“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Saturday, April 5, 2008

Putting a comment on blast ...

“Life is best enjoyed when time periods are evenly divided between labor, sleep, and recreation...all people should spend one-third of their time in recreation which is rebuilding, voluntary activity, never idleness.”
~Brigham Young

I received this comment from p3/4md. It is a bit of a rant, but speaks directly to many of my frustrations with some of the medical students that I encounter.
'I know he's only eleven months, but we think he might be a genius.'

Being a third year med student, almost done with my core clerkships, I'd like to comment on this from our perspective, and then, from my perspective.

First: Medical students are quick learners to do what is most efficient. We always have our eye on the end game. In college, it was medical school, in medical school, it is residency.

Let's just forget about the first two years of medical school in this talk, because quite frankly, in my opinion, it has little to do with how the students will act, clinically.
These statements are true. Like many things we do, it is about end game. What I try to stress to my residents is that they are not training to be residents. End game is becoming a physician. in our case an orthopaedic surgeon. Practice like it.
Residency is based primarily on your step I/II scores and your grades, most probably, your clinical grades.

In our Surgery clerkship for instance, our grade is basically derived 50% from shelf exam score, and 50% by your ward attending/resident.

We as med students know that if we show up on time, and blend in with our peers, we're going to get 80-85% for our clerkship grade. If our resident/attending likes us, and we're actually halfway competant and helpful, we'll get a grade of 85%-90%. If we're lucky, and the attending is nice, we'll get a grade in the 90's.

If we bust our behinds, work hard, and become advocates for our patients, we're still going to ride that luck factor to get a grade above 90% (which is honors.) I've had attendings/residents praise me, say they've learned more from me than they thought they taught me, and still give me an 87.5. Tell me, what do you expect of me to do well? I've had residents and attendings put down "the best medical student I have ever had" etc. etc. in the their comments, and still give me a 95%, why not a 100%? If I performed above expectations, and was the best you have ever seen, doesn't that logically warrant a grade of 100%?

Granted, I know no one is perfect, and some can be more stringent than others, but seriously, give me a break. I've had (in college and other areas,) people say "I don't believe in giving 100's, no one is perfect." Well, by that same logic, if no one is perfect, and 100% can never be achieved, why have the score there to begin with??? In that case, should it not be assumed that 100% is "just less than perfect" ??

Anyway, enough with that rant :) The point is, in order to do really well in our clerkships, the effort required can be overwhelming. The extra effort required to get into the 90's for our grade is tremendous, and many times, regardless of how well you perform, there's still a significant chance that you won't get an exceptional grade.

We all know this. We've all been there. We know that attending "He's a jerk.. it's not worth it".

In the face of studying for a shelf exam or the myriad of ungraded pass/fail papers that you have us write, I am intelligent, I can balance my time.

Why do I do this? Well, I know that if I do well on the shelf, the 5-10% of the clinical grade that may be impossible to receive, will be easily superceded. Enough said.

So why should I bust my hump.. when I can study more, and make up for it on exam, and then some.
I think this is what really frustrates me. It is one of the reasons that I posted previously about grade inflation. When I look at a resident and a student, I don't look at hours spent in the hospital or the kiss @$$ stuff. Most of us can see through the false smiles. What I look for is someone who is worried about doing the next right thing for both patient and team.
Consider the following (and this isn't me being arrogant or whatever.. this is just how it is):

Unfortunately (or fortunately, depending on how you look at it) my parents instilled a good work ethic in this young doctor. I care.. I really do. I work hard, examining patients, talking to them, building rapport, etc. I showed up 30 minutes before everyone else to preround on my patients, even though no one would ever hear my morning report. Yes, I can hear murmurs that residents can't pick up. Yes, I can put in IV's faster/more efficiently than my interns. Yes, when a patient is desat'ing, I have the ABG kit in my hand, and am feeling for a radial pulse before my resident says "we need an ABG." Yes, I've out diagnosed my resident and my attending. Yes, I paid attention, I read alot, and I understood. If i'm thrown in an ICU/SICU, I can navigate my way around, manage patients, and be confident. No, I know I'm not an attending, I know my limitations, but I also know that they're far beyond that of my peers.

Do I think that's because I am smarter, or better than my peers? No. It's because I know I worked harder to know this. And I damn well have the right to be proud of it. :)

Why did I learn this stuff? Because I think that doctors should graduate and know how to save people's lives. To be useful, and not just know a bunch of facts.

So I bust my hump, etc. And I am proud of myself..But then, I look at a peer of mine:

She shows up late, and does the bare minimum. It's a big month if she actually talks/puts her hands on a patient. She's "going into optho... why should she care?" She leaves early.. and studies while the attending is speaking.

No attending/resident is going to bad mouth her.. they're all too nice. They'll say something benign in her evaluation, and give her a grade of ~85. Then, she'll do well on the shelf.. and get honors.

Her transcript says honors
My transcript says honors.

To the residency world,.. we are equal.

I know more, I worked significantly harder.. but in the end, what difference did it make for the "end game?"

Yes, ideally, we all should be looking for the benefit for the patient.. and should learn to be the best that we can be.. Well, I say fiddle sticks to that.

The most important patient in this scenario is yourself. Who is going to sacrifice in a selfless way before themselves. Yes, there are a few.. but that is certainly not the majority.

