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Tag: Medical Students

Should Medical Schools Teach to the Boards?

flying cadeuciiIn the 2012 National Residency Match Program Survey, which is sent out to residency program directors around the country by the NRMP, the factor that was ranked highest with regards to criteria considered for receiving an interview—higher than honors in clinical clerkships, higher than extracurricular experiences or AOA election, and even higher than evidence of professionalism, interpersonal skills, and humanistic qualities—was the USMLE Step 1 score.

When considering where to rank an interviewed applicant, the Step 1 score took a backseat to some of the aforementioned criteria that are perhaps more telling of what kind of person the interviewee is, although it was still one of the highest considered criteria for ranking applicants as well.

When a single exam is given this level of importance in determining a future physician’s most critical period in career development—their residency—we have to look carefully at our system.

Two points of consideration come to mind. First, is it wise to weigh a test score so heavily? Many students and faculty could easily point out that student performance on exams by no means always reflects their clinical acumen and social skills when seeing patients.

Medicine is, after all, an art far more than a science.

Nonetheless, it would be foolish to assume that scores have no worth—a high score on an exam, particularly a behemoth such as the USMLE Step 1, points out many qualities in an individual: hard work, persistence, discipline, and frankly, an understanding of textbook medicine.

And thus, we are left somewhere in the middle—perhaps we should weigh scores less than we do, but when you have to sort through thousands of applications, the only standardized metric to quickly compare is, in the end, a number somewhere between 192 and 300.

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The Real Problem with Board Exams-and How to Solve It

This week there’s been a debate brewing about why so many young doctors are failing their board exams. On one side John Schumann writes that young clinicians may not have the time or study habits to engage in lifelong learning, so they default to “lifelong googling.” On the other, David Shaywitz blames the tests themselves as being outmoded rites of passage administered by guild-like medical societies. He poses the question: Are young doctors failing their boards, or are we failing them?

The answer is: (C) All of the above.

I can say this with high confidence because as a young doctor-in-training who just completed my second year of medical school, I’ve become pretty good at answering test questions. Well before our White Coat Ceremonies, medical students have been honed into lean, mean, test-taking machines by a series of now-distant acronyms: AP, SAT, ACT, MCAT. Looming ahead are even more acronyms, only these are slightly longer and significantly more expensive: NBME, COMLEX, USMLE, ABIM. Even though their letters and demographics differ, what each of these acronyms share is the ability to ideologically divide a room in less time than Limbaugh.

This controversy directly results from the clear dichotomy* between the theory behind the exams and their practical consequences. In theory these exams do serve necessary and even agreeable purposes, including:

1)     Ensuring a minimum body of knowledge or skill before advancing a student to the next level in her education,

2)     Providing an “objective” measure to compare applicants in situations where demand for positions exceeds supply.

So apart from the common, albeit inconvenient, side effects that students experience (fatigue, irritability, proctalgia), what are the problems with these tests in practice? These are five of the core issues that are cited as the basis for reformations to our current examination model:

1)     Lack of objectivity. Tests are created by humans and thus are inherently biased. While they aim to assess a broad base of knowledge or skills, performance can be underestimated not due to a lack of this base but due to issues with the testing format, such as duration, question types, and scoring procedure (e.g. the SAT penalizes guessers, whereas the ACT does not). Just as our current model of clinical trial testing is antithetical to personalized medicine (What is a standard dose? Or, more puzzlingly, a standard patient?), our current model of testing does not take into account these individual differences.

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Training Future Physicians in Safety and Quality

Nearly a year ago, one of my blog posts bemoaned a gap in our training of future physicians—a lack of training in the skills needed to lead projects in patient safety and quality improvement.

I wrote the post after speaking to a group of medical students who were energized about this area of work. Yet, as I reflected on the talk:

“I had to confront the sad reality that most of them will graduate ill-prepared to lead the improvements of quality and safety our health care system needs. They no doubt will know chemistry, biology and physiology, but they may not know about human factors, implementation science or performance measurement—the language of quality improvement. They will know orthopedics and genetics but they won’t know teamwork and systems engineering. They likely know about German scientist Rudolph Virchow, the father of cell theory, yet they do not know John Kotter, the father of change theory whose model for leading change is highly effective and widely used.”

So how can medical students, residents and fellows make quality improvement and patient safety a focus of their clinical careers? On Nov. 10, the Armstrong Institute and the American College of Medical Quality will be hosting the National Workshop on Quality for Medical Education—affordable and open to anyone—that focuses on how medical students, residents and fellows can integrate safety and quality into their clinical careers. What career paths exist? What tools and skills are needed to carry out this work, and where do you get them? What kinds of quality and safety projects are residents and students taking on?

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A Call For a New Primary Care Society

The dream of reason did not take power into account – modern medicine is one of those extraordinary works of reason – but medicine is also a world of power.

Paul Starr, The Social Transformation of American Medicine, 1984

How can primary care’s position be reasserted as a policy leader rather than follower? Even though it is a linchpin discipline within America’s health system and its larger economy – a mass of evidence compellingly demonstrates that empowered primary care is associated with better health outcomes and lower costs – primary care has been overwhelmed and outmaneuvered by a health care industry intent on freeing access to lucrative downstream services and revenues. That compromise has produced a cascade of undesirable impacts that reach far beyond health care. Bringing American health care back into homeostasis will require a approach that appreciates and leverages power in ways that are different than in the past.

But primary care also has complicity in its own decline. It has been largely ineffective in communicating and advocating for its value, and in recruiting allies who share its interests. Equally important, it has failed to appreciate and protect primary care’s foundational role in US health care and the larger economy, as well as the advocacy demands of competing in a power-based policy environment.

