Learning vs. Studying

Are learning and studying the same?

Most people that are in medical school have probably had a conversation that goes something like this.

Non-Medical Student: "You're in medical school! You must love school, I could never put up with four more years of it"

You (or Me): "Well I don't know, I don't really think that I love schooling all that much..."

If you are anything like me, you probably find it really hard to give someone a satisfying answer to that question. I've thought about my own motivations a lot, and this is what I've been able to come up with.

I love learning. I love finding out something new that I think is applicable to my life (or to my future life). I love when I finally understand something, when I spend time trying to wrap my mind around something and then I finally "get it."

I hate studying. I hate being told to read 200 pages of notes and commit it to memory. I hate sitting down in a lecture hall for 5 hours of lectures followed by 3 hours of lab. For me at least, there is nothing fun about that.

I'd love to learn another language, or how to play a musical instrument--or even another sport--but the medical school curiculum is so constrained that there is no time for that. So what you end up with is a bunch of people who are (on some levels) miserable for the better part of two years with one test after another hanging over their heads.

I agree that much of the information learned in medical school is very valuable, but I think that there are much more efficient (and less costly) ways of training our future doctors.

So how would I change medical school to make it better.

The biggest change I would make is to switch to a 3 year preceptorship, broken down like this:

First year: anatomy, histology, physiology (6 months) pathology, pharmacology, microbiology (6 months)

Second-Third Year: 6 months of family practice at 2 different sites, 4 months of internal medicine, 4 months of general surgery. 1 month of Emergency Medicine, OB/GYN, Psychiatry, etc.

Fourth year: 8 months of required electives, 4 months for interviewing etc.

In this system you would have to expand the "shelf" tests to account for longer periods in each rotation, but I feel like this would be a better situation for everyone.

Current doctors can feel like they are having a greater influence on future doctors. Medical students will absorb much more information when facts are associated with real life situations. Patients will have better trained doctors, and hospitals can hire a few less MAs and save some money. In my mind, it seems like medical education is stuck in the dark ages--where medical students are still being taught to memorize side effects for 100s of drugs, even though that information is now only a PDA click away.

Wouldn't that time be better served learning how to be a better doctor instead of a fact-spitter-outer. How many times have you heard from doctors that many of their colleagues in medical school who were great students have made terrible doctors--isn't that a sign that something needs fixing?

Objective Structured Clinical Examination

Today I took the first of many examinations involving standardized patients. It's called the OSCE, but to call it anything more than a checkpoint that 99.9% of med students pass with flying colors is giving it more credit than it deserves.

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Here's how it goes at the best medical school in the country:

You arrive at a floor of an old hospital and stand around and wait for a few minutes with a bunch of other medical school students that are just as nervous as you are even though you all know there is nothing to be afraid of.

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You have some idea that this is going to be a pretty straightforward case ("my elbow hurts"), but the med students who just finished joke that they "never expected that the patient was going to be playing the part of a deranged psychopath," as they walk past.

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Next your herded like cattle into a room where you are given some basic instructions, but all the while the proctor is talking, students are frantically scribbling notes of all the questions that they want to ask while they are in the room--only to find out that you had a few minutes to write after the instructor finishes talking.

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Overhead you hear a mechanical sounding voice say, "Three minutes remaining! Three minutes!" Which is a warning to the students who are currently interviewing patients in rooms 1-10.

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All the while I'm thinking to myself, "What if I seize up in there and forget to do things in the right order, or I ask all of the questions in too mechanical of a way." Or, "What if my patient is a total jerk like the guy that I had to interview during one of our small group practice sessions."

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Then time was called, all of the medical students in the waiting room exit and find the room to which they are assigned (mine was room 5).

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As I'm standing there, my mind is going a million miles a minute. "Should I knock, or shouldn't I--or I could just see what everyone else does--but what if no one knocks and we were supposed to."

