Published by
Stanford Medicine

Category

SMS Unplugged

Medical Education, Medical Schools, Medicine and Society, Research, SMS Unplugged

Research in medical school: The need to align incentives with value (part 3)

Research in medical school: The need to align incentives with value (part 3)

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

This is the final post in a three-part series on research in medical school. Parts one and two are available here.

confusion-311388_1280In my last two posts, I explored the research paradigm of American medical training. The takeaway was that research requirements may create inefficiencies that have a host of consequences, including an unnecessarily long training process, a potential physician shortage, and an underutilization of talent.

In this post, I’ll lay out a vision for a training process that can produce a more effective physician workforce. The role of a physician has changed over time, and the education system must evolve to keep up. I’ll consider three topics: what students should get out of medical training, how schools and residency programs can help them do it, and how the system at large can enable schools to make changes.

What should students get out of medical training?

First and foremost, medical training should produce doctors who have a strong understanding of human health and disease and have the clinical skills to translate that understanding into patient care. The goal should be to produce good clinicians – that’s what the vast majority of doctors will focus on in their careers.

With that said, I accept the premise that medical training is not exclusively about clinical skills. Physicians are bright, capable individuals, and are uniquely positioned to improve the health status of their patients by other means. Schools should empower their students to pursue those opportunities. For the reasons I discussed in my last post, medical schools have decided that the primary way to do that is through research.

Research is one way to push extraordinarily important advances in medicine, but it isn’t the only way. Doctors can also improve their patients’ health by taking on roles in community health, policy, entrepreneurship or management, among others. These involve many of the same skills and techniques as research, but medical trainees don’t get exposed to these opportunities. We should.

How can schools fulfill this mission?

So how can the education system make this happen? At some point, whether it is in college or medical school, students should be given the flexibility to explore multiple domains of medicine and health care. They should then be able to pick the one or two that fit their interests and pursue them in more depth. Many students will choose to do research, while others will select other specialties. If students explore these opportunities and decide that they would rather focus on being an excellent clinician, that should also be doable.

This would allow physicians to become more effective leaders and decision-makers in the health care system. The traditional training process treats medicine as a universe of clinical practice and research, but the physician workforce has unfulfilled potential across a spectrum of other fields.

Continue Reading »

Medical Education, Medical Schools, Mental Health, SMS Unplugged

Free from school

Free from school

SMS (“Stanford Medical School”) Unplugged is 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

Editor’s note: After today, SMS Unplugged will be on a limited publishing schedule until September.

girls running

Summer. It beckons with strawberry warm rays of sunlight, afternoons spent splashing in a pool, and the joys of watermelon-flavored popsicles. We, second-year medical students around the country, look out our windows and see children, newly freed from school, frolicking in the playground next door – and feel miserable. For this is the time when we are experiencing the worst of medical school.

We have completed the pre-clinical curriculum, some of us barely crawling across the finish line. We have spent weeks cramming for the USMLE, an exam described in no softer terms than “the most important exam you will take in your life.” And we are becoming familiar with a new kind of anxiety as we prepare to enter clinics for the first time. Or, rather, my classmates are – I chose to take time off between second and third year.

In the midst of Stanford-high expectations for our professional performance, we are seldom taught exactly how to take care of ourselves. I knew that I needed to change something halfway through second year when I found myself outlining a novel instead of studying during finals week. I nearly failed two exams. But I was happy.

I felt satisfied.

And so, I set about finding a way to incorporate more of writing into my medical school experience. Stanford has funding called Medical Scholars, which is set aside for every medical student to take a year off to work on a significant project or research experience. Their office willingly helped me apply for and receive this funding to work on my novel full-time for a year. I can’t imagine this level of support for an artistic endeavor from any other medical school. And so very soon, I too will be frolicking in the grass, newly freed from school.

Continue Reading »

Medical Education, Research, SMS Unplugged

Research in medical school: The need to align incentives with value (part 2)

Research in medical school: The need to align incentives with value (part 2)

SMS (“Stanford Medical School”) Unplugged is 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.

