“Free Tuition” Isn’t a Primary Care Pipeline

This week, there were two types of discussions on my social media feeds: non-medical friends fascinated by New York University’s announcement of free tuition for all its medical students, and medical friends frustrated that their own schools weren’t so generous (gee, thanks, Vanderbilt!)

To be clear, it’s an impressive and laudable feat to cover tuition—at present, around $55,000 per year—for about 450 students in perpetuity. By the Association of American Medical Colleges’ numbers, 75% of the Class of 2017 graduated with education debt; on average, over $190,000 per student, between eight years of undergraduate and medical studies. NYU raised $600 million in donations to ensure that its graduates don’t have such financial considerations hanging over their early-career decisions.

NYU’s stated rationale here is twofold: to reduce the cost barriers that would prevent some students from pursuing careers in medicine, and to encourage students to choose less-lucrative specialties like primary care. “I don’t want people moving away from what they’re passionate about because of their fear of the money,” said Rafael Rivera, NYU’s Associate Dean for Admissions and Financial Aid.

I think those are pressing problems for medical education, and I applaud NYU for putting forth a bold, ambitious solution. I just don’t think it’s the best fix for either issue.

Free tuition is a definite game-changer for students from less-affluent backgrounds that otherwise might not have been able to afford medical education. As a society, we need these people to become doctors. They’re more likely to return to the communities and populations they’re from to practice. Moreover, seeing as there’s a wealth of literature on the implicit biases that shape our care of women, minorities, and socioeconomically disadvantaged patients, medicine could certainly benefit from the added diversity of represented backgrounds and viewpoints among its ranks.

That being said, NYU students will still have to take on $27-29,000 per year in costs of living and other expenses, which may continue to deter some of those cost-prohibited prospective physicians.

It’s also not clear how this improves access over less costly initiatives, like Columbia’s $250 million plan to eliminate medical student loans. From my own medical school experiences, many of my classmates (though certainly not all) came from well-off backgrounds. I’d estimate at least 30% were themselves children of doctors, myself included. Can’t a university like NYU find a better use for the extra $350 million its plan will take over Columbia’s than to give aid to some students like me who, ultimately, would likely be able to become doctors and attain well-off lifestyles without it? Its education or social work students, for whom a six-figure income at their ten-year reunion is less assured, probably have some ideas.

Free tuition is a start to medical education’s access problem. A real solution, though, needs to consider the myriad ways low-income students are shut out from medicine—like limited early exposure, fewer test-prep resources, and less resume-building opportunities, to name a few—and act broadly to make a substantial impact.

If free tuition is a suboptimal solution for improving access, it’s even worse for solving the shortage of primary care physicians.

A $220,000 four-year tuition relief makes primary care specialties more feasible for altruistic students who are deterred from lower-paying fields by the prospect of loan repayments. It doesn’t, by any measure, make such careers more financially attractive in the U.S.’ current payment structure, in which doctors are paid for doing things, and paid even more for invasive or interventional things than for time spent talking to people or thinking through complex diagnoses.

According to Doximity, the average Manhattan general pediatrician makes $181,000; for family physicians and internists, it’s $205,000 and $207,000, respectively. When an NYU medical student chooses primary care, they choose to forgo the salary of an orthopedic surgeon ($458,000), radiologist ($384,000), or cardiologist ($391,000) out of an intellectual interest or sense of social duty in preventive care or population health management. Against a lifetime of thirty to forty years’ worth of accumulated earnings, the cost of a medical degree—even considering the interest on loans a student might otherwise take—is a drop in the bucket.

Don’t get me wrong: primary care is muchmuch more important than the salary comparison suggests. It’s just not any better a financial decision with a free medical education than without it.

To add an even more cynical perspective, as NYU’s application pool undoubtedly draws even more competitive, talented applicants, it wouldn’t be surprising to see its match list tip even more toward selective specialties like derm., IR, ortho., or ENT.

So, if medical schools really want to cultivate primary care doctors, they can introduce tracks for primary care-specific training and exposure, like the ones at Duke and Johns Hopkins. They can offer accelerated training programs for primary care, as Mercer and Texas Tech do. If they go the scholarship route, like NYU, they can borrow from UC Riverside‘s playbook: it covers tuition, but only if the students stay and practice in underserved Inland Southern California.

What NYU and its donors have done is an incredible gift for its future graduates, one which will surely have an impact on its students’ bank accounts—not to mention, its upcoming years’ U.S. News rankings. It’s every bit as generous and impressive as it seems. It’s not, though, the moonshot strategy for improving access to medical education or promoting careers in primary care that some, like The Atlantic, NPR, or Fox News, suggest.

P.S.: If you’re from NYU Med and reading this, I’m totally not related to any other Utrankars you might see an application from in the next few years.

What matters in a medical school?

