4 Years In Medical School Is Wasting HealthCare Resources

Ezekiel J. Emanuel MD, PhD and Victor R. Fuchs PhD want to speed up the clock in medical school and residency.

If you think 10 to 15 years of training to become a doctor is nuts but decided to go for it regardless, I have some bad news. According to recently published article in JAMA, you where right, it is nuts! More than that, it may be a place to look for cutting unnecessary costs in healthcare. This article calls to question some of the most basic assumptions central to becoming a physician.

The Death of The All Knowing All Powerful Physician

The picture of the lone physician hero fighting off death and disease may seem inspiring but is really just ignorant and impossible in healthcare today. No matter how many of your internal medicine attendings puff up their chest and say "I don't need to get consults" it does not change the fact that we can no longer effectively practice medicine in a vacuum. Learning to work closely with our colleges is something that competition in medical school has suppressed but it is a skill that future physicians need to develop.

The consequence [of trying to train one all knowing doctor] is a broad training regimen... [it] emphasizes the autonomy of the physician rather than team-based care. The new model recognizes that with increasing clinical and scientific complexity, no physician can be a competent triple threat; that few clinicians will also be investigators; that no single clinician can know everything even in his or her own specialty; and that effective care requires collaborative, multidisciplinary teams.*

Less Time In Medical School and Residency Makes Better Doctors

At first this seems like a paradox, but when you consider the time spent learning outdated and extraneous facts or working hard to efficiently take care of more and more useless paper work, it begins to make sense. What if the right of passage was something besides showing how well one can fill out reams of paper work on patients. I guarantee any intern will tell you this takes up most of there waking moments during the first year of training. The current system has evolved to fit this waste and has little reason to correct course because, "that's what interns and medical students are for". However this drives up education costs for new physicians and increasing educational debit also limits the career options for graduating doctors. We are all inherently practical and when faced with a mountain of debt, grabbing a job with the highest pay and benefits will win. Following your desires to work in an undeserved area or taking a risk on a new business venture is a cost that many will not take.

There is substantial waste in the education and training of US physicians. Years of training have been added without evidence that they enhance clinical skills or the quality of care. This waste adds to the financial burden of young physicians and increases health care costs. The average length of medical training could be reduced by about 30% without compromising physician competence or quality of care.*

Read the full article here: Shortening Medical Training By 30%

*Emanuel EJ, Fuchs VR. Shortening Medical Training by 30%. JAMA. 2012;307(11):1143-1144. doi:10.1001/jama.2012.292.

The Battlefield Mentality Of Medicine

 The Physician Casualties of Medical Tragedies

A Guest Post by Dike Drummond, a family doctor who specializes in physician burnout prevention and treatment at his website, The Happy MD.

The mother of the dead baby sat in her husband's arms and simply asked "why?" over and over through the Vietnamese interpreter. I had no way to answer the question. I didn't know why. There was nothing to point to. No defect in the child or mother or the actions taken in L&D.

All I could do was say "I am so sorry" ... for your baby, for you ... for everyone involved.

It was a nightmare, losing a baby during childbirth in my family practice residency. It was THE thing each of us dreaded the most. What happened afterwards was even more devastating in the long run. What happened was ... nothing.

It had been a normal evening on call. The family practice residents ran our community hospital. I would end up delivering over 250 babies in my two years here. It was just before midnight, three women in labor, I had just changed out of my clothes into green scrubs and the typical long white jacket.

As I walked past the first labor room on the left I heard an obvious deceleration on the external monitor. HR dropped from 140 to less than 60 for almost a full minute with what looked like a late pattern. The mother was a Hmong woman who did not speak English. This was her third child. No previous problems in childbirth.

She was doing just fine. Dad was standing by the bed in the half light of the labor room. Everything was quiet - that’s how I had heard the deceleration. The night shift had just come on. A calm scene really, except for the yellow light of my nerves jangling from the deceleration.