This is the second post in a three-part series on research in medical school. Part one is available here, and a third post will run on June 24.

5713991403_99bbdea4e1_zIn my last post, I discussed points brought up by Ezekiel Emanuel, MD, PhD, and John Ioannidis, MD, about research in medicine. The takeaway was that students are strongly incentivized to do research during their training, but those incentives don’t necessarily reward high-quality work. Furthermore, they don’t directly contribute to clinical skills and becoming an effective practitioner. As a result, students may be spending time and effort on projects that fail to maximize value for both themselves and for the medical system at large.

This inefficiency has several consequences. At the individual level, it means students spend more time in training (arguably 30-40 percent more), accrue more debt, and lack the opportunity to pursue other interests. At a societal level, it may contribute to the growing physician shortage and potentially limits the productivity of highly talented and well educated people.

The stakes are high when it comes to designing a system of medical education. After my last post, I spoke to several other medical students about the subject, and many of them felt that research requirements don’t align with their eventual goals. This got me thinking about how we can improve things, but before proposing any solutions, it’s important to understand the mentality that led to the status quo. So in this post, I want to delve deeper into why there are such strong incentives for research in medical training.

In reading and thinking more about the subject, I’ve identified four reasons. The most commonly cited one is that research is a means to a pedagogical end. It’s a way to teach students how to think critically about a problem, analyze available solutions, test those approaches, and then synthesize the resulting information. It’s the scientific method at work, and doctors have to use that method every day.

While true, this alone doesn’t justify medical training’s emphasis on research. It’s possible to develop those same skills through many intellectual pursuits, whether it’s working on a policy platform, developing a health education and outreach program, or even working in a corporate job, among other possibilities.

The second reason is that medical schools are typically part of a research university. As the name implies, one of their primary purposes is to do research – institutional prestige relies heavily on academic output. As members of this community, medical students are expected to participate.

But once again, this line of thinking doesn’t entirely explain why medical training should prioritize research to such a great extent. Consider two other professional schools at a university – business and law. Most students in these programs go on to become practitioners (just like most medical students go on to become practicing physicians). Students have the opportunity to conduct research, but the emphasis is on pursuing extracurricular activities relevant to their career plans.

Continue Reading »

Medical Education, Medical Schools, Research, SMS Unplugged

Flip it up: How the flipped classroom boosts faculty interest in teaching

Flip it up: How the flipped classroom boosts faculty interest in teaching

flipped classroom

SMS (“Stanford Medical School”) Unplugged is 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.

Recently, the flipped classroom — a model of instruction in which didactic content is delivered outside the classroom (usually online), and in-person class time is used for active learning — has infiltrated the educational landscape from kindergarten to professional school.

As a current medical student, I generally agree with advocates for using the approach in medical education. For example, Stanford’s Charles Prober, MD, senior associate dean of medical education, argues in a New England Journal of Medicine commentary that the opportunity for enhanced time-efficiency, student self-pacing, and classroom time freed up for more interactive learning make the flipped classroom a potentially attractive approach for educating physicians. I say “potentially” because, like anything else, the flipped classroom is a good approach only if it is done well. For me as a learner — even a modern, Millennial learner — I’d much rather attend an engaging lecture or study a well-written textbook than watch a lousy online video or struggle through a poorly facilitated interactive classroom session.

So I have to admit I harbored some skepticism when, about about a year ago, Prober invited me to become involved the Re-Imagining Undergraduate Medical Education Initiative, an ambitious project to create a new, flipped classroom-based microbiology and immunology curriculum in collaboration with four other U.S. medical schools, which Scope covered last year.

Although I was excited to have a role in such a large-scale project, I worried that the hype of the flipped classroom trend would overshadow what I thought should be the priority: training our future doctors with the highest quality education — not just the flashiest.