As a fourth-year medical student, I’m no stranger to admissions processes; I’ve been through two, am currently in one, and have at least one more ahead. At each stage, one of the most challenging elements of finding and selecting a ‘best fit’ institution is knowing, in advance, what really matters in a training program. You have an important decision before you—a four-year investment, which will provide the foundations upon which you’ll care for tens of thousands of patients—but, if you’re like me, an unclear sense of the essential factors that ought to shape that decision. What am I really looking for in a prospective institution?

I write about this now because, going through residency interviews, it’s currently all I think about. Every 15 minutes, I’m asked, “So, what questions do you have for me?” I dine with residents, interview with faculty, and tour hospitals, all to address the nebulous question of which program is optimally suitable to launch my career. My co-interviewees and I ask all sorts of queries, with widely varying degrees of significance to the training experience.

  • What is the didactics curriculum like?
  • How is your call schedule structured?
  • Where do residents live in relation to the hospital?
  • How many livers do you do each year?
  • Are there moonlighting opportunities?
  • What’s the free food situation?

It feels clumsy, murky, and at times even silly; am I really going to weigh the ‘food situation’ in my residency decision? How ‘mission-critical’ are strong didactics, case volumes, or moonlighting opportunities, really? While I can’t speak to any of those questions at present, I’ll offer my perspectives on the process on which I now do feel somewhat better equipped to advise: what matters when selecting a medical school.

Does the institution’s mission statement match yours?

A mission statement is more than boilerplate text. It outlines what the institution values and aspires to—and by extension, the role they envision for you as a future physician. My medical school, for instance, defines itself as a regional referral center for complex cases, as well as a hub for leadership, innovation, and scholarship in subspecialty care. The faculty it recruits, the programs it invests in, and the curriculum it instills all reflect those objectives. For the aspiring physician-scientist or sub-subspecialist, it’s a strong fit. For those with professional interests in ‘country doc’ or ‘safety net’ medicine, perhaps less so.

Does the curriculum align with your learning habits?

By now, you likely have a sense of how you learn and study best, so find a school where the educational activities mirror those preferences. If you like to study in groups, favor discussion-based courses, or retain content better when you can situate it in an experiential framework, look for schools that emphasize active learning over traditional lecture. If you’re unable to self-structure your time productively, maybe a school that requires attendance is best for you. The more honest you can be with yourself here, the better your chances of selecting a setting where you’ll succeed academically.

How flexible or adaptable is the curriculum to meet your goals?

Academic interests evolve, almost inevitably. Therefore, even if you’re certain a future in pediatric cardiothoracic surgery awaits, pick a curriculum that affords you the flexibility to pivot if you discover a late latent passion for, say, family medicine or geriatrics. At my medical school, for instance, the third and fourth years are almost entirely elective-driven, which gives students the flexibility to choose their own adventure and adapt as their goals shift.

Even if you’re set on your path, flexibility matters a lot. Medicine offers infinite opportunities to customize your career. In addition to the myriad specialty and subspecialty routes available, physicians can be scientists, entrepreneurs, technologists, administrators, policymakers, activists, educators, ethicists, creatives, and much more. While there are some competencies which are foundational for all physicians, your classmates paths may look profoundly different from yours, and the best curriculum is one that provides the time and resources to train you for the particular career you want.

Is there a formal, student-engaged process to elicit and implement learner feedback?

No medical school is perfect, but the best ones are committed to the idea of rapid-cycle, feedback-driven improvement. When considering a school, ask students and faculty for examples of changes in response to student-voiced needs or interests. Ask how often students have face time with educators and administrators, and what mechanisms exist for students to relay feedback—or even better, to shape administrative decisions in collaboration with deans and leaders. Of course, every school will think it achieves this objective exceptionally well, so seek input from multiple perspectives and ask for particular examples.

Is it an environment where, when you’re not in the classroom, at the library, or on the wards, you’ll be happy?

There’s a lot of down-time in medical school. While it might not feel that way the week before a block exam or during a surgery rotation, medical school (usually) won’t be your life. You will have time to pursue hobbies, hang out with loved ones, explore your surroundings, and have fun .. so make sure your environment is conducive to it. If you’re someone who draws heavily upon support from family, going somewhere distant might not be worth it. If you’re ‘single and searching,’ a small town may not be your scene. Academics matter, but four years is a long time to “grin and bear it.” Pick a place where you’ll find happiness as you define it, and where you can be the person you want to be.

But wait! What about the U.S. News and World Report rankings?

Frequently—looking at you, Indian dinner parties and Student Doctor Network forums—pre-meds wonder how much weight to ascribe to rankings when selecting a school. The unpleasant answer is: they sort of matter, but they sort of don’t.

Reputation, in itself, isn’t terribly important. But those ‘name-brand’ schools are also the tertiary or quaternary care centers where you’ll see the most complex cases, where you’ll build connections with mentors that are leaders in their respective fields, where you’ll reap the educational and scholarly resources that come with a major research institution and a generous endowment. Those opportunities aren’t necessarily exclusive to “elite” institutions, but they might come easier at some places than others. Therefore, my standard advice is this: don’t focus on the rank number, but look for the benefits and advantages that come with it.