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Everyone knocked, so I did. Then I walked into the room and handed the grader (there is a patient and a grader in the room) a sticker with my name on it--from then on you are expected to completely ignore the grader.

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Here's a synopsis of how the interview went (I lucked out and got a really nice patient):

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Me: Hi Mrs. Samples, I'm a medical student at Wayne State--What brings you in today?

Mrs. Samples: Well I've been having this stomach pain for the past few days.

Me: When did it start, what makes it better or worse, how severe is the pain, what kind of pain etc. (waiting in between questions for her to answer)

Mrs S.: 2weeks ago, worse with spicy foods, 5-6, burning

Me (because I knew we were being graded on transitions): So in order to delve a little deeper, I'm going to ask you some questions about your Past Medical History.

(and so on, until I got to social history when I asked her about whether she was sexually active with a partner--which is how they want you to phrase it)

Mrs. S: A PARTNER, I am with my HUSBAND if that's what you mean (she said it jokingly, but her volume took me aback)!

Me: I see. (mumbles something else)

(next up was alcohol--I thought that we were supposed to ask specific questions if someone said they drank anything at all)

Me: So Mrs. S do you drink at all? Alcohol, that is.

Mrs. S: Well I like to have a couple of imported beers every few weekends.

Me: Have you ever felt like you should cut back.

Mrs. S: TWO BEERS, have I ever felt like I should CUT BACK from having TWO BEERS a week. No I haven't

Me: (tentatively) Has anyone ever been annoyed by your drinking?

Mrs. S: ANNOYED BECAUSE I HAD TWO BEERS!?

Me: (not getting that I probably don't have to ask these questions) So I take it you've never felt Guilty about your drinking or had an Eye opener?

Mrs. S: NEVER

Me: Okay, I think it's time we take your blood pressure (which I think I got a little low, by then I just wanted to get out of here--I finished in 12 minutes but most everyone else took less time)

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Then we were sent off to a room to write a SOAP note before we were free to leave. One of my friends had a doctor in the room who asked him if there was "anything else he wanted to ask about the patients past medical history," which worried him because he thought he had already asked all of the questions. I'm just glad I got a trained grader instead of a doctor.

Shadowing

The past two days I have been shadowing a family practice doctor per the requirements of the medical school for completion of the first year, and I was struck with a number of things.

1. I'd like to think of myself as a pretty good communicator, and I don't mean that in a self-aggrandizing kind of way--just ask my fiancee, I'm not always the best at remembering things--but there is something of an art form to medicine. The doctor that I was shadowing absolutely has it down. He know's the "character" that he needs to play during the medical interview process. At times he pretends to be the aloof, almost clown-like character to put people at ease or to get a laugh.

But he also knows that there are times when he has to play the role of counselor, or father, or disciplinarian. There is so much more that goes into medicine than words and formats: he never strictly follows OPQRSTAA (Onset, Provocative/Palliative etc.) when talking about a condition, but he does have his own schpeel that he gives to parents of children under the age of one, e.g. "I like to remind parents to use a lot of sunscreen even if the baby is going to be under an umbrella..."

Moreover, you realize that there are a lot of patients who come in, that he could probably diagnose in a matter of seconds, but still he takes about 5 minutes to talk to the patient about their concerns. For instance, one of the patients who came in clearly was describing a simple pulled muscle, but he still took about 10mins to talk to her about it, before he even began to examine her. Part of it was a desire to rule anything out, but part of it was making sure that the patient felt like she was being heard by someone who cared to listen.

2. The Power of Human Touch. I've heard this a few times throughout medical school but it's important for doctors to touch their patients. Sadly, in this day and age, the first thing that many people would think if you said that was, "Doctor's touching their patients--there should be less of that." Perhaps because of the stigma of the few doctors who touch their patients innappropriately or perhaps due to our Politically Correct/lawsuit happy culture, I fear many doctors may keep their patients at arms length--which is truly sad.