Exam showed her to be 7 cm dilated, head well applied, normal contraction pattern. The decelerations continued. Protocol called me to rupture the membranes and apply a scalp electrode. I opened the amnion hook, had the nurse stabilize the external monitor puck and apply some fundal pressure. The father held the mother’s hand as they spoke quietly to each other in a language I couldn’t understand.

I ruptured the membranes but only a small amount of clear fluid came out. The heart rate dropped immediately to zero as if it had tipped off the edge of a table and fallen to the floor. 140 - 60 - 20 - nothing. Vaginal exam showed no prolapsed cord, no bleeding or any other abnormality. I was the only doctor in the hospital. The OB attending was 15 minutes away. This baby needed to be out right now.

With much shouting to push, my fingers completing the dilation of the cervix and good cooperation from the mom ... we had the baby out within three contractions.

No nuchal cord, no abruption, no blood anywhere ... the child was normal ... except it had been without a heartbeat for almost 5 minutes at this point. Full resuscitation. Epi down the tube. Chest compressions. Nothing. [Heart breaking. Are we getting anywhere? I do not want to call the code and give up.] Suddenly, five minutes of chest compressions and two doses of Epi in ... we have a heartbeat at 160. [Hallelujah] Stop the chest compressions. Let's tape the tube and call the NICU in the big city down south.

As the nurse and I begin to breathe again ... I feel a gentle tap on my shoulder. The father is standing next to me and points at my left hand. I notice that this whole time - as I stabilize the ET tube and the child’s head - the tip of my left pinky has been touching the baby's open eye. I thank the father, change my grip and close the upper lid. I begin to realize this heartbreak of the last 20 minutes is only the beginning.

We got the call three days later. The child showed no signs of brain activity and the ventilator had been turned off. I released the breath I had been holding since that night in this moment of final recognition. The baby was dead. That is NOT supposed to happen to anyone ... ever. Not to the baby, not to the family and not to any Resident.

The director of the residency program and the OB staff held a case review. No "fault" was found. Procedure had been followed. The baby's post mortem was normal. All actions were deemed "appropriate". I was not to blame. That was very little consolation. The baby was dead. My mind ran over and over the events like a gerbil on a wheel.

A little piece of me died that day. Deliveries were never the same joyful wonder they had been before ... they were bullets to be dodged. For years and another 300 deliveries I would occasionally be jolted awake at night by a vision of an amnion hook with a trigger on it.

In the days and weeks afterwards ... it gradually dawned on me that something I had always taken for granted ... was NOT happening. We were a small residency ... only 8 of us running our community hospital. It felt like a family. I had always assumed any tragedy would be met by a rallying around the unfortunate resident.

Here was our collective worst nightmare ... and ... nothing happened. Nothing except the case review and my meeting with the family - both agonizing experiences where I was by myself. I felt tainted, like a failure, an outcast in the wilderness.

I don't blame anyone. I am certain the first reaction among my colleagues was ... "OMG it happened". Followed by, "thank GOD it didn't happen to ME."

It’s the same thought process as a soldier in battle when his best friend goes down as they storm the beach. I don’t know if I would have thought the same things if it had happened to another resident. I don’t know if that fear would have stopped me from reaching out to them. Here’s what I do know...

Most of the physicians I have worked with have their own version of this story; something bad that happened followed by complete isolation. It has hurt us all. Let’s vow to end this compounding of the natural tragedies that occur in our profession. Losing a baby is bad enough. Coming away from the experience feeling that no one really cares and we are all on our own in the end ... is a wound on a wound. This does not have to continue. We do not have to let our own fear stop us from supporting our colleagues in their hour of greatest need.

If you are still reading this article, I want you to know something with crystal clarity. Your Physician Colleague who suffers a bad outcome wants you to come and talk with them. Sit and have coffee, put a hand on their shoulder. Make them a “hot dish” so they don’t have to cook for a couple days. (I am from the upper Midwest ... that’s just what we do) Do it again and again until they say, "enough already".