That’s a lot to think about, so I’ll close with some words of comfort: I’ve worked under many incredibly bright and gifted residents at Vanderbilt, enough to know that it’s nearly impossible to distinguish from observing someone’s clinical skills whether he/she went to Harvard Med or State U. If you’re smart enough to get accepted to medical school and build upon that inherent intelligence with diligent effort, you can go anywhere from anywhere. When the process feels daunting, think back on that, and you’ll get through just fine.

Medical students and physicians: what do you now feel is important in a medical school that you would advise prospective students to consider?


Why professional societies are worth it

As someone who’s all too familiar with the ‘student loan life,’ there are few things I’d recommend as essential buys besides UWorld, ramen noodles, and Keurig cups. One that’s often overlooked by medical students, though, is membership in the professional society for your future specialty.

Cue the collective groan. I know, and I get it: why pay an annual subscription fee to join a club, add a line on your CV, and pay your respects to “the guild?” At first, I felt similarly skeptical. As a digital native, I was confident that I didn’t need my professional society. I had a blog. I had a Twitter account and LinkedIn profile. I could advocate for myself, and network for myself.

Since then, as I’ve furthered my interest in anesthesiology and advanced my involvement in the specialty, I’ve come to see the value that a $10 American Society of Anesthesiologists (ASA) student membership provides. Here, I’ve outlined a few of the high-yield benefits of the ASA Medical Student Component—and, I should add, even if you’re not a gas-passer in the making, these same benefits likely extend to the society for whichever specialty’s caught your heart.

Know what’s happening in the field, and where it’s headed. Through the ASA, I receive a complimentary print subscription to Anesthesiology, its peer-reviewed journal; the ASA Monitor, its monthly magazine; and ASAP, the weekly email newsletter. As an outsider looking in, these publications provide an introduction the ‘hot topics’ in anesthesia research and practice and an overview of educational content that’s likely to be useful on your anesthesia rotation (and not to mention, future training). Not all of it applies to learners, so feel free to gloss over the articles on practice management or billing code jargonology, but you’ll pick up enough to show attendings that you’ve done your homework, and to show interviewers that you know what you’re getting into.

Learn, do, and network at the Annual Meeting—for freeThe ASA and other specialty societies know that their students are their future, and they invest in our growth (and theirs!) by waiving students’ registration fees for the ANESTHESIOLOGY Annual Meeting. This conference is a ‘must-do’ for the future anesthesiologist, without question. It’s an opportunity to learn what’s new in anesthesia through presentations and panel discussions, practice procedures in hands-on skills workshops, and network with residency programs (and future employers!) And again, it’s all for free—which, right behind “go home” and “do you want to do this procedure?” are a medical student’s favorite words.

Support the people who are fighting for your future. In medical school, it’s sometimes easy to be complacent about advocacy, policy, and the landscape of physician practice; after all, life after residency seems so far away that we’re rarely looking beyond the next shelf exam. Even if you’re not looking ahead to the future, your professional society is. That’s why, in the last year, the ASA has been looking out for anesthesiologists and their patients and advocating for physician-led anesthesia care—and for evidence of that, look no further than the Safe VA Care initiative. And these are challenges facing every specialty: family medicine, internal medicine, pediatrics, psychiatry, radiology, you name it. Even if you view your membership as solely an investment in the safety of patients and the relevance of your future profession, it’s well worth it. And of course, if you want to go the extra mile, there are advocacy opportunities and leadership positions available.

When you think about what it costs to become a physician today—medical school tuition, supplies for clinical rotations, test prep resources, residency application and interview travel fees, and much more—a $10 annual membership to the American Society of Anesthesiologists (or your specialty’s professional society), with all it affords, is easily the right decision. If it does present a financial challenge for you, don’t worry; your medical school’s student affairs office, your school’s anesthesiology department, or your state’s anesthesiology society can likely lend a hand. Whatever the case, don’t overlook the chance to tap into this valuable resource and the education, professional development, and advocacy advantages that come with it.

Bottom line: prospective members, join the ASA, or your professional society, ASAp (#badpuns, I’ll admit). For current members: what additional benefits or perks have you gotten from your involvement in your professional societies? Leave a comment to weigh in!

Disclaimer: I am a medical student member of the American Society of Anesthesiologists and a member of the ASA Medical Student Component Governing Council. This blog post is not on behalf of the ASA, nor has it been authorized or supported by the ASA (or any other organization) in any capacity; it represents my views, and my own advice for my fellow future anesthesiologists, alone. [In short, I speak for myself, because I’m fairly certain nobody wants me to speak for them anyway!]

MedX|Ed: Fast Four

Medicine X is an event that’s one part performance art, two parts academic conference, and three parts social movement. The last 24 hours have been a whirlwind of awe and inspiration that’s left me speechless—sorry, tweet-less.

