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Volume 3, Issue 1
Spring 2007:

A Guide to Understanding and Coping with Medical School and Residency Training

Kenneth P. Fowler, MD

Cell 2 Soul. 2007 Spring; 3(1):a8

Forty thousand people strive every year to gain acceptance to American medical schools. However, there are deep personal sacrifices in the training to become a physician that most who want to enter the process never anticipate. This guide provides a brief description of the American medical education process for the benefit of college premeds, medical students, and non-medical people alike, and then offers some general coping strategies for surviving this process, which everyone agrees is truly an arduous endeavor. The experiences described during medical training reflect the summed opinions of a number of medical students and physicians I have known who have been trained in a variety of institutions and do not reflect situations in any particular school or residency program.

The Premed Years

The first step to becoming a physician is to enroll in a college premedical program. There are set required undergraduate courses (biology, calculus, inorganic and organic chemistry) that all medical schools demand be taken before applying for admission. Unfortunately, there is little relevance between the required classes and the actual practice of medicine other than if you can "tough out" organic chemistry and calculus courses in college you will likely survive biochemistry and physiology courses in medical school. With the focus on the key competitive premedical classes, students may miss opportunities taking classes that are more relevant to actual medicine. For example, humanity and arts courses may engender empathy and human dignity, and English and philosophy courses may develop writing and thinking skills.

Most medical schools require applicants to take the MCAT, a standardized test based on the premedical sciences. Premeds should assess if their science classes have really prepared them for the material covered in the MCAT because sometimes professors focus on their own interests rather than standardized content. Extra studying through commercial programs such as Kaplan may be required to pass the MCAT exam with scores adequate to enter medical school.

Coping with Medical School Education

In medical school, the first two years focus on the basic sciences, while the last two years, the clinical years, are spent working with actual patients. Basic science years are sometimes referred to by medical students and residents as "the pre-cynical years." In basic science, the students are really just learning the language of medicine. The most common analogy used to describe the heavy workload is that "it is like putting one's mouth over a fire hose turned on max flow." In some schools there is little monitoring of the faculty for the quality of their teaching. This can be stressful to medical students who must spend up to eight hours a day sitting in class. Just as in the premed years, the material taught can be obtuse with little relation to the practice of medicine. Young PhDs do much of the teaching in the basic sciences; but these faculty typically have never been in medical school and their interests are solely in medical research. The traditional method of teaching the basic sciences is to divide the two years into normal and abnormal processes. More recently many medical schools have taken a systems-based approach along with clinical medicine classes (physical exam skills, etc). In either system, a huge amount of material must be memorized.

As students recognize the importance of class rank, the first two years often become a time of cut-throat competition and occasionally underhanded tricks. The grueling pace of studying leads to a loss of connection with loved ones. Ironically, well-meaning attempts to entrain empathy into exhausted students takes more hours away from time that could be spent with family or doing non-educational-related activities. An attitude of "it'll all pay off in the end" can give way to "this better be worth it!" — the latter an attitude that can lead to resentment, burnout, and unwillingness to treat the underserved later in one's career.

As indicated, the third and fourth years are spent on the wards and in the clinics. The third year is the first opportunity to actually experience the practice of medicine. The transition to clinical deductive thinking can be truly stressful-indeed, frightening to some. The third year is also the time when students are supposed to figure out what kind of physician they want to become. However, the brief clerkships (usually four weeks) are too hectic for some students to make thoughtful career decisions. Good grades from clerkship directors and a strong letter of recommendation from the dean are critical; generating good impressions impact students' actions on a daily basis.

The tasks of the third year medical student, or clerk, are highly variable and often not pleasant. Students may only be allowed to be an observer, or may be placed in charge of all rectal exams, or may be assigned the duty of primary phlebotomist (blood-drawer, more common in inner-city hospitals). Fortunately, residents are no longer allowed to send out medical students to pick up pizza while on call! Usually, third year students examine patients with an intern, attempt to make diagnoses (often chided for not being right), and then write daily co-signed progress notes. Fourth year students do "subinternships" usually consisting of following along patients with a senior resident, who must co-sign all orders. As part of the four-year long training period, several day long national board exams have to be taken and successfully passed.

To get a residency position, the vast majority of applicants join "the Match." After interviews, each applicant and each program submit a rank order list of programs or applicants, respectively, that they would like to match with. It is in the best interest of each party to order their list by preference, not by order of likelihood to be chosen by the other, since both programs and applicants tend to mislead each other into believing that they really want to rank the other party highly.

Medical students may not realize that there are many more residency positions than U.S. medical students (at least 125% of the total U.S. medical school class). Hospitals are highly motivated to have residents — cheap labor plus $85,000 per resident per year from federal government (paid for out of the Medicare budget). Overall, America needs more physicians for the poor, rural folks, and the soon-to-be elderly baby-boomers. Some specialities, however, have managed to become very competitive — dermatology, radiology, certain surgical subspecialities (plastics, otolaryngology, urology, orthopedics) — by sharply limiting the number of resident positions. Primary care fields — family medicine, general internal medicine, pediatrics, obstetrics and gynecology, and psychiatry — are having trouble recruiting residents because the earning potential in these fields is less.