Many patients that come off the streets may have been physically abused or mistreated for their whole lives, and the chance to touch someone in a loving way--e.g. rest one's hand on their shoulder, or even hold the stethescope so that one's fingers rest on their back--is often lost.

3. There's so much pain in this world. One of the women who came into the office had been put on large doses of inhaled steroids to treat a very bad asthma attack that she had had. Her face was the slightest bit edematous and perhaps a bit moon shaped (as is common with high glucocorticoids). And a few minutes into their discussion she said, "My face is so fat...I feel like a freak." And she began to cry. My heart just broke for her.

Maybe because I could empathize or maybe because it is just human nature, but I couldn't help but well up with emotion for her. I wonder if you need to remember how to respond to the patient, while not letting it affect you. Or maybe you just let it affect you and move on, I don't know.

More to come

Saccadic Eye Movements

Put one finger about arms length in front of you. Now slowly sweep your finger from the far left of your visual field to the far right, while tracking your finger with your eyes. Notice how you can "see" the blurry background even if you are focused on your finger.

Now place the finger of one hand at arm's length near the border of your peripheral vision on the left and the finger of your right hand at about arm's length near the rightmost border of your peripheral vision on your right. Now quickly switch from focusing on one finger to focusing on the other finger.

By now you are probably thinking, "This is supposed to be interesting, it seems pretty routine to me." But dig a little deeper. In order for you to switch your focus from one finger to the other, your eyes "saw" everything in between. But did you experience a sweeping image, or did you see one image "jump" to the next image.

If our brain merely interprets the information from our eyes as is, you should see a fast, blurry sweep as you shift your gaze. But you don't! Somehow your brain blocks out almost all of the input from the time you decide to shift from one finger to the next. It's almost as if all that exists between one focus and the other is a timeless vacuum. The movement of focus from one object to the next is called Saccadic Eye Movement.

And where does the time go? When you looked from one eye to the other, did you perceive any delay? I don't think that I do. Although the time between looking at something on one end of your vision and the other end is only a matter of tenths of milliseconds, imagine all the times that you switch focus during a year--it must be on the order of minutes when all added together. Not to make this stray into the realm of science fiction, but where does all the time go? It seems as if your brain tells you that the time never existed.

We know so much about the human body but we know so little, and it's things like this that keep us coming back for more--despite the drudgery.

Where Do We Get Off

Where do we get off. When did medical students start thinking that they run the show? Has disrespectful behavior always been a problem at schools of graduate education? Is it because we all have a bachelor's degree in something and we think that qualifies us to complain nonstop?


One of the most disturbing trends that I have witnessed while at medical school is the drastic increase in the amount of complaining and improper conduct towards professors. During the class time, a student once raised his hand to ask a professor a question, here's how it went:



Student: Doesn't that enzyme do the opposite in the presence of insulin

Professor: Well, I don't think that is correct

Student: No, that is correct



Since when is this considered acceptable behavior? Since when have we decided that that is appropriate for future professionals?

I think it goes back to how many in my generation were raised. A lot of people have mentioned that our generation was the first "you can do anything!" generation. What I mean by that is that most of my generation had parents that told them they could do anything. Never mind that they have no singing ability, you are the worst parent in the world if you don't make them feel like they are the next Pavaratti.

I've always thought my parents did it well. When I was a kid, I wanted to play professional basketball. Rather than just say, "Sure you will someday, you can do anything you set your mind to," he was very pragmatic about it. He said things like, "If that is something that you want to do, than you will have to make big sacrifices to get better at the sport." And I did, for awhile--but then my friends wanted to play with GI Joes, or there was a new movie out at the theater, and I gradually realized that professional basketball wasn't in my future.

I think the best thing that parents can do is encourage their children that many things in life are attainable through hard work, but without having certain innante physical or mental gifts, not everything is possible. If I am 4'7" I'm probably not going to play center for the Piston's someday. If I don't have anything resembling a singing voice, I probably won't be a world famous singer. This doesn't mean that I shouldn't work hard, but I should have parents who can see the gifts that I have and steer me in the right direction.