First and foremost, I have to applaud Medicine X for its unique approach to medical education. Traditionally, medical education meetings are where deans, program directors, and educators meet to prescribe a top-down vision of what’s best for medical learners. MedX|Ed—and naturally, MedX is anything but traditional—takes the opposite approach. It begins with the end users, learners and patients. Next, it identifies these users’ needs in an evolving healthcare system and dynamic social-technological climate, and imagines how academic medical ecosystems might be re-engineered to better support them.

What a wild idea: that medical students might actually have a vested interest in crafting their ideal learning modalities, and that patients might actually have a vested interest in shaping their ideal provider’s skill set. Imagine that.

As the MedX webcast and tweet-stream illustrate, when students, patients, providers, and educators converge, the discussions are delightful, and the ideas are incredible. If you’re not keen on combing through 6,500+ tweets of lofty ideation, raw emotion, and heated disruption, here’s a “fast four” of take-always to ponder.

Reimagining pre-med. Creative destruction of medical practice starts with creative destruction of medical training, which starts with creative destruction of medical admissions and selection. If we want scholars, innovators, and humanists, why do we, as Nisha Pradhan critiqued, put physician-hopefuls through a meat grinder of memorization and multiple-choice assessments? As a medical student, I never solve Diels-Alder reactions or draw Krebs cycle intermediates. I frequently search for the subtexts in dialogues and make perceptual assessments of subjective situations—you know, fluencies I built from my humanities coursework. How might we rethink pre-medical prerequisites to actually hold relevance to the practice of medicine?

Reimagining med ed. Anki, Picmonic, Firecracker, Pathoma, Goljean, DIT, UWorld: the last decade has seen an explosion of digital study tools, tutorials, and Q-banks in medical education, and it’s all driven by the increasing centrality of standardized testing in residency selection. Have dreams of derm? Better splurge for that $500 test prep resource. Now consider that this ‘Step 1 economy’ exists in addition to a medical education that costs $30-60,000 per year. Medical students today are dually enrolled in the study of patient care and the study of Step 1. Why is that? If our tests are so detached from the curricula they evaluate, shouldn’t we aim to close the gap? How might we redesign assessments to capture a holistic excellence in clinical practice, rather than an acute ability in factual recall?

Reimagining patient ed. It’s no coincidence that the word ‘doctor’ derives from the Latin word ‘docere’: to teach. At its core, to be a physician is to be an educator. In today’s volume-driven healthcare system, though, that teaching interaction is often confined to a brief moment at the close of a patient visit. As more physicians become content creators and digital connectivity becomes ubiquitous, might we extend patient education beyond the clinic? It’s easy to imagine a near future where a patient’s ‘presenting complaint’ triggers an email with curated educational content, like an Evans Health Lab video, ahead of a visit. Such ‘flips’ would allow more time for the clinic visit to focus on hands-on teaching or addressing questions. How might we use digital media, informatics, and educational theory to inform a ‘flipped classroom’ for tomorrow’s patients?

Reimagining educators. Traditionally, teaching moves down the hierarchy: attending physicians teach residents and fellows, who teach medical students, who sit at the bottom of the totem pole and try not to mess up. As we continually extend the competencies and fluencies expected of providers in an age of accountable care and networked medicine, perhaps the best educators aren’t solely physicians. Maybe the best educator on empathy, bedside dialogue, and the patient experience is, as Dave DeBronkart and Emily Kramer Golinkoff proposed, a patient. And maybe not even just learning from a patient lecturer, but from a patient’s chronological illness narrative on social media,or from a patient who brings their ‘Google biopsy’ results to an appointment. How might we create structure opportunities for trainees to connect to and learn from non-conventional teachers?

Clearly, we have much to think about, and even more to still accomplish. Again, a huge kudos to MedX for extending the vision of ‘nothing about me, without me’ from the clinic to the classroom. And a final note for healthcare students: now that we’ve been given the opportunity to participate and speak, we’re charged with the responsibility to co-lead and actively shape our learning ecosystems. Let’s get to work.

Closing question: what are your “how might we’s” from MedX|Ed, and how do you envision implementing them by MedX|Ed 2016?

Well, Here Goes Nothing

It’s finally here.

After 13 years of K-12 schools, four years of college, and one year of pre-clinical medicine, I’m finally doing the unthinkable: stepping beyond the classroom, trading chalkboards for charts, swapping study guides for stethoscopes, and putting 18 years of learning into application at the bedside.

Well, sort of–there’s still grand rounds, morning report, and core didactics. And I’m far from done with textbooks or tests. But it’s hands-on, and it’s dynamic, and it’s the closest I’ve ever felt to actually doing anything tangible, applicable, or useful, so I’ll seize the opportunity for a little ‘hooray!’

Just one thing: I’m scared to death–tense, timid, terrified, and (D) all of the above.