There are some stories even our significant other and parents can never understand ... only another doctor can fathom the feelings. The next time tragedy strikes in your medical community, reach out to your sisters and brothers. PLEASE don't run from them because of your own discomfort. They are not contagious, nothing is going to rub off on you.

Don't let the natural "battlefield mentality" win out. Notice it and act in spite of it. It will make a huge difference to your friend. I promise.

This is the time when you can step up and pay it forward. Just be there ... when it counts the most. You never know when you will desperately want them to do the same.

-Dike Drummon M.D. The Happy MD

Your Waiter Has A MD?

Residency Match Day can close a door for medical students. 

Read Anthony Youn MD's article on CNN here

I met Sam* in the OR a few years ago. A polite surgical technician in his early 30s, we’d often chat after work.

Sam obtained his medical degree from a school in Eastern Europe prior to immigrating to the United States. Now he spends his days cleaning surgical instruments and his nights working in a restaurant.

“Someday I’ll be a surgeon, just like you,” he says to me.

How did this happen? Sam had a bad Match Day.

Medical training in the U.S. involves four years of medical school followed by 3 to 6 years of residency training. International graduates must also attend residency in the U.S. if they wish to practice here.

On Match Day, graduating medical students learn which residency program they’ll be joining. Residency determines a physician’s field of medicine. For a young doctor to become a pediatrician, for example, he or she must complete a pediatric residency.

This year Match Day occurs today, March 16.

According to the NRMP, last year 971 graduates of U.S. medical schools were shut out, accounting for 5.9% of U.S. grads. Graduates of international medical schools fared even worse - less than 50% of them obtained a residency.

That means more than 7,000 doctors were left with a diploma that said “M.D.” but no guarantee they would be able to use it.

This situation is only going to worsen. Due to the pending doctor shortage, the Association of American Medical Colleges (AAMC) has called for a 30% increase in medical school enrollment, or 5,000 more doctors each year. College universities have responded to this demand, with 18 new medical schools currently in the process of opening.

The increase in the number of medical students would lead to an increase in residency positions as well, right?

Wrong.

Since 2001, the number of first year residency positions has increased by 3,000, compared to a whopping increase of 6,500 applicants. The slow growth in residency positions is likely due to a 15 year freeze in Medicare support. The current federal budget problems make lifting the freeze unlikely in the near future.

BTW: Dr. Youn was recently interviewed by Medical Spa MD.

They Tell Me That Medical School Will Change Me

By Tamara Moores, a fourth year medical student at Loma Linda University specializing in Emergency Medicine.

They tell me that I’ll change.

They always do.

In our first two weeks of medical school, freshmen students are assigned to shadow senior students working in the hospital. When I was a freshman, my senior student’s final comment to me was “Wow. You’re really enthusiastic… That will change.”

Now as a fourth year medical student, today’s version of the story was – “intern year will change you. You may look the same on the outside, you may portray that same bubbly, sunshine personality, but inside you’ll be different – harder, less tolerant, mean.”

They say it with confidence, they say it with authority, brooking no disagreement, allowing no doubt. Attendings, residents, nurses – they all deign to tell me my future – “there’s no way you can stay that energetic, it’s incompatible with a medical career.” Over and over I have heard this. As a medical student, I am supposed to listen and learn - to be guided by these wise elders. This morning when I heard the prediction for the 100th time, like always I politely listened with a half-smile. Yet silently my spirit roared “How DARE you smugly tell me the fate of my soul?! How DARE you justify your own insecurities about your passionless heart by attempting to degrade mine?”

Medicine is a unique environment. In my short foray into this time-honored, traditioned society, I have been buffered and shocked by the rampant negativity that oozes through the hospital walls. People seem to even take pride in their ability to bemoan their situation.

“Oh God, another consult from the ED, think they managed to even do a physical exam before calling?”

