Category Archives: medical education

Hope and Skepticism about the New MCAT

by Karan Chhabra and Allan Joseph

The MCAT (better known as every pre-med’s recurring nightmare) just went live with some pretty big changes intended to better prepare premedical students for the healthcare system of tomorrow. We’ve got a guest post over at Dan Diamond’s Forbes blog examining and reacting to the changes. A small excerpt:

That’s why we applaud the AAMC for resisting this bias and placing social science, psychology, and the humanities on the same plane as pure science — where they belong. The new MCAT sends a new signal to aspiring docs: they need this knowledge just as much as they need hard science, and the medical community now demands they have it…

But unless admissions committees firmly commit to selecting “broader” applicants in all aspects of their applications, the newest version of the MCAT will fail in the same way its ancestor did.

This is something we’ve thought a lot about, but we’re really interested in hearing your thoughts — take a read and let us know your thoughts on Twitter (see below) or in the comments.

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Karan is a medical 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.

Allan is a third-year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.

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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.

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.

The Real Problem with Medical Student Debt—Investors, Look Here!

by Karan ChhabraAllan Joseph, and Josh Herigon 

America might never agree on how much doctors deserve to earn. But there ought to be much less debate on the immense debt today’s medical students incur on the way to becoming doctors. Few people are more aware of the stress of medical student debt than med students themselves and there is evidence that it affects our specialty and practice decisions later on down the line.

Enter this tweetchat. What began as a typical med student complaint about their debt load evolved into a provocative discussion about the underlying factors and potential solutions to the debt problem. We’ve incorporated some notes explaining perhaps unfamiliar concepts, but otherwise this is the unvarnished product of a few med students procrastinating on a Sunday night.

@JoshHerigon: Median med school debt today = $170k vs in 1978 = $48K (adjusted for inflation). http://goo.gl/iTtMH9 #meded [original tweet]

@krchhabra: ARGH RT @JoshHerigon: Median med school debt today = $170k vs in 1978 = $48K (adjusted for inflation). http://goo.gl/iTtMH9 #meded [original tweet]

@allanmjoseph: @krchhabra @JoshHerigon Yes, but…more demand than ever for spots, & vastly higher teaching/resources since then. Complex issue. [original tweet]

AJ: The easiest way to tell if med-student debt is becoming an acute problem is if the demand for medical-school spots (easily measured by the number of applicants) is declining relative to the supply. That’s just not happening. In fact, the opposite is.

@krchhabra: @allanmjoseph @JoshHerigon I’m skeptical that teaching is any more resource-intensive than it once was (except perhaps for standardized pts) [original tweet]

KC: Standardized patients are actors paid by medical schools to act out clinical scenarios as we pretend to be doctors. They’ve been a useful component of clinical skills instruction for several decades—but their help isn’t free.

@allanmjoseph: @krchhabra @JoshHerigon At least here, our student:instructor ratio is insanely good, and so are our useful support structures. [original tweet]

@allanmjoseph: @krchhabra @JoshHerigon Not saying it’s all reflected, but I also don’t think it’s an apples-to-apples comparison. [original tweet]

@JoshHerigon: @allanmjoseph @krchhabra Our campus is probably nicer… [original tweet]

JH: Even more than a decade ago when I was an undergraduate, the arms race between universities to build bigger and better facilities was well underway. Examples are not hard to find. Medical schools and academic medical centers are active participants in this trend. In 2007, my own institution announced a 10 year, $800 million expansion. It’s not clear how capital improvement projects impact student tuition—administrators argue such projects are paid by dedicated capital funds, supported by the state, private donations, and/or bond initiatives. But, new facilities increase annual maintenance budgets and in the face of shrinking annual operating budgets, where do administrators make up the difference? Again, the impact of capital projects is not obvious; what is obvious is that tuition rates have not decreased with these projects.

@krchhabra: @JoshHerigon @allanmjoseph But we’re talking about secular time trends. Is your student/teacher ratio better than it was 20 years ago? [original tweet]

@krchhabra: @JoshHerigon @allanmjoseph of course there’s more small group learning than there used to be. But that doesn’t justify 3x price increase [original tweet]

@krchhabra: @JoshHerigon @allanmjoseph I use “price” intentionally – schools can charge whatever they want; the govt and students will always oblige. [original tweet]

KC: Once an English major, always an English major. I’m trying to highlight the difference between prices and costs here–costs the amount of resources expended in providing a service (a pretty objective quantity), whereas prices are chosen by the seller (often based on the highest amount the market will tolerate). What I’m trying to say is, the rapidly rising price of medical education doesn’t necessarily reflect increases in its underlying costs.

JH: Federal support of education through student loan programs has increased access to higher education, but at what cost? Students are now insulated from the true price of their education. Their tuition payments are abstract numbers on a page they see once a semester. Financial aid counselors (in my limited experience) fail to explain the true financial impact of student loan payments. Students are sold on the various deferment options, repayment plans, and forgiveness programs (most of which students won’t qualify for or will increase the overall cost through deferred interest payment). Even with sufficient explanation, it’s hard to fully conceptualize until you make that first payment.