Another reason that I think that there is so much trouble with respect and discipline is the Political Correctness wave of the 90s-2000s. Don't get me wrong, there are aspects of PC that seem reasonable, such as eliminating the terminology of phrases such as "you people," e.g. "you people are all the same... But one of the downsides of the PC movement is the idea that there is nothing that is right or wrong.

Heaven forbid a teacher uses red ink to grade a paper! Who knows what might result from that! The child's fragile psyche could be forever damaged as a result from the 70% that they got on a test. It's pure ridiculousness and I think that it has contributed to the mentality that many of my peers have that they are always right. Not to mention the fact that they are probably angered that medical school grades are on a strict curve, and that 2/3rds of the students don't get scores above 90% anymore.

In summary, it's very frustrating to be surrounded with so many smart yet rude medical students, especially when the few obnoxiously vocal will be thought of as representative of the entire class.

Why Medical School is Awesome (Opening Black Boxes)

We live in a world of black boxes. Most of us go through the day fairly oblivious to why things are the way they are. We know that a spark ignites a mist of gasoline to power our car. But can we explain the process of the internal combustion engine much further than that? I know that I can't.

The same is true for our bodies. Which isn't to say that the average person is completely ignorant of biomechanical processes, I've known since high school biology that when one puts their hand on a hot stove a reflex arc is triggered that causes you to quickly remove your hand before you are even consciously "aware" of it. But with that level of knowledge, you sometimes don't even know what you don't know.

But one of the best aspects of medical school is that you are constantly confronted with aspects of medicine that most of the world views as a black box. For instance, the subject matter for today was the anatomical basis for pain. To me, pain has always been more of an idea than something concrete. Pain is what happens when you try to open a package with a sharp knife and it slips and cuts into your finger. But in medical school you get the opportunity to dive deeper.

You can understand the basis for why you rub your arm after bumping it on the table. You can understand why people with spinal cord damage have very little return of functionality below the damage, but even better you have a whole new set of deeper questions you can explore.

Somewhere within the difficulty of medical school are the things that keep us coming back, things like opening up black boxes.

Second Thoughts on Information Sharing

After being very opinionated about how I would never share information relating to study material here, I found out something interesting about myself.

I received an email informing me of a new program that is just beginning this summer for students in between their first and second years of medical school. As far as I know, this email only went to me, and only because I had applied for a similar program that they decided to discontinue. At the bottom of the email they asked if I might be able to spread the word as they wanted to have 9-10 students take part in the externship this summer.

So what did I do. Without even thinking twice I put together an email that made this program sound like it was the best internship ever, and sent it out to the entire class. For a moment I thought about not sending out the email because the more people that applied, the more competetion I would face, but a second later I decided to send it out anyway. I guess it just goes to show you that someone can support healthy academic competition while still believing that competition doesn't have to extend to all parts of life.

Information Sharing in a School With Relative Grades

I'd like to think of myself as a pretty friendly, open person.

In the past I have played on team sports, I would hope that those people on my team would say that I am a "team player."

But if I knew of a website that I thought could help students to do better on a test, I would in no way feel morally bound to inform my entire class via an email.

First, for the unindoctrinated, this is what I mean when I say relative grades. The basis for grading in medical school is done by standardizing how you did on a test with how everyone else did. Therefore if you scored lower than average on one test, your standardized score would reflect that--even if your raw score was 98 out of 100 possible, if everyone else got 99% you would have an unimpressive looking relative score. In the opposite scenario, if the average score on a test was 50% and you got a score of 65% correct, you would probably honor.

ALL medical schools must quantify how students rank within their class. Before one of the two people who read this write an angry comment, read on. You may say, but my school doesn't have grades. Generally people that say that follow up by saying "all we have is Fail, Pass, and Honors." I've got news for you, when you fill out an application for residency you medical school must provide some way of distinguishing your Pass from the other 100 students, if I'm not mistaken this is given on a scale of 16 with the middle of the bell curve set at 8, and with a 16 representing the top 1% of students or so. Although I have not confirmed this personally, I've heard people say that the only time they are graded is in 3rd and 4th year--I find that hard to believe, but I'll take their word for it.

