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Medical Education’s Future Still Bleak: Why, What to Do

Why the System Creates Bad Teaching and Almost Killed My Love of Learning

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by Alec Palmerton, MD in Plan

Let’s be honest: education in medical school is rocky at best. I remember coming to Stanford, a premier institution with a very small medical school class, excited to learn from some of the most brilliant minds in medicine.

Boy, was I disappointed.

Teachers had a difficult time explaining even the most basic concepts, lectures were often disorganized, and very often it felt like the professors didn’t even care.

At first, I was pissed. Why pay almost $100,000 a year to attend a school if the implicit expectation is that you’ll just teach yourself? Were the teachers incompetent, or was medicine really that hard to explain?

Feeling Overwhelmed and Unsupported

The Medical Education System Disincentives Good Teaching

Over time, however, I realized that it wasn’t a problem with Stanford or my teachers, but rather a problem with the entire medical education system. People respond to incentives, and what I didn’t realize as an early medical student was that most of my professors were being actively disincentived to teach by not being paid or promoted based on their teaching.

Put it this way: if you were being paid very good money to work as a physician, were promoted based on your academic research, and weren’t compensated at all for your time preparing lectures, questions, or teaching medical students, what would you do? In a fee-for-service system, where physicians are paid for doing more procedures, do we still wonder why there are many more surgeries per capita in the United States than in other countries where there is no such incentive. The same is true in education, where very few people are paid, and certainly not in a way that is commensurate with what they would make doing clinical activities.

I was talking with one of the ICU fellows recently, an extremely well-liked, charismatic guy who had graduated from MGH, was extremely well respected in the department, and had been heavily involved with education. I asked him, since he had been my attending at one point, whether he would continue to do education, and try to get on any of the educational committees or boards. He took a minute to think about his answer, and said carefully that if it were to happen, he wouldn’t fight it, but that he wouldn’t go out of his way to pursue medical education.

As a first year medical student, I would’ve been perplexed. How could someone who very clearly loved education and was incredibly brilliant/talented at teaching hesitate whether he would want to share those gifts with the world? As a final year resident, I can completely understand where he’s coming from. He has a wife, two children, a new house with renovations, and years of accumulated debt – he would have to fight a lot of self-interest in order to follow his passions in education. Spending his one free day during the week on preparing lectures, doing case series, or other academic projects, has to be balanced with spending time with his family, and his other financial obligations.

Life happens for attendings, too.

Your professors are no different. As a medical student, I felt the system, by providing incoherent/disjointed lectures from disinterested professors seemed like it was trying to beat my love of learning out of me.  Now, as I approach being an attending, I see more and more that it systematically and perniciously saps away the love of teaching from all but the most ardent educators.

So, what can you do?

First, recognize that most medical schools teach and test to the lowest common denominator.  Teachers have no incentive to teach or test you based on themes or principles (I.e. things that actually make sense). Instead, exams focus on memorizing facts, rather than applying principles or understanding connections.

Do not get lulled into a false sense of security that memorizing facts will lead to success on the USMLEs/clerkships/shelf exams.  Everything will change when you take Step 1.  You have to figure out ways to teach yourself, and remember that information, even if it won’t be explicitly tested yet.

Second, use resources that focus on mastery over memorization, and prioritize the application of information, since more and more of Step 1 and Step 2 are focused on the clinical application of principles.

The Yousmle Step 1 and Step 2 Decks are focused not only on the mastery of topics, but also their clinical application.

For example, how would differentiate septic shock from hypovolemic shock by touching someone’s feet?

I can still hear the dry, unimaginative lectures in medical school, listing in bullet point format the different characteristics of hypovolemic vs. septic shock.  Eventually, what I learned instead was to connect the pathophysiology to the presentation in a way that I would never forget it, and also be able to actually USE it to crush my exams.

In septic shock, because the primary problem is vasodilation, there’s an increase in blood flow to the extremities, so they will feel warm, because of this increase in blood flow. In hypovolemic shock, however, because of the baroreceptor reflex, where hypotension causes an increase in sympathetic tone, which causes vasoconstriction, there will be decreased blood flow to the extremities, which will cause them to feel cold.

Just like this simple example, which helped me to correctly identify sepsis in an hypotensive patient when I was an intern, the more that you understand and integrate your knowledge across different systems, the better you will do on your USMLEs and Shelf Exams.

So, even though it’s not your fault that learning medicine is so difficult, it’s your responsibility to learn the body as well as you can, not only for the exams that will determine much of your residency application, but also for your ability to care for patients.

To learn more about the Yousmle Step 1 and Step 2 decks, click here.

What do you think?  Do you think that medical education isn’t broken?  If not, what can we do to fix it?  Leave your response in the comments!

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Want FREE Cardiology Flashcards?

Cardiology is key for impressive USMLE scores. Master cardiology from a Harvard-trained anesthesiologist who scored USMLE 270 with these 130+ high-yield flash cards. You’ll be begging for cardio questions - even if vitals make you queasy.