“That professor has no idea what’s on boards.”

“I can’t believe we have to be here.”

“This computer system is a joke.”

By far the most common conversation in a hospital is complaining. Tomorrow, try something different - stop and listen to the myriad people talking at work. The ratio of negative to positive conversations will overwhelm you.

Why is hospital culture like this? Shouldn’t a place of healing be full of warm emotions, positive thoughts, and uplifted people? Why is a ‘negative nancy’ the most common type of medical professional we meet? What are we doing wrong? These questions often come to mind during my workday. There is no easy answer. At the very least I know my top goal is to NEVER become that stereotypical cynical physician, and instead be the uncommon doctor with true passion for medicine.

So how do I accomplish this in such a caustic environment? Have no doubt, even at my current bubbly baseline, it is a daily war to maintain my heart for this career. So many physicians before me have fought this battle and lost. How can I succeed where they have failed?

A resident who I highly respect recently told me ‘be careful what you say, because talk patterns become thought patterns.’ This, more than anything, is my first defense against cynicism. It is SO easy to fall into conversation filled with complaints. These tiny conversations seem harmless, but over the course of a lifetime they shape your soul. Now at the end of my medical schooling, and at the cusp of residency, I am awed by the power of the spoken word. It’s undeniable - what we say both molds and reflects what we think.

Overall I believe the best weapon against developing permanent pessimism is to be deliberate in how we react to daily adversity. How do we respond to a floridly difficult, unpleasant patient? Do we moan about how annoying they are? Do we ruminate about how unfairly they treated us? Permit me to suggest a different response. Instead of focusing on how unjustly that patient has treated me, I instead try to feel gratitude. Whether or not it’s right, these difficult patients make me grateful that my life has not put me in their position. They must be really unhappy inside, to so poorly treat the people who are trying to care for them. When I am mistreated by an attending, I remind myself that they are but a momentary discomfort, and soon will be gone from my life. Over and over I find myself fighting to see the positives in my life. It is a deliberate, intentional strategy, which allows me to shine out with joy even in the little moments of the day.

I firmly believe that working as a medical professional can be a path to a life filled with meaning and passion….if we let it. Not all days are perfect, but most days I feel like I’m the luckiest girl in the world to be in my chosen career. The patients are interesting, my skills are stretched, and I feel fulfilled. Beyond these personal reasons, more than any other career, medicine reminds us how short and precious life is. We deal in broken bodies, lives cut short by car collisions, by strokes, by chronic disease. How lucky we are to be able to move our bodies without wheelchairs, to be relatively self-sufficient. Working in the medical field reminds me daily that everything can change in a moment. It is this acute awareness of the frailty of life, which makes me embrace life with so much abandon. It is this knowledge that gives me joy in the workplace, even during the rough days. To put it bluntly, life is too darn short to be grumpy.

So why am I reflecting via this forum? Perhaps because I hope that I am not alone in this fight. Perhaps I hope that by starting a discussion, we might nudge forth a change in the standard hospital culture. Maybe with forums like this, we can shift the caustic paradigm. Here’s to hope.

About:: Tamara Moores is a fourth year medical student at Loma Linda University. She is specializing in Emergency Medicine. https://www.facebook.com/reflectingthelights

Submit a guest post and be heard.

Ultra Gunner Interview Tips: Medical School and Residency

This guy has the right idea, but the glasses just pushed it over the edge.I feel sorry for anyone who crosses paths with me on the interview trail

However, because Matt gave some nice thoughts on residency interviews, I thought I would add a few; some of his where just not my style. So to complete his post, here are a few from my personal repertoire. No need to thank me with gifts, just leave me a comment with your adoration and let me know how well they worked for you.

It’s important to Take Control of the interview

As soon as possible, you must establish your new place in the pecking order as a resident physician or college student turned med student. Showing them that you don’t put up with crap is a great attribute for a doctor. If you don’t like a question they ask just shoot back with,

“Not important, next question.”