By way of example (hopefully I'm not belaboring the point), at Wayne State we have a system of Z scores where the average on any given test is set to equal a Z score of 500. For instance, if I scored 75% and the average was 75% then my Z score was 500. If I scored an 85% my score would be near 600 (considered "Honors"). A score of 65% would be on the border of failing. Unfortunately, as mentioned above, you can have a very high raw score and a relatively low Z score (once I scored 92% with a z score of 460).

Getting back to the topic, one of the questions someone told me to ask the interviewer when I interviewed for medical school was, "How competitive are the students at the medical school?" In other words, is there a sense of teamwork at the medical school or is it everyone for themselves. To which, most would answer that there is a sense of comraderie in medical school. And there is. But can there be comraderie among people that are competing. I think that there can be, and I don't buy that competition is a bad thing.

Like it or not, we live in the era of American Idol and banning red pens. Perhaps in a reaction to how they were treated as children, there is a whole generation of parents that thought they should lie to their children about their children's abilities. "Sure Johnny, you can be a professional singer, you've got a great voice!" "Of course you can play in the NBA, who cares that you can't make it in the basket." At the same time we tell our teachers. "Don't use red pen to correct homework--it hurts students feelings." Luckily my parents always told me I could do anything I set my mind to, provided that I had some degree of God-given giftedness (I could practice basketball 'til I was blue in the face, but there isn't much need for undersized guys who can't jump).

I hope that our generation treats our children the way that my parents treated me. So that we don't have shocked children who are told for the first time that they can't sing by American Idol. And who realize that to become a doctor/engineer/teacher, you have to outwork a lot of people and that maybe it takes a C or D to realize that.

I've come to the point where I can admit that having a life is going to cost me getting an "Honors" in medical school--it just isn't worth losing all social interaction in the name of grades. Because of competition, I am driven to study many times when I'd rather relax. Because of competition I am able to set realistic goals. Because of competition we have highly educated doctors. Because of competion, I won't send out a mass email. Now if I can just figure out where to find all the information I want to keep to myself.

“Life doesn't imitate art, it imitates bad television.”

-Woody Allen

Cheers for Fears

Hey med students, please stop signing off letters with "cheers," we're not from England and were not in a 90s sitcom. And last time I checked, I don't have a glass of anything in my hand.

In Defense of Gunners

Gunner. GUN-ner. noun: Considered by most to be the most annoying type of medical student, a gunner is a student that is "gunning" for a residency and willing to do whatever (they think) it takes to get said residency.

I am not a gunner.















If anyone would like to see that my grades bear this out--I'd gladly put my Z scores up here. You would not be impressed, which isn't to say they are abysmal, but enough about me.

Why defend the gunners, you ask. They are probably already busy defending themselves at this very moment to one of their annoyed classmates--why stand up for them?

Here's a confession: I hated gunners. I hated how anytime there was anyone with any clout who spoke to us, the gunner(s) of the classroom would be sure to ask them limitless amounts of questions just so that the would stick out from the class. I hated how I could study most of the time most of the days of the week and I was still just an average student because of the 1/4 of my class does absolutely nothing but study, sleep, and eat (while we're on the topic, I hated that people could openly mention that they studied way less than me and still did better on a test). I hated how obvious gunners would make their "networking" with doctors, other med students, etc. It got to a point that I even nicknamed one of the gunners in my class Verizon Wireless (it's the network).

Here's the one thing that I can say I respect about gunners: they know what they want, and though they probably aren't going about it the best way, they are doing what they think it takes to get what they want.