In the days to come, I anticipate carefully budgeting my umms, uhhs, and I don’t knows. I expect to know all the right answers–that is, about five minutes after the question’s been asked and the resident’s moved on. I plan to stockpile the responses that are valid for almost any question; I’m told ‘cytokines’ and ‘idiopathic’ are reasonably reliable. The unshakable conviction that I’m only here because of an admissions office clerical error is back, right on cue from this time last year.

Here’s the wild part, though: even though all that’s true, and sleeping in is about to mean 8:00am, and a two-day weekend is about to be a vaguely fond memory of days past, I’m still really, really amped for this.

These next few months, there’s no telling what might happen. I might get to introduce a life into this world. I might get to reboot a heart that’s stopped beating. I might get to offer someone a word of comfort in their waning days. Even the most simple of things sound like opportunities–I might draw upon 19 years of lessons and lectures to decipher what’s making someone feel crummy, then find a way to make them feel less crummy.

It’s going to be petrifying, but profound. Terrifying, but terrific. Wild, but wonderful.

As I embark on this next chapter, then, these are my promises to myself. In the months to come, I hope to revisit these promises, to measure my personal growth against them, and to hold onto them as my compass, my ‘true north,’ of moral and intellectual character.

Start humble; stay humble. This one’s easy, especially when you don’t have the expertise or credibility to be anything but humble. As I grow in this clinical life, though, I hope to retain what it feels like to not have the answers, to speak from a place of low hierarchy. and minimal confidence.

Remember that everyone’s an educator. Even while learning to think like a doctor and do as doctors do, I hope to bear in mind that there are many things to be even better learned from my other colleagues and collaborators: from nursing, compassion and advocacy; from social work, resourcefulness and relationship-building; from environmental services, perseverance and ‘can-do’ willingness.

Seize every moment like it’s once-in-a-lifetime. This year, I’ll rotate through 100 specialties, and 99 of them won’t be my future profession. In other words, for anything I do this year, it could be the first day of the rest of my life, or the last time I ever deliver a baby or close a surgical incision. I’ll inevitably be tempted many times this year to skip a learning opportunity or cursorily participate in an educational experience–”I’m never going to need this skill.” When that happens, I hope to catch myself, to cherish everything as potentially unique, and to stay open to the moments that might unexpectedly captivate me.

Resist a reductionist view of the patient. Toward the end of first year, I knew I was overdue for a summer break when I’d catch myself tuning out of the ‘irrelevant’ parts of the patient narrative, feeling impatient with the details that weren’t pertinent to a diagnosis. As the medical student, I have the gift of being ‘non-essential’; my histories and physicals are, most likely, just educational exercises. In that context, I hope to remember that it may occasionally be more impactful to defer the review of systems to allow a patient space to reflect. I hope to remember that there’s more to patient care than a detailed differential.

Exist beyond medicineFor better or worse, medicine isn’t my all-consuming identity, my sole purpose. I’d like to think I exist beyond the hospital, in the form of values, leisurely pursuits, and relationships. Naturally, this won’t be the year I chase my dreams of seeing the world, or the year I take a step back to focus on my relationship. The hours of clerkships and the drive to study more, to know more, to perform better will be demanding, and these will come first. I hope, for my sake and for the sake of those dear to me, that this medical apprenticeship doesn’t become everything–the only thing–that I’m about.

So there it is–the manifesto of who I am now, and who I hope to become (or not become) by the conclusion of this whirlwind of a year. Preachy? A bit. Sappy? Definitely. Over-ambitious and doe-eyed? Sure, probably. Still, I know the odds are against me, and chances are high that I’ll end this year more jaded, more skeptical, and less empathetic. And maybe, just maybe, if I set my goals to an aspirational degree of virtue, goodness, and empathy .. then I’ll land somewhere in the middle, and fare just okay.

Well, here goes nothing.

On ‘Leadership’ in Medicine

In medicine, there are many buzzwords that are thrown around so frequently and loosely as to lose meaning or purpose. I’m looking at you, ‘patient-centered.’ And you, ‘disruptive innovation.’

Now that it’s August–the season of medical school orientations and white coat ceremonies–there’s another that, as if on cue, is making the rounds: leadership. This time of year, medical students are treated to speech after speech by deans who wax poetic about the physician-leader.

“We brought you here not to be 9-to-5 employees, but leaders in medicine.”

“We’re not just in the business of training doctors; we’re developing leaders.”

At the time, I was a fresh-faced, doe-eyed disciple in my first days of a lifetime in medicine, and I hung onto every word of the sermon–enchanted, captivated, inspired.

In the coming months, though, that inspiration turned to curious inquisition. Inquisition turned over to weary skepticism. One year in, I’ve started to deconstruct and critically evaluate the ambiguous aspiration that is ‘physician-leadership,’ a process that’s led me to these questions.

What’s a physician-leader? A year ago, we were challenged to be more than “9-to-5 employees”–to go beyond the ‘ordinary’ work of doctoring and patient care to advance the frontiers in scholarship, administration, and healthcare delivery.

