feelings that you two might have towards each other when the relationship ends, I have two cautions of my own.

First, medical school is just like high school: you know all of your classmates and you know all of their business.  My campus is not alone in spreading gossip through the school.  Some things are true—such as two students having an affair—and some are just plain false—such as two students having an affair.  The problem comes in when everyone else believes these rumors to be true and then, finding them to be too juicy, will pass them on to other members of the class.  If you want a private life, you must realize that other students are off-limits—including upper classmen.

The second warning is about the small selection of datable students.  Some people will already be married or in other long-term relationships.  Many of the women will be asexual (i.e., they aren’t looking for a relationship of any kind).  Therefore, the pool becomes very small.  To compound that problem, let’s take a moment to look at the type of person that decides to become a doctor.  Everyone of my readers is well aware of the sacrifices that must be made to get to medical school.  The applicant must be near flawless in every part of the application: good grades and scores, the right extracurriculars, saying the right things during interviews, etc…  The only type of people who would willingly put themselves through this kind of torture would have to be crazy—literally.

I’ll be the first to admit that I’m a bit weird, but compared to my classmates, I’m probably the most balanced one here.  One artist has stated that there are 12 types of medical students.  I’ll just summarize as saying that they’re all nuts.  The women here have more issues than a magazine stand.  These people could fill psychiatry textbooks as case reports.  Just keep that in mind when you start flirting with one of your classmates.  Also, several students are completely controlled by their parents.  Usually mommy, M.D., is footing the bill, meaning that mom comes on the dates with you.  Seriously, I knew one girl who had certain rules for her condo because her mother told her to enforce them.

Go on a clinical rotation, find yourself a nurse, and never look back.

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