Happily, my worries have proved unfounded. I have seen the faculty and staff from the five schools work tirelessly to produce an impressively high-quality final product. In fact, I have even come to believe that the flipped classroom model intrinsically helps incentivize medical faculty members to prioritize teaching.

Continue Reading »

Medical Education, Medical Schools, SMS Unplugged

An extra year of medical school? Sign me up

An extra year of medical school? Sign me up

SMS (“Stanford Medical School”) Unplugged is 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. 

sandglassesThe process of training to become a physician is a complex and mysterious process to most outsiders, but there are two things that everybody seems to know: 1) how expensive it is, and 2) how long it takes. (One of the first things people ask when I tell them I’m a first-year medical student is, “So, how many years do you have left?”)

Because these issues represent major barriers to entry to the medical profession, some medical schools have begun piloting MD degree programs that are designed to be completed in three years rather than the traditional four. The benefits are easy to see: By shortening the training by one year, students save on a year of expensive medical school tuition and are also able to contribute to the health-care workforce one year sooner.

In a climate where much of the discussion is about how we can shorten and streamline medical education, many people are surprised to hear that I, like many of my Stanford classmates, will actually likely choose to take an extra year during medical school – for research, service, or an additional degree. Given that I also spent two years working between college and starting at Stanford, my inefficient path will have added three or four extra years on to my education when all is said and done.

Am I foolish for condemning myself to years and years of training before actually starting my “real life” as a doctor? For me, the thought process behind extending my training an extra year is actually very simple: I just really like being in medical school. How many other opportunities will I have to take classes in medicine, law, and statistical programming – all in the same term? When else in my life will I be able to soak up wide-ranging experiences from general pediatrics to neurosurgery, without committing to either?

To be sure, I don’t view these experiences as being part of the “most direct path” to becoming a competent, successful physician. But from a selfish perspective, they might help me better find a career path that suits me well. And from a societal perspective, I like to think that these larger life experiences will help to shape and define my unique set of values, philosophies, and skills as a caregiver to people in need – a framework that goes beyond the highly standardized requirements for medical training.

This is not to say that years of additional time are the best thing for everyone. I admire and envy those people who already know what they want to do and how they want to do it, and three-year MD programs offer those people a chance to make much-needed contributions to society as quickly as possible. However, to the degree that longer programs allow us the flexibility and independence to develop ourselves, I believe that they are an invaluable option for many aspiring doctors.

Nathaniel Fleming is a first-year medical student and a native Oregonian. His interests include health policy and clinical research. 

Photo by Leland Francisco 

Medicine and Society, SMS Unplugged

My grandfather’s body: Loss and mourning in India

My grandfather’s body: Loss and mourning in India

SMS (“Stanford Medical School”) Unplugged is 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.

6847161038_c6e69c4185_zI’ll pick up where I left off – after the rain.

My grandfather, a pioneering cancer surgeon in the city of Kolkata in India, a dynamic and daring individual, had been ill since a fall in February. I flew home to be with him, and our family took close and attentive care of him both at home and through multiple trips to the hospital.

The morning my grandfather ultimately passed, I had been by his side from an hour before, called in because his pulse was dropping to half of its normal range. His eyes were still closed in sleep, his forehead cool, and a feeble pulse fluttered at his wrist. We called an ambulance, realizing that he was sinking, but feeling ambivalent about transporting his body to the hospital and having him hooked up to intravenous lines and various leads and wires – something he had told us he did not want. In the meantime our family crowded onto the bed, surrounding him with loving thoughts, and I turned on one of his favorite CDs, a collection of devotional Hindu songs dedicated to his guruji, Sadhu Baba. By the time the emergency doctor came up to our seventh floor apartment, about thirty minutes later, his pulse was gone and his heart had stopped. I checked the time: 7:10 a.m.

