Any advice for aspiring medical students?

Not much. Everybody is going to have a different experience in medical school depending on their expectations, their past experiences, and their willingness to modify their ideals to conform to the realities on the ground. I’m trying to get away from giving advice in favor of relating some of my experiences and opinions and letting the reader make of them what he will.

But I guess the basics are the most important, that is, to study hard, keep your eyes and ears open, and try not to get so caught up in what is, once you strip away the self-congratualtion, just a somewhat difficult professional school. Medical school doesn’t have to consume you and it is possible to have other interests. This is not to say that there won’t be periods when you will have time for nothing else but you do get to go home. The subject matter is very interesting but it ain’t that interesting all of the time. If it was more people would show up to embryology lectures.

I’d also like to add that, if you consider that most medical students do not work while in school and that you can skip what are generally useless lectures at will, with a good course syllabus there should be ample time to both study and master the material. I was not the best student being something of a slacker (and I should have studied a lot harder) but I comfortably passed everything. There is time enough in the day. With a little self-discipline you should have a low-stress first and second year and still make good grades.
In other words, keep up with your studies and you can avoid the desperate all-night study groups that blossom like nervous flowers, the tattered petals of highlighted index cards strewn over the tables in the library, as your disheveled peers try to cram a few weeks of material into a frantic string of all-nighters. I never could pull all-nighters. I lack the stamina and, as I may have mentioned once or twice, mightily dislike going without sleep.

But do what works. I’m just suggesting that there is no need to panic like many of you new first years are probably doing right now. Don’t sweat it. Keep plugging away. It is going to get easier and by the middle of second year you are going to be able to cover three times as much material in a third of the time and laugh, yes laugh, that some punk-ass biochemistry course ever intimidated you.

What’s the biggest shock for many medical students?

Not being as smart as you think you are. Let’s face it, most of you have until now been at the top of your class in high school and college. You’ve studied hard and received both excellent grades and frequent validation that your hard work and discipline has set you apart from the lumbering proles who go to college for the chicks and the parties. It’s not as if you become stupid on the day you matriculate into medical school but, as everything is relative, on that day you will find yourself surrounded by a hundred other highly intelligent people getting hosed down with a tremendous volume of information, wondering if you are going to be able to keep up. And you will look around and see your peers apparently effortlessly mastering the material while you desperately struggle for a barely passing grade on the first test. That first “72″ chills your spine, especially if you are used to “high honors.”

When I was in college, I had to take a ridiculously easy Art Appreciation course to sastisfy the distribution requirements for my major. Easy as it was, I was surrounded by students who were really sweating it including a couple of guys in the back regularly formulating cheating schemes whereby they could scrape by with a “D.” Many of you will feel like those guys after the first exam.

Traditional Lecture or Problem Based Learning?

Traditional lecture. No question about it. If you are accepted into more than one medical school and can pick between a lecture-based curriculum or Problem Based Learning, flee as if from the Devil himself the PBL school.

For those of you who don’t know, Problem Based Learning is a fancy word for “Seminars.” Instead of sitting in a traditional lecture following a rational plan of study, you will be divided into small groups and, under the supervision of a faculty member, teach youself the material through the highly inefficient process of self-discovery. It sounds good on paper and the medical schools that have embraced it will try to sell it as if it were going to replace sliced bread. In practice however, it can be a nightmarish voyage into a sea of ignorance on a ship full of clueless people who all want to be captain.

Problem-based learning is an admission by medical schools that most of first and second year is self-study. Instead of following this admission to its logical conclusion, that people should study on their own, Problem Based Learning was devised to justify both freeing up faculty to concentrate on their real interests and to not provide lectures while still collecting tuition. If you look at it like that it almost makes sense because otherwise you would have to believe that many highly intelligent people devised an intricate solution to a non-existent problem.