Here is the type of "gunner" that I can (almost) like: He (or she) is certain that he wants to get into a difficult residency, e.g. derm, plastics, ortho. Because of this he realizes that he definitely can't completely let grades go by the wayside, but at the same time he has friends, a life, and is seen at the medical school on non-test days. Rather than annoying everyone else by monopolizing a speaker's time, or being the first to answer all of the questions in class, he gets to know doctors on their own time, or talks to the speaker after words (although too much of this would be borderline :)

To summarize, actual outright gunning is annoying and is a great way to alienate your friends (that you won't have for long), but those that are simply pursuing what dreams they have I can respect. The difference is true gunners take satisfaction in being thought of as a gunner, while the others would just be content to be in whatever specialty they like when they finish medical school.

"People have got to know whether or not their President is a crook. Well, I'm not a crook. I've earned everything I've got." -Richard Nixon

Verie Inn Secyure MD, MBA, Ph.D, MPH, JD, FACS, CRNA, CPA

"There is nothing so stupid as the educated man if you get him off the thing he was educated in."

Will Rogers

Does anyone really need multiple graduate degrees?

I always thought it was interesting to analyze the type of people that get into medical school. A few people went to medical school because everyone in their family for the past 4 generations have been doctors. Some go becasue their parents said that they would pay for the education plus living expenses. Still others got into medical school because it was just something to do. While the vast majority of people get into medical school for the right reasons, I think it is the last group that is the most interesting.

Picture this, a smart undergraduate student, who also has considerable foresight, realizes about the end of their sophomore year of college that they are about 9 months from having to know what they want to do. Many students harness this fear to do some serious soul searching and decide upon a career choice such as going into business or becoming an accountant or teaching high school. Then there is the small but definite minority that decides to finish up their undergraduate degree and then decide on some graduate school ad hoc.

But, you might say, medical school has so many hoops that you have to jump through (MCAT, ACGME etc.) . How could someone decide to spontaneously pursue a career in medicine? I think that there are two ways that it is done. First, someone takes classes to get a Masters of Basic Medical Science (read: I couldn't get into medical school the first time I tried). Or you could have someone who takes an extra semester or two in order to squeeze in the requisite year between taking the MCAT and getting into medical school.

The long and short of it is this. A definite percentage of students in medical school are only in it for either the prestige/respect factor, or because they had nothing else to do. Which gets back to my first point: there are very few exceptions where someone could justify the need for multiple degrees.

1. MD/Ph.d: I have asked those who should know on multiple occasions why someone would want to do this. Generally, the response is some mumbled "I just don't know exactly what..." At the very least it means 10 years of combined schooling/residency, and for what? So that you'll be a better researching physician? Why not just take two years during residency and do some research, then you can develop your own goals rather than piggybacking on the work of someone else who probably isn't doing something that you're that interested in. I can almost guarantee that it would be 1000 times more valuable to do research as a resident because you would have much more freedom to do exactly what interests you and because you would have much more experience at that time. By that time you will have a much better idea of what you want to do with your medical life. I just don't get this one--maybe I'm just not smart enough to. The one benefit is that instead of paying for school you get paid ~14k for 7 years, but I wouldn't trade two less years of professional life for 28,000.

2. MD/JD: This is the only one that I can see reasonable people doing. If you want to spend the rest of your life suing doctors, you might as well get an idea as to the innerworkings of the medical machine. Seriously though, if you wanted to devote your life to the service of mankind both medically and legally, e.g. working with the poor, then this would absolutely be a noble calling.

3. MD/MPH: I'll be honest, I really know nothing about an MPH other than it stands for Masters of Public Health. But just the same, I can't imagine that you learn more about public health by sitting around in lecture halls than you would be spending the same amount of time following around those who work in public health.

4. MD/FACS I just found out that FACS stands for Fellow of the American College of Surgeons, this would actually be something I think should be strongly encouraged.

So in summary, I think that multiple graduate degrees are ridiculous and I realize that a CPA is not a graduate degree. I apologize for the rambling nature of this post--but at least I'm the only person that has to read it ;)