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Medical Education, Medical Schools, Stanford News

Medical students start “transformational” journey

Medical students start "transformational" journey

With the help of Lars Osterberg MD, MPH, and Dr. Neil Gesundheit, MD. they give Brandon Turner  his official white coat at at the Stanford Medicine White Coat and Stethoscope Ceremony on Friday, August 22, 2014,at Stanford School of Medicine.  ( Norbert von der Groeben / Stanford School of Medicine )

The new school year has begun for students across the country, including Stanford’s 90 first-year medical students – who started class on Monday and spent last week at orientation activities anxious and excited for the  journey to finally begin.

To help the students prepare, faculty talked to them about the emotional and academic challenges of medical school and emphasized that it can be metamorphic and, not surprisingly, somewhat stressful. “They are seeing life and death,” said one faculty member at orientation, who added that medical school “is a transformational time the likes of which I don’t think you see in any other level of education.”

The week of preparation concluded with the traditional stethoscope ceremony, which I wrote about in an article published online today. The ceremony symbolizes the importance of the personal connection between doctor and patient, and during the event each student walks across the stage to accept their stethoscopes. As Laurie Weisberg, MD, president of the medical center alumni association, told the students:

The great thing about the stethoscope is you have to be close to your patient to use it. This is your chance to truly interact with the patient. You are listening to what the patient has to tell you.

In his address to the students, Dean Lloyd Minor, MD, told them the four-year, or longer, journey would change the way they see the world and that they “will learn some of life’s most valuable lessons from your patients.” He also highlighted some of the demographics of the new class:

Fifty-one percent of you are women; 15 percent of you are from communities underrepresented in medicine; 21 of you were born outside of the U.S., coming from China, Columbia, India, Vietnam, just to name a few. You come from a diverse and wide range of universities — 10 of you from Stanford, 13 from the Stanford of the East [Harvard]. Eighteen of you already have a master’s or a doctorate, and many of you have already published research, participated in varsity athletics, shined in the arts and contributed to your community.

Previously: Abraham Verghese urges Stanford grads to always remember the heritage and rituals of medicine, Top 10 reasons I’m glad to be in medical school and “Something old and something new” for Stanford medical students
Photo, of Brandon Turner receiving his official white coat at a ceremony last Friday, by Norbert von der Groeben

Medical Education, Medical Schools, SMS Unplugged

Buzzwords in medical school

Buzzwords in medical school

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

Learning in medical school often feels like learning a completely new language. There are numerous acronyms (OPQRST, CAGE, etc.) and molecules (IL-1, TGF-beta, etc.) and more. But most striking to me are two particularly ubiquitous buzzwords: “high-yield” and “protected time.”

I feel like I heard both these terms – and particularly the former – thrown around every single week of this past school year. “High-yield” has been used to refer to, as you might guess, the material that yields the highest amount of gain – i.e. for us students, it’s the material that’s going to show up on our tests. This term pervades not only conversations among classmates but also study materials. First Aid – one of the main Step 1 book resources – takes pains to highlight “high-yield” concepts, and Pathoma – another Step 1 resource – goes even further, identifying ideas that are not just “high-yield” but also “highEST-yield.”

This idea of focusing on “high-yield’ concepts bothered me at first and continues to bother me a little bit today, largely because my classmates and I often determine for ourselves what is “high-yield” and what is “low-yield,” dedicating our study time to the former and ignoring the latter. The worst part is that we may be ignoring information that may be “low-yield” in the context of exams but actually “high-yield” in the context of patient care. The flip side of this is that we only have a certain number of hours in the day; perhaps it makes sense for us to be judicious about what we focus our attention on?

Another phrase that has been widespread in medical school is the term “protected time.” I started hearing this during the very first week of medical school, when we had part of our afternoon off for “protected study time.” Later in the year, I attended a panel featuring five pediatricians. The question of work-life balance came up, and one of the doctors mentioned that she carved out “protected time” to be with her 2-year-old daughter every evening between 5 and 7 PM. This statement was met with general appreciation but also minor panic. There are so many aspects of our life that deserve “protected time” – family, friends, time for creativity, and more – and yet, again, there are only 24 hours in a day. Where does “protected time” start and end? And what does it include? And is it really reasonable to expect “protected time” when there are so many patient -care demands for physicians to navigate?