The fierce partisans of PBL (who make Mac users seem tolerant by comparison) will sneer at the traditonal lecture curriculum which they say “spoon feeds” the student. The implication is that those of us who prefer lectures to seminars are a bunch of big fucking babies. Maybe lecture is “spoon feeding” but Problem Based Learning is like throwing the jars of baby food at the baby and laughing as he struggles to open them. Actually, I don’t accept the metaphor. Like I said, it’s all self-study. Many people don’t even go to lecture but study efficiently on their own which is hardly spoon-feeding. The difference is that a lecture curriculum has a rational plan, starting with the basics and working up to more complex topics which is the ideal model for a curriculum. Why this isn’t obvious only shows that the faculty at many medical schools have mutated to a level of intelligence where their giant brains have crowded out the common sense lobe.

What’s the bottom line? Studying in a group is highly inefficient, often highly annoying, and puts you firmly on somebody else’s schedule for a significant portion of the day. Instead of just studying you are asked to become an active participant in someone else’s group dynamic masturbatory fantasy. My medical school dabbled in Problem Based Learning and by the end of a typical three hour group session I was ready to shoot myself in the head.

I cannot say enough bad things about Problem Based Learning. Almost everybody despises it.
Podunk or Top Tier?

I am immensely grateful to those who pursue careers in academic medicine, careers that advance the science of medicine and train future physicians, and I am second to none in admiration for the most excellent faculty at my program. With that being said, I have no desire to teach, conduct research, or to become involved with academics once I finish my training. Neither do most physicians for that matter. So with this in mind, what really is the difference between going to your inexpensive, relatively unknown state medical school and a major academic powerhouse?

Not much if you just want to practice clinical medicine. I’m not discounting the value of prestige however. If you want to do a cardiology fellowship at Harvard a medical degree from Yale and a residency at Duke will put you way ahead of some rube coming out of the medical sticks. On the other hand, I rotate at a hospital that most of you have never heard of and probably couldn’t find on a map but it has a cardiology program that turns out first rate cardiologists who have no trouble finding jobs or patients. You just have to know what you want and what you are paying for it. All other things being equal, the more prestigious the program the worse the medical students and residents are treated and the more time you will spend as somebody’s entourage. Consider carefully then your choice. If you know that you want to work at medicine like a regular job it makes no difference where you go and location and lifestyle should trump all other considerations (except for Problem Based Learing).

In the end, it just comes down to what the t-shirt is worth.

Like any rotations?

Sure. I like working in the ICU. I didn’t always, of course, as the ICU is probably the most intimidating rotation for medical students and interns. The patients there are horrifically, almost obscenely, sick and the comforting medical paradigms on which you rely seem to be turned on their heads. This is not, for example, a rotation where you can usually have a polite conversation with the patient and explore, in perfect order, the history and the review of systems. In the ICU the patients often come in with nothing but a vague transfer note and an incomplete list of medications. They can’t talk and there is not always a family member to fill you in on the patient as they head south before your eyes, possibly for the last time.

It is a rotation where you have to do something big, and soon, for most of your patients and this kind of decisiveness is something that doesn’t come naturally. You have to learn, in short, to be the kind of doctor that goes into the patient’s room when something goes wrong, not the kind who leaves the room to get help. Emergency medicine residents tend to like their ICU rotations because this kind of thing is right up our alley. In turn our ICU nurses apparently really like to have the Emergency Medicine residents rotating because we’re not afraid to make decisions and don’t have to call a synod of attendings and residents to do a lumbar puncture or intubate.

How do you feel about pharmaceutical sales reps?

I’m working on an article about pharmaceutical reps. The short answer is that I don’t take gifts from them, don’t need their crappy pens, and as I eat for free at my program don’t need to eat their lunches even if I wanted to (which I don’t). Part of my antipathy is my dislike for bad salesmen which most drug reps are. Give me a good salesman selling a good product in which he believes and with him will I gladly do business. Drug reps however, tend to be smarmy glad-handers peddling products which they do not understand using questionable statistics and glitzy marketing. It’s embarrassing and I cringe to watch a typical drug rep present his little spiel before a noon conference to which he has provided food.
(To be continued…)

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