Since then, though, I’ve seen some sparks of inspiration among the seemingly mundane that reveal a broader sense of leadership. There’s the country family doctor who, as a lone knight, stewards the health and wellness of an entire community. There’s the intensivist who speaks up to oppose medically futile care and guide patients to ‘a good death.’ Does one have to be an Ezekiel Emanuel or an Atul Gawande to be a physician-leader, or can we find and appreciate glimmers of leadership in the day-to-day labors of being ‘just a doctor?’

What’s it mean to train physician-leaders? As orientation became an ever-faint blip in the rear-view mirror, so became the relevance of leadership and transformative thinking in our day-to-day coursework. If we were being trained as physician-leaders, how was our training any different from that of physician not-leaders? I think we learned anatomy the same way. Same for physical diagnosis and pathology, too. A year in, I’m not sure how exactly one trains as a physician-leader, as opposed to a not-leader.

To train physician-leaders is an admirable aspiration, but it would be a little more admirable if there were a little more substance to it.

What’s with the love of leaders? As the old adage goes, if everyone’s special, then nobody really is. Likewise, if everyone’s a leader and trained from the start to think only as a leader, is there anyone left to be led? Students are selected into medical school by leading in the classroom, leading in activities and organizations, and leading in the community. When students who have only ever led arrive at medical school and are instructed to lead, does it compromise the profession’s ability to form hierarchies or collaborate?

I wonder if medical schools ought to teach, along with leadership, the principles of good followership–active listening, influencing from below, knowing when (and how) to challenge a leader. Perhaps then, we’d see stronger cohesion and collegiality, both within our profession and among the health professions.

Don’t get me wrong, now–the importance of effective leadership in medicine by physicians, for physicians is hard to overstate, especially at a time when doctors are facing increasing pressures from changing practice models, shifting payment structures, and growing information technology demands. For now, though, leadership as it’s preached and praised in medical education is a notion without clarity, an ambition without substance.

Speeches and sermons at orientations and white coat ceremonies are good. If we want to do better, though, maybe we should recognize and teach the brand of leadership that happens not only at the highest levels, but in “9-to-5 medicine.” Maybe we should actually think critically about what it means to train physician-leaders as a functional practice, rather than a buzzword not reflected in the curriculum. And maybe, just maybe, we should understand that there are limits and complements to a singular emphasis on leadership that are worth instilling, too.

The eStudent: Nothing About Me, Without Me?

I recently had the wonderful privilege of being accepted to present at a conference on medical education. I’m excited; this is a first for me!

It also came with a less-than-wonderful ‘first’: the privilege of paying a hefty conference registration fee.

Now, I can appreciate that organizing a conference is an expensive endeavor. Venues cost. Staffers cost. Esteemed keynote speakers cost. I get that.

What I don’t get is how a conference on medical education can accurately reflect interests and engage stakeholders in medical education by pricing out the main recipients of medical education: students.

Sure enough, looking over this conference’s speakers list, students are scarce. Plenty of deans, administrators, clinician-educators, and research scholars, though. It’s a conference about learners, but without learners.

To be fair, this isn’t a new phenomenon. Last year, I was elated to see the AAMC webcast its Medical Education conference. With great interest, I watched. I learned. I chimed in via Twitter when the dialogue called for (more often, presumed) a student’s perception or perspective.

And then I rolled my eyes when the post-conference survey, to the question, “Which of the following describes your role?” failed to include the option, “Student.” That moment spoke volumes, and it said everything about the student’s role in educational innovation and curricular design.

This is the essence of the problem. As students, there has to be a bigger role for us in medical education than taking post-intervention comprehension assessments or filling out satisfaction surveys. There has to be, to draw upon clinical analogies, a shared decision making model that invites students’ values, goals, and habits throughout the design process. Medical education without student engagement makes about as much sense as patient care without patient involvement.

To give credit where it’s due, I’m lucky to attend an institution where the student voice is present from the inception of an educational design process. But my experiences on the national scale imply these are outliers, not norms, and that’s a fundamental flaw.

ePatients, as advocates for access to their clinical records and active involvement in their own care, have in recent years coined the moving message, “Nothing about me, without me.”

That’s the attitude we need in medical education. That’s what we have to aspire to, and advocate for. To be eStudents: learners who don’t just participate in and function within an educational ecosystem, but actively shape it.

Searching Under the Streetlights

Walking home the other night, I walked upon a man knelt on the ground, searching for something under the streetlight. He told me he was searching for his wallet, and I, too, got on all fours to help.

After some time, I asked, “Are you sure you dropped it here?” The man laughed, “No, of course not! I lost it a few blocks over that way, but the lighting is much better here.”

As a child, I found this often-recited parable silly; what sort of nut does that? In these first months of medical school, I found my answer: we do.

Despite medicine’s obsession with data, evidence, and validity, when it comes to education and assessment, we search under the streetlights. Time and time again, we look not for the metrics that are important, or the outcomes that matter most, but those that are easiest to obtain.