@allanmjoseph: @krchhabra @JoshHerigon Fair enough. Aside: I also think med students whining about debt can come off as tone-deaf, even if justified. [original tweet]

AJ: Quite frankly, when physician unemployment is nonexistent and even the lowest-paid specialties average six-figure salaries, we don’t have a lot to whine about. The reasons to care about this, from a policy perspective, are the positive externalities (that don’t accrue to doctors) from having the best and brightest students enter medicine.

@krchhabra: @allanmjoseph @JoshHerigon in light of future incomes? Perhaps. Though I think the average doc’s income will drop vs those trained in 78. [original tweet]

@allanmjoseph: @krchhabra @JoshHerigon From a systemic standpoint, they probably should, at least in many specialties. (Shh, don’t let the AMA hear!) [original tweet]

@krchhabra: @allanmjoseph @JoshHerigon it’s okay. There will always be surgicenter facility fees for when we need a quick buck (right?) [original tweet]

KC: Historically, doctors and hospitals have been paid separately for work that happens within a hospital’s walls. Doctors get a “professional fee” for their time and expertise, and hospitals get a “facility fee” for nursing care, materials, and all the other costs they incur in providing care. But in physician-owned surgical centers, doctors get both the professional fee and the facility fee. It’s as lucrative as it sounds, though Obamacare plans to curb these arrangements.

@JoshHerigon: @krchhabra @allanmjoseph Ha! Or you can always moonlight during residency… [original tweet]

JH: Moonlighting is when a doctor works outside their regularly scheduled hours (typically overnight, hence the name). Residents have historically done this during their training to supplement their paltry salaries. However, resident work hour restrictions are now decreasing this (moonlighting hours count against the total hours worked).

@JoshHerigon: @krchhabra @allanmjoseph Not saying med school should be free or even debt-free, but we need lower prices and better loan terms. [original tweet]

JH: I believe loan terms are the core issue and have been for a long time.

@krchhabra: @JoshHerigon @allanmjoseph You nailed it with loan terms. Super generic, don’t account for reliable, delayed income doctors get [original tweet]

AJ: Most medical students borrow for medical school through the federal government’s Stafford loan program, as well as the Graduate PLUS program if needed. It looks like there’s a lot of repayment options, but when you dig into it…they’re all variations on very few themes.

KC: And the problem with that is, the incomes of med school grads have little in common with those of other grad schools. Most grads (law, business, PhD, etc.) see a healthy income soon after graduation, increasing steadily thereafter. Medical school grads look forward to 3–10 years of paltry income while they’re training, followed by a huge jump once they’re board-certified. Loan payments can be suspended while in training, but the debt still accrues interest at a rate equal to other graduate loans. This makes little actuarial sense when you consider how low physicians’ default rate ought to be, compared with graduates of other programs. (Physicians’ unemployment rate is 0.8%, versus 2–3% for graduates of any graduate/professional school.) A tailor-made loan for medical students would adjust for physicians’ comparatively low incomes at graduation as well as their substantial, reliable incomes after residency. Though I’m not an actuary, I think loans on these terms would be much more fair and affordable.

@allanmjoseph: @krchhabra @JoshHerigon Absolutely. 100 percent agree with you there. [original tweet]

@JoshHerigon: @allanmjoseph @krchhabra One of you guys should create a start-up that buys up med school debt at better terms. 😉 [original tweet]

@krchhabra: @JoshHerigon @allanmjoseph I’ve actually given this some thought. Just need a few wads of money I don’t currently have 😉 [original tweet]

@JoshHerigon: @krchhabra @allanmjoseph Me too. [original tweet]

@allanmjoseph: @JoshHerigon @krchhabra And now I’m giving it thought instead of reading about NK cells. Let’s find an angel investor. [original tweet]

@allanmjoseph: Hey, followers, @krchhabra, @JoshHerigon and I have a killer business idea. Who wants to give us a few million to make it happen? [original tweet]

AJ: We joke about this, but it’s moderately surprising some enterprising financial firm hasn’t found a way to make this happen. (There’s probably a regulation about federal student debt that hampers it, but still.) More obviously, though, there’s room for policy changes to improve this system.

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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.

Allan is a first year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.

Josh is a fourth year medical student at the University of Kansas School of Medicine with an extensive research background and deep interests in technology. Follow his writing on Twitter @JoshHerigon or at mediio.

Cost-Conscious Medical Education

by Allan Joseph

I’ve got a post over at Costs of Care talking about how medical education can reinforce so-called “high-value care” in preclinical teaching. Here’s an excerpt:

Start with the physicians and professors who lecture pre-clinical students. Rather than working with a whole department of, say, cardiologists during their clinical rotations, pre-clinical students have just a few lecturers shaping their initial exposure to cardiology. That means getting just two or three physicians to integrate cost-consciousness into their teaching can shape the way an entire class of trainees thinks. This is a high leverage activity that will change the students’ perspective on cost very early on.

Go on over and take a look!
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Allan Joseph is a first year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.