Category Archives: getting personal

Has med school changed for the better?

by Karan Chhabra

 

Every third-year has heard it.

…When I was in your position, I was taking 24-hour calls every other night. If my resident was there, I was there….

We’re regaled about the glory days, without shelf exams, without phlebotomists, and—by god—without those work-hour restrictions. The days when medical students wouldn’t dare ask their residents for help, or residents their chiefs, or chiefs their attendings, and so on. I hear a bit of romance: the heroism of providing total patient care, exactly when the patient needed it, unfettered by handoffs or outside interference. I envy the skill required to practice medicine almost-literally in one’s sleep.

As the veteran doc continues his (yes, usually his) soliloquy, he may admit that it wasn’t the safest model for patients, or the most humane for trainees. He may today be a better doctor for it, but he’s a bit ambivalent about whether it should remain exactly the same today. Presumably he wasn’t alone, because since the good ol’ days, the third year of medical school has morphed into something barely recognizable.

Now, rather than arriving before our residents and leaving after, our time is “protected” in many ways. We have lecture days devoid of patient care, service-learning commitments, and other activities designed to expand our learning beyond the hospital’s four walls. We have shelf exams demanding a much broader scope of knowledge than a typical day on the floor. Occasionally we’re granted a bit of time to study for said exams. Sometimes, we even have weekends.

This is progress, in many ways. Teachers with the right training are supervising patient care. We’re gaining exposure to ambulatory care, where the bulk of American medicine takes place. We’re acquiring the research skills to practice up-to-date medicine as it evolves, rather than learning from sheer repetition. We’re learning how to communicate humanistically and practice ethically. And, in fits and starts, each generation is learning a bit more about how the many pieces of the healthcare system fit together.

But I wonder how much has also been lost. Residents’ duties have gone from the bedside to the computer, where information flows in and orders stream out. We can “round” on vitals and labs at the nurses’ station without ever laying eyes (let alone hands) on the patient. Nurses, phlebotomists, and other members of the workforce have taken over so much of what we formerly called “patient care”—which in turn has evolved from a tactile task to a cognitive one. It’s no surprise that medical students’ experience has followed suit. By the end of a clerkship, we can rattle off pathology, pharmacology, and differential diagnoses till even the attendings fall asleep—but heaven forbid we’re asked to start a difficult IV. I worry I’ll end up in a new generation of well-read, friendly, ethical, system-conscious doctors who’ve learned the textbook but forgotten the patient.

As a student, the times when I’ve lacked longitudinal patient contact have been the most taxing. The hours spent chasing labs and consults or “rounding” at the nurses’ station are the ones that leave me wondering what medicine has become. And I have to ask if the apparent epidemic of physician burnout is really about too little human contact rather than too many hours on the floors. Some have decided that rather than returning to patient care, we should be learning on simulators instead. But to me, that would represent the pendulum swinging even farther away from those we must eventually serve. Lest the establishment forget, we will someday be treating patients rather than machines and multiple-choice problems. Will we be ready?

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Karan is a third-year student at Rutgers Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

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Is “progress” in medical education backfiring?

by Karan Chhabra

A good bit of fuss surrounds the evolution of medical education. The way we’re taught sometimes seems as susceptible to trends than the clothes we wear—one decade trumpets the “integrated,” systems-based curriculum, the next decade moves to the “flipped classroom,” and the cycle continues. Of course, these changes are based on educational theory, and their outcomes are often studied rigorously. But every now and then, when I rotate with a doctor trained the old-fashioned way, I wonder what has really been gained—and whether something has been lost—since the days they were taught.

I’ve seen how older physicians recollect tidbits from their preclinical years (decades ago) that my classmates and I can’t seem to remember past a few months. I wonder how much of this is the result of the way they were taught. Of course, there are many confounders here: our own intelligence versus those physicians’, our generation’s perpetual state of distraction, and perhaps the volume of material we’re expected to retain. The “old way” of teaching by discipline (anatomy, pathology, pharmacology, etc.) seems far less intuitive than the way we’re currently taught, by organ system (cardiovascular, gastrointestinal, etc.). To mentally switch from psoriasis to anti-arrhythmics in the same day seems like work.