As I’m about to enter my second year of medical school, some of my questions remain unanswered. How can my classmates and I make sure to learn medicine well enough and thoroughly enough that we can both meet and exceed expectations in patient care? Is identifying “high-yield” material an ineffective, shortsighted approach? And how do we identify what falls under “protected time”? Here’s hoping I figure out this tentative balance during this upcoming year!

Hamsika Chandrasekar just finished her first year at Stanford’s medical school. She has an interest in medical education and pediatrics.

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From August 11-25, Scope will be on a limited publishing schedule. During that time, you may also notice a delay in comment moderation. We’ll return to our regular schedule on August 25.)

In the News, Medical Education, Medical Schools, Stanford News

Rethinking the traditional four-year medical curriculum

Rethinking the traditional four-year medical curriculum

In an effort to meet the needs of medical students, physicians and patients, a number of universities are considering ways to shorten the traditional four-year medical curriculum without compromising quality of care. The New York Times reports that “a recent, unpublished survey of 120 medical schools, conducted by the New York University School of Medicine, found that 30 percent were considering or already planning to start three-year programs” and notes that the American Medical Association is among those advocating for such innovative approaches. Denise Grady writes:

More than a dozen medical schools already have programs to move students more quickly from the classroom to the clinic, but by shortening premedical studies rather than medical school. Among them are Albany Medical College, Northeast Ohio Medical University and the medical schools at Boston University, Drexel, George Washington, Howard, Jefferson, Meharry and Northwestern. Gifted high school seniors or early college students are guaranteed admission to medical school if they perform well during freshman year of college. Combined bachelors/M.D. programs have been around for half a century, but these students complete both degrees in six or seven years instead of the usual eight.

“I absolutely think it’s doable,” said Dr. Charles G. Prober, senior associate dean for medical education at Stanford School of Medicine, which is considering such a program. Well-designed programs to accelerate doctors’ training “don’t send them out prematurely, but send them out with adequate tools, recognizing that they will grow,” said Dr. Prober, who writes and speaks extensively on medical education reform. “Real learning begins when you are actually beginning to take care of patients, doing what you were trained to do.”

While research is scant, a few studies show promising results. Comparisons of graduates of three-year programs at the University of Calgary and McMaster University to graduates of four-year Canadian medical schools found “equivalent performance.” And a small study at Marshall University in the 1990s, which for almost a decade incorporated fourth-year requirements with the first year of residency in family practice, declared it a success for “carefully selected candidates.”

Indeed, educators make clear that not all students can handle the accelerated curriculum. Dr. Prober notes that with the explosion of medical information, students more than ever must learn to work smart, figuring out what they need to memorize and how to find out the rest. Part of the education process today is learning to collaborate and tap the expertise of others.

Previously: A closer look at using the “flipped classroom” model at the School of Medicine, Combining online learning and the Socratic method to reinvent medical school courses, Rethinking the “sage on stage” model in medical education and Stanford professors propose re-imagining medical education with “lecture-less” classes

Medical Education, Medical Schools

Does medical school debt cause students to choose more lucrative specialties?

Last week, we re-published a Wing of Zock post on medical school debt. Over on that same blog, Julie Fresne, director of student financial services for the Association of American Medical Colleges (AAMC), takes issue with one of the original writer’s points: that concern over medical school debt affects students’ decision about specialties. Fresne writes:

While many claim that debt leads medical students to choose more lucrative specialties, AAMC research indicates that debt does not play a determining role in specialty choice for most students. The report, “Physician Education Debt and the Cost to Attend Medical School,” includes a section outlining evidence on the “minor role of debt in specialty choice.” Studies show that specialty choice is a complex and personal decision involving many factors. Some students with high debt do in fact choose primary care and AAMC data suggests that there is no systematic bias away from primary care specialties by graduates with higher debt levels…

Previously: It’s time for innovation in how we pay for medical school, 8 reasons medical school debt won’t control my life and Will debt forgiveness program remedy doctor shortage?