I share my experiences as a reminder of the poignancy that these rituals may hold. Though these may be private moments…doctors can and should be attentive to them

Mourning is a culturally-mediated experience, and in the world of our family grief was a physical, tangible thing. When the uncertainty of my grandfather’s situation (Was he really gone? What else could make a pulse disappear?) turned to disbelief, and the disbelief to heavy acceptance, our first reaction was to hold the hands that lay tenderly on either side of him, to run a palm along his cool, sunken cheek, to hug his flesh.

I was with him as his body was painstakingly dressed in his favorite cream suit and a lilac tie, with fresh socks on his feet and gold-rimmed glasses in place. He remained resting in his bed, as family members and friends poured in to offer their respects, to pay darshan: to see and be seen by him. The air conditioning was turned on to keep the body cool in the draining April heat.

I was there two days later, when his body, this time in his black suit with a red tie, traveled through the town in a long, silver hearse and was brought back home. We pulled into the apartment complex, where loved ones lined up. They opened the doors at the back of the glass case where his body lay, and placed flowers over his chest, or touched his feet in a gesture of respect toward one’s elders. Some mourners wailed and threw themselves onto his body, or pulled at his clothes, letting their tears dampen his clothes. One bewildered, heartbroken friend and former patient kissed my grandfather’s feet.

And I was there – along with at least 50 other people – at the cremation grounds, where his body was showered with petals, blanketing in fragrant wreaths. Then, the flowers brushed away, we prepared him for cremation, covering his skin with ghee. His three children held a flame and circled around him in prayer, then his body was hoisted into the electric cremation pyre. I was there when we waited thirty, forty, long minutes for the flesh to disintegrate and liberate his soul.

Continue Reading »

Medical Education, SMS Unplugged

“Us” and “them”: Losing the patient perspective

“Us” and “them”: Losing the patient perspective

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.

holding hands - smallThis past Saturday, I received a call from a close friend from college that went something like this:

Friend: “Hey… so I’m in the ER right now, and I didn’t know who else to call.”
Me: “WHAT?! OH MY GOD WHAT HAPPENED?!”
Friend: “They think I have appendicitis.”
Me: “Ohhhhh – oh my gosh, thank goodness. I thought it was something really bad.” (nervous, relieved laugh)
Friend: “Wait, why are you laughing? I’m freaking out right now. What if my appendix explodes inside me? I’m so scared.”

A flush instantly spread across my face. I felt terrible.

In my head, appendicitis was relatively low on the list of all the possible horrible things that could have happened to my friend. I knew it was a common condition, that an appendectomy was a straightforward procedure, with minimal risk, and that of all the body parts to lose, the appendix wasn’t the worst by far.

When my friend mentioned that he might have appendicitis, my mental reaction was to think of all the factors that go into that diagnosis, and I was bursting to ask if he had guarding or rebound tenderness, and if the doctor’s said anything about McBurney point. (Side note – I’m currently studying for Step 1 – not that that excuses my impulse to run through a mental illness script). When that flush washed over my face, it was because I was shocked at myself: Why did I not – first and foremost – put myself in his shoes and try to feel the same pain and panic he was feeling?

I immediately apologized – again and again and again. Over the next few minutes, he asked me questions about appendicitis, how likely it was that his appendix would rupture, and more. At the end of the phone call, we had made plans to meet the next day, after his surgery, and my friend was calm. I, however, felt unsettled, and so guilty.

At our “Transition to Clerkships” retreat this past Friday, we sat in small groups and reflected on our individual hopes and fears for clinics. One of my fears was that I might become jaded or desensitized to patients’ conditions and not react with the empathy my classmates and I have cultivated and practiced so carefully. This incident with my friend brought that fear to the forefront of my mind.

I think that in many ways, it is a blessing for a physician to be somewhat desensitized to human suffering (after all, I can’t be fainting all over the place, can I?). But I also think there’s value in reflecting on how we can work to retain and prioritize that element of emotion that makes us human and that makes a doctor someone who is kind and trustworthy. As I move into clerkships this June, I sincerely hope I’m able to find that balance.