The consequences have been withering constraints that have diminished primary care’s value, and that have thwarted its roles as first line manager of most medical conditions, and as patient-advocate and guide for downstream services. Combined with fee-for-service reimbursement and a lack of cost/quality transparency, primary care’s waning influence has precipitated a cascade of impacts, allowing health industry revenues to grow at more than four times the general inflation rate for more than a decade, with unnecessary utilization and cost that credible estimates suggest is half or more of all health care spending.Continue reading…

So it Turns Out that Lots and Lots of People Still Want to Be Doctors


As I noted last week, I get a little annoyed by the seemingly constant public complaints of physicians, coupled with threats to leave medicine and dire warnings that no one will want to be a doctor in the future. This is in spite of it still being one of the most trusted professions around, and one that is darn well compensated. So it’s nice to see that the general public hasn’t bought into this meme yet (from the AAMC 2011 Medical School Enrollment Survey):

  • First-year medical school enrollment in 2016–2017 is projected to reach 21,376. This projection represents a 29.6% increase above first-year enrollment in 2002–2003 and comes close to reaching the 30% targeted increase by 2015 the AAMC called for in 2006.
  • Of the projected 2002–2016 growth, 58% will be at the 125 medical schools that were accredited as of 2002. New schools since 2002 will experience 25% of the growth, and the balance (17%) will come from schools that are currently in LCME applicant- or candidate-school standing.

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Medical Students Want You to Know

Snyder_michelleHow many of us can remember a world without cell phones? Today’s medical students would undoubtedly be among that group. So it is no wonder these future physicians rely heavily on technology as they embark on their career path. We surveyed more than 1,000 medical students who are Epocrates subscribers about technology (software, hardware and EMRs) and other pressing industry topics.

The survey found 45% of respondents currently use an iPhone or iPod-touch, followed by Palm and BlackBerry devices. Even prior to the launch of the iPhone, Apple has connected with this younger generation and continues to play to its strengths. Our survey did not address carrier preference, but it appears students may be more device focused; nearly 60% of non-smartphone users planning to purchase an iPhone within the next year. It is also worth noting that students may be looking at what device residents or attending physicians are using as well. In the first year of availability, over 100,000 physicians are actively using Epocrates software on an iPhone/iPod touch. We still see a significant number of physicians using BlackBerry and Palm devices, so we expect those respective populations to grow as well.

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Tweaking Medical Education to Leverage EHRs

Tweaking Medical Education to Leverage EHRs

By GLENN LAFFEL

Glenn

Author’s Note:The purpose of this 5-part series is to make the case for implementing a widespread, systematic approach to HIT education in medical schools and continuing medical education programs for physicians. Previous posts reviewed challenges posed by the HIT Deluge and the Impact of EHRs on Medical Education.

EHRs have begun an inevitable march into the lives of all physicians. The US government has established an ambitious plan for their deployment, and providers seem both eager to comply and anxious to avoid financial penalties associated with not doing so.

But as described in Part II of this series, EHRs can have deleterious effects on the education of medical students and residents. These include disrupting interactive sessions involving educators and trainees and complicating patient-physician communication.

Jay Morrow and Alison Dobbie of Texas Southwestern Medical Center argue that much of this negative impact derives from a mistaken perception that EHRs are a health care delivery method rather than a medium through which physicians deliver care. It follows from this argument that the quality-improving, cost-reducing benefits of EHRs can only be realized if multiple systems and user-based factors are aligned to optimize utilization of the new medium.

Medical educators can begin the alignment process by developing answers these 3 questions:

When Should EHR Education Begin?
Arguably, the process should begin as early as possible. Since the 1970s, medical curricula have included non-science oriented courses such as “Introduction to the Patient,” “Communication Skills” and the like. These courses present ideal opportunities to introduce the new medium.

Students in such courses should be taught to navigate through and use basic EHR functions such as order entry, lab look-up, messaging and charting. Ideally, this exposure should occur outside the clinical setting so trainees can focus on mastering the EHR interface itself. At this time, it should be possible to identify those in need of extra help with keyboard skills, and to provide assistance as necessary.

Keyboarding skills should not be assumed, even for the current generation of physician-trainees. In a 2007 focus group of first-year students at Texas Southwestern for example, 62% of the participants expressed concerns about such skills, and many claimed to have better texting than typing abilities.

If students master keyboarding and EHR navigation skills before starting their clinical rotations, they can focus the latter time on traditional learning exercises, such as clinical reasoning, diagnosis, acquiring medical procedure skills and interacting with ancillary caregivers and patients.

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Impact of EHRs on Medical Education

By GLENN LAFFEL

Glenn

Author’s Note: This the second of a 5-part series whose purpose it is to make the case for implementing a widespread, systematic approach to HIT education in medical schools and continuing medical education programs for physicians. A previous post reviewed challenges posed by the HIT Deluge.

Countries around the world are racing to digitize patient medical records. In the US for example, the American Recovery and Reinvestment Act allocated $21 billion to an incentive program designed to encourage the “meaningful use” of such systems.

The Federal government’s largesse is based on the premise that EHRs will improve the quality of care and reduce its costs, but the move will impact the health care system in many other ways as well. One area sure to be impacted is the education and training process for new physicians.

What kind of impact can we expect? In some ways, EHRs appear to enhance medical education, but there are as many or more instances in which the impact appears to be negative. Thankfully, careful planning can mitigate most of the collateral damage, a topic to be covered in this series’ next installment. For now, we’ll settle for a review of the good, the bad and the ugly.

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