Medical Education, Medical Schools

It’s time for innovation in how we pay for medical school

handstiedThere is a tremendous amount of handwringing among students, workforce researchers, and medical school deans about the record amount of debt that medical students incur – more than $175,000, according to the Association of American Medical Colleges. This has unintended consequences, including student selection of more lucrative specialties and placing medical education beyond the reach of low-income and minority students. The average household income for a matriculating medical student is more than $110,000 per year. We must get serious about reducing this debt. A talented medical workforce is a national priority.

[Louis Sullivan, MD,] authored an op-ed piece published in the Washington Post on June 9, 2014, “The Outrageous Cost of Working in Medicine.” In the piece, Sullivan discusses this challenge from both diversity and equity perspectives. He wrote, “You shouldn’t have to come from a wealthy family (or be willing to tolerate a lifetime burden of debt or the deferral of buying a home and starting a family) to go into health care.” Yet 60 percent of medical students hail from families with incomes in the top 20 percent of the nation. Meanwhile only 3 percent come from families with incomes in the lowest 20 percent.

National policymakers believe that, because professionals with medical degrees have high earning potential, they should therefore be in a position to repay loans in excess of $250,000 to $300,000. It simply hasn’t worked out that way for many talented young people who have turned away from the health professions altogether. The “gentrification of health care” serves no one well.

(In this post, I’m not talking about financing graduate medical education – GME – which is funded by Medicare, Medicaid, and academic institutions. In March 2001, Joe Newhouse, PhD, and Gail Wilensky, PhD, published an article in Health Affairs on GME asserting that it does not meet the economist’s definition of “public good:” benefits that are equally available to everyone that cannot exclude consumers from consumption. In the same issue, Uwe Reinhardt, PhD, and Adepeju Gbadebo, MD, pointed out that if GME is indeed a public good, society must also be willing to pay reasonable costs. In return, the leaders of academic medicine must inform society what each component of their social mission really costs, and be willing to be held more formally accountable for their use of the resources.)

What options exist to decrease undergraduate medical school debt?

Decrease medical school tuition and increase efficiencies. Tuition is actually a small part of most medical schools’ revenue. Most revenue comes from clinical services, transfers from teaching hospitals, and research funding. Although less than 5 percent of total revenue at most schools, tuition payments are still significant enough that their loss would impair the institutions’ ability to sustain their missions. There is significant variation in medical school tuition between and among public and private institutions. We could analyze the costs of education to determine if efficiencies can be realized using shared core faculty, distance learning, and MOOCs (massive open online courses) “to inform society what each component of their social mission really costs, and be willing to be held more formally accountable for the use of resources,” per Reinhardt and Gbadebo.

Make medical school free and government-funded. Peter Bach, MD, and Bob Kocher, MD, propose that medical school should be free. In their May 28, 2011, New York Times editorial, they advocated a new way of paying for medical training to address the looming shortage of primary care doctors and to better match the costs of specialty training to the income it delivers. They proposed that the government pay medical school tuition and then defray the costs of $2.5 billion per year by charging doctors for specialty training. This is not the first proposal to recommend making primary care training more accessible. The National Health Service Corps helps doctors repay their loans in exchange for a commitment to work in an underserved area, but few doctors sign up.

Make medical school more affordable for students committed to public service. The Wall Street Journal on April 22, 2014, published an analysis of federal student loan debt forgiveness programs, which increased nearly 40 percent in the past six months. One program, “Pay As You Go,” requires borrowers to pay 10 percent a year of their discretionary income – annual income above 150 percent of the poverty level – in monthly installments. Under the plan, the unpaid balances for those working in the public sector or for nonprofits are then forgiven after 10 years. At least 1.3 million Americans are enrolled in the program.