Hamsika Chandrasekar is a second-year student at Stanford’s medical school. She has an interest in medical education and pediatrics.

Photo by george ruiz

Medical Education, Patient Care, SMS Unplugged

The first time I cried in a patient’s room

The first time I cried in a patient’s room

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.

Moises bedside sketchThis blog entry marks my last contribution to SMS Unplugged. I am two months from graduating from Stanford Medical School and starting my adventures as an intern. My fiancé and I happily matched at Baylor for our residencies and look forward to contributing to patient care in Houston. Having finished my clinical duties and finding myself spending less time in the hospital, I didn’t anticipate the powerful experience I would have at a patient’s bedside this past week.

In my clerkships I have encountered various situations in patient care that are difficult to deal with: the weight of sharing a negative prognosis, the death of a patient, disappointments in personal performance. Through these encounters I took pride in remaining professional and controlling my emotions, finding a balance between showing empathy and connecting with my patients but not allowing my personal feelings to take over. More specifically, I have never cried in front of a patient. This changed last week, and it happened in the most unexpected of moments.

As a teaching assistant for the second-year class my responsibilities include recruiting patients for students to interview and examine. For the most part, it’s a tedious thing to do and can be a task to dread. But every now and then I meet a patient that reminds me how amazing patient – and human – contact can be. During my last recruitment session, I met a patient that made me cry. I cried not for her, but because she cried for me.

In the process of introducing myself I could tell that she was a warm and caring person. This made it easier to open up to her when she asked about me, where I was heading next, and what life plans my fiancé and I have. It’s not usually a conversation I would have with a patient that I’ve only known for two minutes, but something about her genuine interest was welcoming. Wrapping up our conversation, I began to thank her and make my exit when she reached for my hand and asked if I could give her just two more minutes. Instead of continuing with generic conversation, she closed her eyes and began to pray while holding my hand tight.

Praying with a patient wasn’t new; several patients in the past have asked for me to share moments of prayer with them, and they were beautiful moments. But this time it was about me. She prayed that I have a good residency experience and that I emerge from my training well prepared. Then she opened her eyes and revealed the tears that she would bless me with. She asked that I never forget the dynamic that I will share with my patients. She asked that I always remember to look my patients in the eye, check my position of power and recognize the intelligence of my patients, and more than anything “kick the heck out of life.”

Continue Reading »

Events, Medical Education, Medical Schools, Pediatrics, SMS Unplugged

A Match made at Stanford: From medical student to resident

A Match made at Stanford: From medical student to resident

SMS (“Stanford Medical School”) Unplugged is 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.

IMG_1127On March 20, in synchrony with thousands of senior medical students across the country, I received an envelope that determined where I would be spending the next three years of my life for residency training.

My academic advisor, Oscar Salvatierra, MD, had come out of retirement to share this day with his students. He had supported us over the years, from studying for our first-year exams to choosing a specialty and applying to residency. He supported my husband and me in the additional challenges of tackling medical school as a married couple, guided us through my husband’s decision to pursue a combined MD/PhD degree, and even weighed in on our decision to have a child during medical school. Now, on Match Day, I was so grateful that he was the one to call my name and hand me my letter.

“Open. Open. Open,” my daughter demanded, grasping for the bright red envelope with the same steady persistence that she normally uses to ask for raisins. My husband took her from my arms so that my shaking fingers were free to open the envelope and unfold the letter. It was real, right there in black and white: I’ll be staying at Stanford for a pediatrics residency.

I grinned, then I cried, then I started soaking in the hugs and congratulations of my family, friends, and mentors who all knew how desperately I had hoped for this outcome. But the fun part about Match Day is that there is more than just your own news to celebrate. Within minutes, I was fighting through the crowds to track down my friends and classmates to find out where they had matched. I was incredibly impressed, but not at all surprised, to hear about the excellent programs they will be attending across the country.