It’s simple and direct, and they will respect you for it. I think.

Remember Medical Schools and Residency Programs Want What They Can’t Have

Be sure they understand you are doing them a favor by taking your time to interview with them. I even say, “Look, you guys are basically retarded if you don’t rank me #1.” I’ve executed this technique flawlessly at my last interview, and it worked like a charm. All they could do was shake their heads in amazement. What can I say, I’m a winner. I win.

Another free tip: cutting the interview short or coming a little late is a perfect way to set the tone and impart your importance.

Bring Every Conversation Back To Focus On You, Always

Though I cannot think of a time when this advice would not apply, it is especially true during interviews. Remember to implement this tip at all times during your interview visit. Eating out with the residents, during hospital tours, or even when conversing with other applicants. Remember, when they ask,

"Do you have any questions for us?"

The only reply is, “Yeah, what part of my resume do you like the best?”

Stand Out From The Crowd

Guys: Do not be afraid to rock the white suite! Trust me on this one! The white coat is a symbol of physicanhood and strutting into a residency or medical school interview with a sharp white suite just plants the seeds in everyone’s mind.

Girls: Don’t be scared to strut your stuff. Clothes with slits anywhere and everywhere are a must. This rule applies double if you are applying for Orthopedic surgery residency.

ZDoggMD: Medical Standup Comedy

Get your ER comedy fix.

This is ZDoggMD's standup medical comedy from the Mel Herbert’s Essentials of Emergency Medicine 2011. Lame and offensive…well, you really haven’t seen nothin’ yet.

You'll want to notice how ZDoggMD riffs on his students... Now that's just not nice.

Part 1

Part 2

5 Uncommon Approachs to Residency Interviews

Thoughts from the interview trail

Finally the interview season is wrapping up. Here are 5 points to emphasize before embarking on the path to the rank list.

1) Interviews are more exhausting than you might originally think.

It takes a lot of work to put on your "game face" for 36 hours, to make sure you don't say anything inappropriate and to think of insightful questions to ask so you don't look disinterested. Be careful when planning your travel schedule to include time for rest, as a tired interviewee comes across as boring and unenergetic, traits which stellar board scores can never make up for.

2) If you don't enjoy the residents or attendings at an institution, perhaps it just isn't a good fit.

Don't be too hard on yourself. If you're miserable at work, you will not be academically productive and your patients will not get the care they deserve. The best team is a team with excellent work relationships, and though in your head a program might be your top choice, perhaps you will be better off in the long run somewhere else.

3) There's no reason to be nervous. 

Most interviewers these days just want to get to know you. Occasionally one will put you on the spot or ask tricky questions. You can prepare for the typical interview questions by pondering them ahead of time (things like "what was your biggest failure?"). The unexpected interview questions like, "what is the therapy for recurrent acute myeloid leukemia?" are likely questions other students would struggle with too, so just be humble and move on rather than letting one question destroy the whole conversation.

4) Some interviewers are quiet and difficult to talk to.

Perhaps this is the way they are typically or perhaps you just don't have much in common with the interviewer. A solid strategy at this point is to take control of the conversation by bringing up topics that augment your applications, either academic or personal. Perhaps if you've done a lot of travel, you might ask "are there opportunities for residents to do international electives?". Or if you're strong in research, perhaps you could ask, "what are the research opportunities like here?".

5) Be confident. You might think you don't deserve the interview or are concerned about matching, but they brought you in for a reason.

If you're at the interview, you're qualified to do the work. At this point they want to see if you will be a good fit for their program, a program which they have worked hard to build and which they have big dreams for the future. If you're a part of that future, they will be interested regardless of your board score.

One excellent and very detailed book to check out is, "The Successful Match: 200 Rules to Succed in the Residency Match" by Dr. Katta and Dr. Desai.

Best of luck to everyone going through the match. Please feel free to comment, as discussion makes us all better.