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Events, Medical Education, Medical Schools, Stanford News

Abraham Verghese urges Stanford grads to always remember the heritage and rituals of medicine

Abraham Verghese urges Stanford grads to always remember the heritage and rituals of medicine

Dr. Abraham Verghese, MD, MACP a speech at the Stanford University School of Medicine Convocation on Saturday, June 14, 2014. ( Norbert von der Groeben/ Stanford School of Medicine )

More now from Saturday’s commencement ceremony, courtesy of my colleague Tracie White, who recounts the sentiments of the day in a medical school news story. During the event, White reports, graduates reflected on their years of hard work, thanked their loved ones and faculty members for their support, and took their first steps as doctors.

During his opening remarks, School of Medicine Dean Lloyd Minor, MD, told the new doctors, “Have the courage to follow unmarked paths… Listen to your patients. They are trying to tell you the diagnosis… Above all else, listen to your heart.” He was soon followed by Stanford physician and best-selling author Abraham Verghese, MD, who delivered the keynote speech and urged graduates to look to the time-honored role of the physician-patient connection and learn from this relationship. As White wrote:

[Verghese] began his remarks with words of warning, noting that soon-to-be-published research shows that medical students spend as much as five to six hours per day in front of the computer during their clerkships.

“That just astonishes me and worries me, and you are not doing it by choice, but because that has become the nature of our work,” he said. “You will need courage and determination to push back when things detrimental to your time and your care of the patient are being thrust at you. Electronic medical records don’t take care of patients: You and our amazing colleagues in nursing and the other health-care professions care for patients.

“People take care of other people,” he said to loud and long applause from the audience.

Both heritage and rituals, like the ritual of commencement, play an important role in the career of a physician, he said.

“You are also participating in a timeless ritual… when you get to examine a patient. You are in a ceremonial white gown. They are in a ceremonial paper gown. You stand there not as yourself, but as the doctor. As part of that ritual they will allow you the privilege of touching their body, something that in any other walk of life would be considered assault…

“The ritual properly performed earns you a bond with the patient… The ritual is timeless, and it matters.”

More photos from the day can be found in this gallery, published earlier on Scope, and on the medical school’s Flickr page.

Previously: Stanford Medicine honors its newest graduates, Congratulations to the Class of 2013!, Stanford medical school alum fulfills lifelong dream to participate in commencement ceremony and In commencement address and Atul Gawande calls for innovation around “entire packages of care”
Photo by Norbert von der Groeben

Medical Education, Medical Schools, Stanford News

Medical students take time to thank their patients

Medical students take time to thank their patients

thank you tree - smallWith their heavy academic workloads and the constant demand to keep up with the ever-growing body of medical literature, one might question whether medical students have time to learn and absorb the importance of developing the human connection vital to the doctor-patient relationship. Here’s something that provides strong evidence that they do: A group of fourth-year medical students here started a project to thank patients for being their most important teachers.

In today’s Inside Stanford Medicine, I write about the project, which featured 35 anonymous thank-you cards from medical students arranged into a display for the recent Medicine and the Muse Symposium. Some cards touch on life and death issues, some focus on the importance of hands-on medical training, and others express simple appreciation of the human bond. Reading over these heartfelt letters, it’s clear that the students recognize that the patient-doctor connection is key to their medical education. Here’s a sampling:

I will always remember that you asked me for an ice-cold Slurpee from 7-Eleven in broken words when you finally gained consciousness and spoke to me. I will never forget your gentle but firm nod expressing that you wouldn’t want artificial feedings prolonging your life… Taking care of patients like you and helping them in times of need makes medicine worthwhile… You taught me how to be a good physician and I will always remember you.”

Thank you to the patient with vasculitis and related short gut syndrome for sharing your physical pain as well as worried for the future with me. Thank you to the former physician with mental health concerns for teaching me humility. Thank you also to your families for teaching me about the impact of illness on your lives as well.

Thank you for reminding me why I chose to do medicine. For showing me that we can improve medical care further. For you and future patients.

Previously: Medical students and author Khaled Hosseini share their muse with Stanford community and Reality Check: When it stopped feeling like just another day in medical school
Photo by Jia Luo

Events, Medical Education, Medical Schools, Stanford News

Stanford’s senior associate dean of medical education talks admissions, career paths

Stanford's senior associate dean of medical education talks admissions, career paths

Okay, so you want to go to med school. Let’s talk! Last month at Med School 101, Charles Prober, MD, senior associate dean of medical education, got serious with a group of aspiring medical professionals who all happen to be high-school students. (The annual event brought 140 teens from 10 local high schools to try on the role of med student for a day.)