So we are in a constant battle. And the grade is king, it truly is.
Although grade is king, you should always do what is right. End game is being a physician.
So, after a year of dealing with this junk.. yes, I now sometimes I find myself debating if I should put that extra effort in. I do it anyway, because I think it is the right thing to do. I feel obligated. I know I am not well accompanied in this thinking.

Most of us learn to just "get by".. and this is evident by the strength of the interns. Most of the interns I've encountered are babbling fools. Why? Because they "just got by" in medical school. It creates a vicious cycle. It sets the stage for residency.

In the wake of the recent match.. I feel bad for the folks who have to decide on these candidates. They all have honors.. they all did well. How do they judge work ethic and good clinical skills? It's almost impossible.

*sigh* what is ahead in the future..

p3/4md, I love this comment because I can feel your frustration with the system and the abuses of the system by your peers. The hardest thing for a residency selection committee to do is find people who have good work ethic and clinical skill. It is one of the reasons so many programs take people who rotated with them. Hang in there young padawan.

“The self-confidence of the warrior is not the self-confidence of the average man. The average man seeks certainty in the eyes of the onlooker and calls that self-confidence. The warrior seeks impeccability in his own eyes and calls that humbleness. The average man is hooked to his fellow men, while the warrior is hooked only to infinity.”
~Carlos Castaneda


Anonymous said...

First of all, thanks for the blast'aroo over there.. Makes me feel proud *tear*.

I wanted to shout and give the perspective of some of the medical students.. because I think the whole problem with the residents (beyond the whole 80hr work week,) first begins with the medical student :)

You can see my frustrations brewing. I've posted before on here a few blogging's ago. I gave myself the name anon#2. I believe my rant on that post was about the fact that my 1/2nd year grades lacked the luster of my clinical grades. And yes, I did read your blog on the grade inflation.. it speaks directly to me.

I'm curious to hear about the grade distribution at my school as far as the clinical honors is concerned. I'm sure that my administration will not willingly give me that info. They're never helpful :)

It's a shame it is so cold *brrr* up by you...I might hesitate in my application over there ;) I think we'd have a fun time actually interviewing, regardless if you liked me or not.. oh yeah, and that implies that you all would grant me an interview :)

Anyway.. love the highlander reference.. and look forward to some more interesting posts.


Anonymous said...

I can hear the world's smallest little violin playing the score for p3/4md's tragedy he calls life.

Give me a break, yeah, med school was hard because of the politics, but you know what, that's pervasive throughout life.

This seems like the type of student who's arrogance and over-enthusiasm is a turn off to the residents and attendings that work with him.

When I look for someone I want to work with the #1 trait is that they are cool and easy to get along with. The fox hole criteria. #2 is that they work hard and DON'T COMPLAIN. #3 is that they know their stuff.


Anonymous said...

Oh whatever man. It was a commentary on the problem with attitudes of students today. Not about complaining how hard it is *for me*. At no point did I say "I had to work hard because of politics... it's not fair." I said something more like "I work hard 'cause I should, and no other reason.. Sometimes I think about how the system stinks... But I deal with it anyway." In fact, that actually goes quite well with your #2, so stop being so bitter, it's not becoming of you :)

Also, it's mostly not politics. If I were saying that people had to kiss @$$, it'd be a different story.

Also, #1, I hope we cross paths some day.
#3-- Not going to say anything.. it's not my place.


BoneDoc23 said...
This comment has been removed by the author.
Someonetc said...

p3/4md: i could tell this was a rant of frustration.

it ain't cold up here. btw

oh, that was a star wars reference not a highlander reference :)

D: you are correct in saying that students that give off "arrogance and over-enthusiasm" tend to turn off the evaluators. i think i would order you traits differently though
1. know their stuff
2. they work hard and DON'T COMPLAIN
3. trait is that they are cool and easy to get along with. The fox hole criteria.

Anonymous said...

yeah.. I know about the star wars reference ... I was referring to the "end game" part.. but then i realized the poster you posted wasn't that. Yeay for cell phone text browsers :)

BTW, pretty much everything is on your blog makes reference to star wars.. :O) I guess that's cool ;) haha.. I love star wars.. Can watch IV/V/VI many times over.. but hans whatever his name is.. irritates me.


Anonymous said...

It is too bad that medicine has grown
the agenda of how best to get the brass ring. Medicine is about the
patient, not the doctor. Maybe we
should dump the scoring system, and focus on some sort of objective evaluation, "evidence based", if you
will. Medicine is going in that direction anyway.

Anonymous said...

Моя история из жизни: мы как-то с мамой ехали в маршрутке,( мама спец по всем видам мяса на глаз определяет что это), на остановке залазит подвипывший мужик с куском свежака в одноразовом пакете. Едем. Маршрутка резко тормозит,мужик по инерции бежит вперед и пакет рвется ,оттуда выпадет свежак ,дальше мамины слова- " Мужчина,у вас вымя выпало!" я медленно сползаю под сиденье , пассажиры ржут, мужик красный - выбегает на следующей остановке :)))

Anonymous said...

Вообще да, мне это напоминает ситуацию с выборами призидента Украины. Выборы прошли, а не факт, кто призедентом будет. Да, блин, демократия. Хех, простите за флуд небольшой, навеяло просто.