Residency Training-Becoming a Competent Physician

Graduates from medical school have spent at least eight years studying, typically owe $150,000 to $250,000 in education loans, and yet are in no way prepared to start taking care of patients. Residency training is required. The residency experience has inspired many works of literature — works that are generally not uplifting stories (such as House of God and Mount Misery by Samuel Shem; Intern Blues by Robert Marion).

Internship is the first year of residency, primarily composed of inpatient months (depending, of course, on the chosen specialty) involving many hours of "call" (working on the hospital wards). Some specialties require internship in internal medicine or general medicine ("transitional year") before starting training (including fields such as dermatology, anesthesiology, psychiatry, and other specialties as well). Internship is intended to be a year of close supervision — usually provided by senior (upper level) residents and supervised by experienced attending physicians (those with full medical licenses who have already graduated from residency).

Residents exist in a grey world between student and attending physician. They are medical graduates who are both learners and providers of health care. Residents are critical to the functioning of large teaching hospitals (academic medical centers). Teaching hospitals are typically managed by enormous bureaucracies, which make the residents' work all the more taxing. Hospitals save money by employing residents: residents reduce the number of physicians needed for the hospital to function and they sometimes perform non-medical tasks (patient transport, phlebotomy, nursing tasks). In exchange, the teaching hospitals give residents experience with working with a variety of very ill patients, including performing surgeries and other procedures under the supervision of attending physicians. A public benefit to this arrangement is that it tends to improve access to healthcare for the poor.

The medical education system creates a pyramid hierarchy: medical students at bottom, interns slightly above, then senior resident (in charge of making sure everything runs well), sometimes a fellow (a graduate of residency pursuing further training and subspecialization), and on top of the whole team is a legally-responsible attending physician who is required to confirm the findings on the written notes and ensure the quality of the care provided. This system has vulnerabilities — as with every hierarchy, there is the potential for abuse of those lower on the totem pole.

Medicine is well-known for its long work hours. Students are prepared for this lifestyle through the large volumes of material that they are expected to learn in short periods of time during their premed and basic science years. In many (if not most) academic medical centers, working hard and handling problems is part of the culture, and residents' performances are constantly evaluated both by attendings and other residents. The culture of "being strong" is passed from one generation of residents to the next. This tradition has created abuses. Until recently, working over 100 hours a week was common in most medical and surgical residencies (with a few exceptions). The original argument for this method of teaching was that it allowed learners to see the full course of a disease as it progressed through its natural course. Numerous studies now show that medicine's failure to place limits on work hours can be measured as a mortality rate (both of physicians and patients). Under threat from Congress, the ACGME (Accrediting Committee for Graduate Medical Education) has limited work hours to 80 hours per week plus no more than 24 hours of continual work (with an additional six hours for transition of care and education). Resistance from the older generation of physicians and from some residents has been significant, in part because of concerns about a decrease in the quality of training that reducing the hours can cause.

Prior to the end of residency, trainees must pass the final steps of the medical board exam. The residents then apply for permanent medical licenses in the state or states where they plan to work. Any time a physician moves to a different state, a new license is required. After graduating from residency, physicians take a test to become board-certified, which signifies a higher level of competence (and better reimbursed for services).

Survival Tactics

Given the length and complexity of medical training, the hierarchical nature of the training, and the egos of the people who tend to be attracted to medicine, the potential to run into problems exist. Having just survived the process, I offer a few pearls to deal with the stresses in medical training:

  1. Don't take the injustices or abuses personally. Acknowledge the unfairness of the hierarchal medical education system. The system is designed by institutional competing interests, and these interests do not always consider the welfare of the students.
  2. Apply the tactics of Admiral James Stockdale, a prisoner of war for eight years in the "Hanoi Hilton" where he was tortured at least twenty times.1 He credited his survival to first, confronting the brutal facts of his situation, and second, maintaining a determination to not only survive but to overcome the situation. Through acknowledging the harsh reality of his imprisonment, he was able to save his life and the lives of numerous U.S. POWs. Stockdale's tactics apply well to surviving medical training.
  3. Identify physicians as mentors to guide you. The medical education system is quite complex, and everyone needs some guidance. Institutions are supposed to formally provide mentors but all too often mentoring takes a low priority. Medical education can be most disorienting (especially when combined with lack of sleep) and it is important to get a reality check from a physician friend who has been through the system.
  4. Finally, the most important step in medical education is the first one… which is to understand one's true motivations for being a physician. Without figuring this out, it is hard to justify to one's self the enormous sacrifices that will be required to become a practicing physician. In the midst of rough seas during one's training, it is most important to remember the reason for wanting to become a physician in the first place.

References

1 Jim and Sybil Stockdale, In Love and War (Maryland: Naval Institute Press, 1990)

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