In his session recorded in the video above, Prober discussed the wide range of possibilities a person with an MD can pursue, including patient care, research and education. He also described the many factors the School of Medicine‘s admissions team considers when selecting candidates – 7,500 applied for 90 spots last year – and described how MCAT scores are only part of the equation. “We look for the distance traveled,” Prober said. And that distance can include non-medical interests: “We want to attract people into medicine who love history, English and computer science” as well as medicine, he explained.

Previously: High schoolers share thoughts from Stanford’s Med School 101, At Med School 101, teens learn that it’s “so cool to be a doctor” and A quick primer on getting into medical school

Events, Medical Education, Medical Schools, Stanford News, Technology

Using technology and more to reimagine medical education

Using technology and more to reimagine medical education

Over on The Health Care Blog, Michael Painter, MD, JD, shares his thoughts from a recent meeting at Stanford’s medical school inviting medical education leaders to debate big questions in their field. Painter, a senior program officer at the Robert Wood Johnson Foundation, explained that meeting participants discussed ways that educators can use technology and other tools “to help create a durable culture of health for all.”

From the post:

In 2013 we extended a $312,000 grant to Stanford Medical School that will support work by five medical schools, Stanford, Duke, University of Washington, UCSF and University of Michigan, as they create a consensus knowledge map of the critical things medical students should learn.

Why a knowledge map? The simple answer: because there isn’t one, and we need one if we’re going to build massive core online medical education content.

Why change now? There’s building pressure on fortress academia: pressure to push health care toward high value, pressure for health care to center itself on the patient rather than the professional, and pressure from technology, specifically the ability to move previously closely held knowledge of the expert more efficiently to the learner.

Here’s where this mapping effort also starts to get interesting. It wouldn’t be that surprising if these education leaders ticked through all the reasons why change is too hard—why it can’t or won’t happen. Instead something marvelous is happening: they’re challenging each other to examine the time they spend with their students—asking if they ignite the kind of passion in their learners that others ignited in them.

An even more hopeful sign—these leaders want to connect the teaching of new healers—from the beginning—with the key partner: the patient. Their early reimagining is fixed on patient and story.

Previously: A closer look at using the “flipped classroom” model at the School of MedicineCombining online learning and the Socratic method to reinvent medical school courses, Using the “flipped classroom” model to re-imagine medical education and Stanford professors propose re-imagining medical education with “lecture-less” classes

Medical Education, Medical Schools

Using digital resources to redefine the medical education model

iPad_032514Today on MedCrunch, Stanford medical school alumna Stesha Doku, MD, examines how digital resources can enhance the traditional medical school curriculum to ” help health-care professionals succeed in their goals to deliver quality care.” Highlighting online learning sites such as PodMedics, which offers medical and surgical video tutorials, Doku writes:

What we gain from the growth of such applications and more general sites such as Khan Academy is that the physical classroom is becoming less relevant. It’s not so much a question of the classroom being not enough, but rather if the classroom is the correct place to deliver our learning materials in the first place. If so, are we delivering distilled and most importantly relevant information?

While we value those who are ‘smart’ in medicine, we must make more effort to value those who can translate their knowledge into improving outcomes and progressing our field. This may mean spending less time on acquiring knowledge that has no application. This may also require spending more time practicing application.

As reported previously on Scope, the School of Medicine is developing the Stanford Medicine Interactive Learning Initiatives, which utilizes the “flipped classroom” model to make better use of the fixed amount of educational time available to train doctors.

Previously: Social learning in a medical photo-sharing app for doctors, A closer look at using the “flipped classroom” model at the School of Medicine, Combining online learning and the Socratic method to reinvent medical school courses, Using the “flipped classroom” model to re-imagine medical education and Rethinking the “sage on stage” model in medical education
Photo by Stanford Ed Tech

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