But that may in fact be the secret to its success. I’m referring to research on “massed practice,” rapidly learning subjects en bloc, as opposed to “interleaved practice,” switching between learning tasks rapidly and revisiting the same topics day after day. A recent article (thanks Skeptical Scalpel) shows a relevant example:

 

Consider this study of thirty-eight surgical residents. They took a series of four short lessons in microsurgery: how to reattach tiny vessels… Half the docs completed all four lessons in a single day, which is the normal in-service schedule. The others completed the same four lessons but with a week’s interval between them.

 

…The difference in performance between the two groups was impressive. The residents who had taken all four sessions in a single day not only scored lower on all measures, but 16 percent of them damaged the rats’ vessels beyond repair and were unable to complete their surgeries.

 

Why is spaced practice more effective than massed practice? … Rapid fire practice leans on short-term memory. Durable learning, however, requires time for mental rehearsal and the other processes of consolidation. Hence, spaced practice works better. The increased effort required to retrieve the learning after a little forgetting has the effect of retriggering consolidation, further strengthening memory.

 

This effect isn’t limited to technical skills. The article also references cognitive tasks, like geometry problems. I wonder if it’d extend to preclinical medical education as well. I can personally relate to how a disease seen in one organ system, say in November, may literally never be seen again under an “integrated” curriculum.  It’s far easier to learn the pathogenesis of strokes and their treatment in the same week—but easier is not always better. Perhaps a trickier, thornier learning process is also sticker in the long run.

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Karan is a student at Rutgers Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

Quick Plug: Teach Medical Students How To Be Placebos

by Karan Chhabra

Quick heads-up: Dr. Ishani Ganguli was nice enough to post a piece of mine on her blog, Short White Coat, hosted by the Boston Globe. Check it out and — most importantly — share your thoughts!

Key quote here:

What I take away from placebo research is that how we do our job is just as important as what we do. The notion that drugs and surgery are the only treatment we can offer has become a self-fulfilling prophecy. Medical training and research are decidedly focused on what drugs to give when – knowledge necessary, but not sufficient, to serve our patients. This may distract us from the psychological and social mechanisms beneath the human response to treatment. Rather than inventing a new procedure that might not be more effective than sham, we should be inventing ways to get the benefits of a sham without cutting the skin.

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Karan is a student at Rutgers Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

The Wild West of the Individual Market

by Ross White

Ask most people to list the important birthdays of early adulthood and they would likely choose 18 (legal adulthood!), 21 (alcohol!), and 25 (lower car insurance!), but what about 26? After the last three months, I respectfully submit that turning 26 just became important for many. As you may know, a provision in the Affordable Care Act allows young adults to stay on their parents’ health insurance plan until age 26. I naturally cheered the provision when I started graduate school a year and a half ago, forfeiting employer-sponsored health insurance coverage—but it made the fall into the private insurance market an acute experience.

I started researching my insurance options in D.C. early. I had a good idea of what kind of plan I wanted: reasonable premiums and deductible, decent prescription coverage (I take daily maintenance drugs for asthma, allergies, and another well-managed chronic illness), and flexibility in provider choice. After thoroughly browsing and speaking with agents at several companies, I decided to enroll in a PPO plan from one of the largest national health insurance companies (Company A—an initial that might mean more than you think). I was given an initial quote consistent with what I could reasonably pay as a part-time employee and full-time student. As an aside, it did not make sense to enroll in insurance through my school because premiums are on a semester basis, so I’d have had to pay retroactively for months without coverage. Great! That’s settled, right?

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Pills, Pills, Pills (Or Not): Is It Up to You?

by Shana Montrose

The Diagnosis
Close your eyes and imagine a person with high cholesterol. Did you imagine a 20-something, white, middle-class woman, who eats kale, has low blood-pressure and doesn’t weigh enough to donate blood? Neither did I.

I didn’t know my cholesterol was being checked until my doctor ordered a second blood test, this time requiring a 12-hour fast. Not believing I was a candidate for high cholesterol, I suggested the lab results had been thrown off by a wine-and-cheese party I’d hosted just days prior.

A nurse called with the results. She said my cholesterol had progressively increased over the past few months and that the doctor had written a Lipitor prescription. Continue reading