Exhibit A: the way medical students are evaluated. Some time ago, Ashish Jha asked Twitter, “What makes a good doctor?” The results don’t have NEJM- or JAMA-caliber rigor, but they’re telling; ‘Competent/effective’ ranks fifth, after ’empathetic,’ ‘good listener,’ ‘compassionate,’ and ‘humble’ … even ‘intelligence’ is eighth. And yet, I’d challenge any medical student to tell me, with confidence and candor, that their medical curriculum values those traits above clinical knowledge. I don’t blame my school, but the system; there’s a reason that, of the 759 pages in my First Aid for the USMLE Step 1 book, the social sciences are a succinct 13.

The conversation about post-Flexnerian medicine, competency-based assessment, and holistic evaluation is refreshing. But there are buzzwords thrown around at conferences, and then there are the day-to-day realities—where a clean divide exists between the things that really matter, and the things that are easy to measure. In medical school, clinical knowledge comes before empathy, listening, or compassion, because clinical knowledge is a number. A discrete, objective data point that fits nicely on a bell curve.

Even as I complain about the system, I absolutely understand it. Last block, I scored a 91% in the Medical Knowledge competency. A good, clean, objectively quantifiable 91%. Meanwhile, my peer reviews ranged from ‘sub-optimal’ to ‘above average’ in Integration of Knowledge, and ‘entry-level’ to ‘aspirational’ in Professionalism. The result: I passed Microbes & Immunity, even though I might be terrible (or wonderful) at putting ideas together and working with others.

Perhaps the reality of medical education today is that we simply don’t yet have the tools and evidence to align what matters in learning to what matters in clinical practice. Maybe the informatics platforms aren’t refined enough to reliably identify the ‘well-rounded physician.’ But if that’s the case, then let’s take a moment to erase the buzzwords, look past the illusion, and admit to ourselves what’s really going on: that we’re searching under the streetlights.

Remember Me?

Man … it’s been a while.

When you’re in school enough hours per week to call it a full time job, other things fall by the wayside. Like the cups and plates stacked in my sink. Like the girlfriend I see those one or two times a day I look up from my textbook. And certainly, the blog where I’d naively hoped to chronicle the daily experience of it all.

If anything, the silence on this page in recent months speaks to where life is at right now. Every day, there are new lectures to learn, new cases to cover. And every night, as the clock hits 1:00am and I’ve downed my third cup of coffee, I count the hours till my alarm clock is set to ring and tell myself that I’ll put thoughts to paper another day. It’s always another day, every day.

I’m reminded often of a post I penned a few months ago, wondering why healthcare providers don’t often enough translate their frustrations in clinical practice into innovative solutions:

It’s attention – or more specifically, the scarcity of it. Nobody recognizes the opportunities for creative destruction in healthcare better than the people who spend each day in the trenches of clinical medicine. But after patient care, administrative hurdles, research responsibilities, teaching duties, continuing education, and something that might resemble a personal life, providers have neither the interest nor the capacity to cultivate an innovative spirit.

And that’s exactly it. Make no mistake, I absolutely love medical school. I love drawing out concept maps that tell a story of disease from the etiology to the pathophysiology and clinical manifestations. I love when I’m able to sit with a patient, elicit the right narrative threads, and connect them with what I’ve learned in class to weave an initial diagnosis. I love working with experts across the spectrum of health and wellness as part of a patient care team.

But when I step back for a moment, I realize that the reason I’ve felt a persistent, nagging frustration these last few weeks is that I’ve been so focused on the present, so concentrated on the lecture notes, the flash cards, and the mnemonic devices, so fixed upon what is, that I’ve completely stopped reflecting upon what could be. In the interest of comprehending the things I’ve been taught, I’ve deferred my curiosity about the things I haven’t.

I came to medical school to be a life-long learner—at least, that’s the buzzword they threw around at the interview, and at revisit weekend, and at orientation. But I don’t feel like one, at least not in these last three months. Still, the one piece of advice I do remember from those days of orientation is to stick with the habits and hobbies that make us who we are.  And, by getting back to writing and reflecting, I plan to do just that.


Do No Harm: The Student’s Paradox

This is my first post for ‘Com(med)ore,’ my new blog. Here, I hope to chronicle my experiences as a medical student at Vanderbilt University over the next four years, from White Coat Ceremony to Match Day. In the lead-up to medical school, I’d like to share some of my essays reflecting on my time as an emergency medical technician during my undergraduate years. Thanks for reading; any feedback and comments are welcome!

What happens when medicine’s cardinal dictum meets its steep learning curve?

Primum, non nocere. First, do no harm. This is medicine’s golden rule, every health professions student’s North Star of guidance. For in medicine, there is much that appears futile, much that weakens our foundational preconceptions of ‘right’ and ‘wrong,’ much that offers some distant, plausible benefit beyond the horizon. All this, we justify with the understanding that, if nothing else, we leave our patients no worse off than as we found them.

