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Has Med School Changed For the Better?

karan chhabraEvery 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?

Karan Chhabra is a third-year student at Rutgers Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives. He blogs at Project Millennial, where this post first appeared. 

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9 replies »

  1. Karan,

    Thanks for your thoughts – I realize they may not reflect an extremely popular view in the medical education world these days.

    Like Dr. Amsler above, I am DEFINITELY one of those old guys (white, male, and yeah, believe that doctors are NOT interchangeable with “mid-levels) that you illustrate. And yeah, I took call occasionally that was 30hrs on, 16 off, then 30 on, then 16 off, for a month. That’s “every other night” call on the trauma service, if you are keeping score. Most of my training in med school and residency was of course not that rigorous, but it did separate the “men from the boys.” (the best house officer from that grueling rotation was of course female!).

    I wholeheartedly believe that today’s med students don’t get enough clinical exposure, especially with regard to “bedside” procedures such as IV’s, NG tubes, phlebotomy, etc. 30 yrs ago, when I was a 1st and 2nd year student, I used to hang around the ER so I could learn these skills. I didn’t come from a “medical” family so the only time I had been in a hospital before med school was getting my tonsils out.

    I also believe that much of my time as a student was exploited as free labor by the hospital. Today’s students (I have served as med school faculty for many years) have a MUCH better knowledge base because they are able to pull up research articles, have time to read, and aren’t running around the hospital looking up lab results.

    I’m glad those bad old days are gone, but I also decry the loss of procedural skills, and approach that doctors now “punch a clock” and house officers simply leave and go take a nap after “X” hours. Sick people don’t punch a clock. Codes come in at all hours. SOMEONE has to know what’s going on with your patient, and the answer isn’t going to be in some computer or ipad somewhere.

    When I was an Attending, it used to drive me nuts when making rounds, I would ask, “how is Ms. Farkle today?” to my house officers and be told . . . “oh, the resident is off today.” But Ms. Farkle is still sick and had a CT-guided drainage of her liver abscess yesterday. I want to know how she is doing this morning, and someone needs to have seen her before the Attending does.

    I would urge the soon-to-be Dr. Chhabra to pursue every opportunity to rotate in rural settings, where he can obtain some direct supervision in suturing, drawing labs, maybe even putting in a chest tube. You might be exhausted at the end of this rotation, but you’ll feel infinitely more prepared for residency and possibly “moonlighting.” Come see me and I’ll be glad to proctor you! Good luck!!

    BTW, did I mention that we used to walk 6 miles uphill in the snow to school at 4 am . . . ??

  2. Technology is constantly changing and therefore we are having to adapt ourselves to these changes. What is great is that we can acknowledge this and therefore in the future, med school will adjust accordingly. At the moment, the curriculum for the future looks like it will be preparing physicians to use new technology effectively. However, is it safe to spend all these hours working with new technology and getting used to it, rather than actual contact with patients? That of course is what the real world in medicine expects. Would love to hear your thoughts. Great read. Yasmine Bachir x

  3. Perhaps more time needs to be spent learning about the proximate causes & interventions for illness rather than the admittedly more intellectually aesthetic fourth order causes.

    A graduating physician who knows more about Rawls Distributive Justice than Heimlich maneuver is useless. Although good company for a drink

  4. Sad, but true. I retired almost seven years ago after thirty five years of Internal Medicine/Primary Care practice. My focus usually was to get to know my patients as people and try to help improve their lives. Listening and talking to them was an essential part of this process. Now practitioners are beholden to the payers and the computers with little interaction with the patients. Is this progress? Is this improved patient care? I don’t think so.

  5. I believe medical school and resident training has gone to hell. The hours have gotten light and the workload isn’t nearly as intense. Also, so many “remembrances” have accumulated over the years, that doing really well on exams should be expected. At one point you were required to think during an exam. However lately, buzzwords and buzz phrases give the answer away.

    Patient care is no longer the priority either. I have seen so many young residents walk into a patient’s room without really interacting…Although H&Ps are in template form everywhere, every story becomes generic and patients no longer feel that connection with their physician. I suppose this comes along with the “change” we see in healthcare. Overall, med training/school has changed for the worse.

    The real future for MD’s would be to combine their training with either an advanced finance or management degree.

  6. Medical education (and pharmacy education) reflects what the drug companies want, not what is best for the patient.

    For chronic bronchitis and asthma they should tout Cromolyn by nebulizer and oral anti-histamines to keep airway inflammation down.

    The drug companies has a misinformation campaign against antihistamines for asthma treatment starting in the 1960’s. Then when the FDA found out that their was no basis to contraindicate antihistamines in asthma, the literature then stated “has not been proven of value”. What that really means is no clinical drug trials were done.

  7. Honestly, physician burn-out is not due to patient interaction….The real demon in burn-out in area of medicine is the bean counters that tell us to do more with less, increase the number of patient/customers seen in a given amount of time. and mandatory azz covering paperwork.

    Honestly, it’s no longer about the patient, customer but keeping the stockholders content

  8. Karan,

    I’m pretty sure I’m one of the old guys you referenced. I’ve also taught academic medicine, over a decade ago when the current model was just coming into vogue. On the plus side today, I see that most students/interns have a wider knowledge base of diseases than I did. On the negative side, I see students who are computer-savvy and bedside manner- ignorant. As you noted, you will be treating people, not machines. I required my students to refer to our patients by name rather than pathology, and to know something about their lives, families, etc. I also required them to demonstrate proficiency in hands-on procedures: IVs, central lines, arterial lines, thoracentesis, etc. One of the things I see lacking in the current generation of physicians-in-training is stress: of course you’re getting pimped mercilessly, and running your butt off chasing down results. However, with the periods of “crew rest” mandated in most training programs, you are rarely called upon to do critical thinking in a sleep-deprived state. My first three years of practice was as a GP, wherein I gained a world of appreciation for primary care. I segued into Anesthesiology because of an interest in critical care. My residency was intense, and I would not care to repeat it- however, it did teach me to think on my feet. I do not envy you, because I feel that you have identified the problems that you will face- and most of them are only resolved with experience, which you are being denied. Best of luck, Doctor.

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