Except, that is, when the task requires it.

To the novice EMT student, the teaching hospital is a daunting place. Everyone—except you—seems to have a defined task and purpose. The attendings review charts, the residents conduct physical examinations and obtain histories, and the nurses administer procedures and monitor patients. Amidst the structured chaos of the emergency department, it’s hard for a learner to not feel like a weed in the grass, an inessential intrusion lacking roles or responsibilities. In the overcrowded county ED, where beds of agonized patients spill out the exam rooms into the hallways, even observing from a corner means being in the way.

I was only too happy, then, when a voice barked, “You, student, get over here.” I looked up clumsily and, seeing a nurse across the room gesturing in my direction, hastily obliged. Without even a glance away from the computer screen, she thrust a plastic bag of supplies into my hands. “Here, make yourself useful. Bed 23 needs an IV.”

I walked over to ‘Bed 23,’ whose name was Ms. Suarez, an elderly Latino woman whose grandmotherly, pleasant demeanor belied the throbbing pains and swelling in her leg. Recalling our classroom instruction, I recited the didactics in my head. Position the arm. Apply the tourniquet. Arrange your equipment. Flush the extension set. Sure enough, there it was: a bouncy, blue-green line right in the crease of her elbow. I swabbed the site, unsheathed the catheter and mumbled, in a hesitant tone that surely betrayed my naivete, “A little poke; un poco dolor!”

Tensing to subdue the quiver in my hand and heart, I readied myself for the plunge. Just like class. This is just another manikin … except, one with nerves, emotions, and probably, a temper if you don’t get this right. With a deft motion, I pulled back the wrinkled skin and inserted the beveled tip into Ms. Suarez’s arm. Anxiously, I fixed my gaze upon the catheter, hoping desperately for the flash of scarlet that meant a job well done. Nothing—damn. I looked up to Ms. Suarez, her pained, yet forgiving, gray eyes meeting mine as if to say, “There, there.”

And here, I thought it was the healthcare provider’s role to do the caring and comforting.

A band-aid later, I again prepared myself, determined not to let down this frail grandmother who reminded me so much of my own. Place tourniquet. Flush tubing. Palpate vein. Cleanse site. Unpackage catheter. Insert stylette. Bevel down. Aim shallow—not too shallow. Once more, I searched in anguish for a flash in the catheter, but found nothing.

“Dig around in there,” a resident at the next bed advised, “Sometimes, you’ve got to explore nearby to nail it.” My eyes darted from the catheter, to Ms. Suarez, and back. With every additional failed attempt, with each futile dig, I saw her flinch in agony, her lip steadfastly bitten in attempt to mute her expressions of pain.

Finally, head down and tail between my legs, I sheepishly returned to the nurse’s station and admitted that I hadn’t been able to perform the most elementary of tasks. I watched as she, almost effortlessly, placed the IV, my eyes too ashamed to confront Ms. Suarez’s once more. “Don’t sweat it,” the nurse casually remarked, “Some people just have bad veins.” As if the responsibility for my errors wasn’t mine, but the fault of Ms. Suarez and her ‘bad veins.’

We always default to ‘do no harm’; it’s as much a staple of medicine as the white coat, pager, or stethoscope draped over the collar. Yet in the natural learning curve of patient care, to err, to fail, and to hurt are almost inevitable. That first blown IV, the first failed intubation attempt, the first perceptual error by the novice diagnostician—these are the unavoidable costs of developing mastery. If we don’t try and fail on the first patient, it’ll be on the next person, or the one after that; the climb to competency must start somewhere. As reluctant as I was to make further attempts after my struggles with Ms. Suarez, I acknowledged that continually trying—even if it sometimes meant failing—was the only way to eventually emerge a proficient provider.

When doing harm is likely, or probable, or seemingly inevitable, how can we, as students, respond?

First, we can find mentors that don’t berate failure, but comfortably acknowledge and constructively address it. The pressure to perform and the stigma against failure that pervade cultures of healthcare often don’t prevent mistakes, but perpetuate them. As Clayton Christensen said, an organizational philosophy of ‘failure is not an option’ is really an unwillingness to discuss or improve upon failure.

Second, we can ‘bend’ the learning curve through practice. No manikin, drill, or application can truly replicate the bedside experience, but they can approximate it. After my first unsuccessful intubation attempt, my preceptor challenged me to practice the task until I could do it correctly and under time for 100 repetitions. The next attempt, then, was simply my 101st consecutive success; muscle memory and the comfort of experience made the difference.

Finally, and most critically, we can offer our patients the gratitude, humility, and candor they deserve for being our most important educators. Despite our best efforts, harm happens. The best we can do for our patients is to thank them for walking with us up that steep learning curve, so that we can someday provide for our future patients and community the highest standards of care.

In this patient encounter, names, events, and details have been altered and fictionalized to protect patient anonymity.