As I stepped back into my apartment later that morning, clutching my residency Match letter, it felt a lot like bringing a newborn baby home from the hospital: it was odd and unsettling to walk back through familiar doors into my familiar home when our family’s life was all at once so deeply changed. In residency (like becoming a parent), I am going to have to work harder than I’ve ever worked before, and be challenged in ways I haven’t even imagined. But at the same time, I have no doubt that it will be worth it, and that this was exactly what I want for my life.

I hope that my classmates are feeling the same excitement to start the next phase of the journey. Congratulations to the Stanford Medicine Class of 2015 on an incredible Match!

Jennifer DeCoste-Lopez is a final-year Stanford medical student who will soon start a residency in pediatrics at Stanford. She was born and raised in Kentucky and went to college at Harvard. She currently splits her time between clinical rotations, developing a new curriculum in end-of-life care, and caring for her young daughter.

Photo courtesy of Jennifer DeCoste-Lopez

Aging, Global Health, Medical Education, Patient Care, SMS Unplugged

After the rain: Experiencing illness as a medical student and granddaughter

After the rain: Experiencing illness as a medical student and granddaughter

SMS (“Stanford Medical School”) Unplugged is 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.

rainy groundIn India, when the first heavy droplets of rain meet dry earth it releases a particular kind of smell: a dampness arising from sizzling soil that in Bengal we call shnoda gondho. It is raining on the second day we go to visit my grandfather in the hospital.

He has been readmitted to the hospital, after spending a week recovering at home from a hospitalization for rib fractures and bleeding into his lungs. The irony of his hospitalization is not lost on his family: that a renowned doctor, one of the first cancer surgeons in the city of Kolkata and one who spearheaded oncological care in this region, is now gowned and sitting in a hospital bed. This happens frequently, of course, for doctors are not immune to being patients, even if we would like to think so. The problem is that we are little prepared for the unstructured, unscripted nature of experiencing illness rather than treating it.

Certainly for my grandfather, a man who even recently traveled to multiple hospitals each day to supervise surgeries and see patients in clinic, being confined to bed for respiratory treatments and being unable to walk without support feels equivalent to being bound up, tied down, and chained to the hospital. This is the way illness imprisons. For his family, used to seeking his wise medical advice on various things from pesky coughs to unremitting cancers, we are unprepared to now help make decisions for him.

We never stop being medical students, and later we never stop being doctors, whether in relationships with family members, friends, acquaintances, or strangers in emergency situations

Perhaps this reflection is too personal for a forum created for sharing medical school experiences. But I suppose my realization is that medical school is not a place but rather a privilege we hold. We never stop being medical students, and later we never stop being doctors, whether in relationships with family members, friends, acquaintances while traveling, or strangers in emergency situations.

But, as I spend these three weeks with my grandfather and my family in Kolkata, I find that it is important to play both roles: that of medical student, the one who can help translate the staccato of medical jargon into fluid lines, and that of loved one, the one who listens not via an earpiece through the taut drum of a stethoscope but through bare ears and naked eyes, the one who listens for and is moved by the cries of pain, or suffering, or confusion, or desperation, of the ones they love.

In many ways the loved one is the harder role to play, for it is the role with no lines. No chest x-rays to evaluate in the morning. No medications to re-dose for a rising creatinine. No growing charts of oxygen saturation, or heart rate, or urine output. As someone who has recently grown used to doing these things on the medicine wards of Stanford Hospital, I now acculturate to a more improvisational kind of care. Placing a soothing hand on an aching back. Sitting at someone’s bedside while he nods in and out of sleep. Holding down an arm so that it doesn’t tremble like the string on a harp. In Indian hospitals, the family must often arrange to bring the medications that the doctors have prescribed and may often visit the hospital multiple times a day to bring food. We mix rice with soft, curried vegetables or boiled eggs and offer them to our loved ones, hoping to find through these labors some connection, some solace.

As family members we grasp for metaphors. In India, these metaphors of illness are often built around ideas of hot or cold, of water or wind. Perhaps that is why I find it so poignant that it rained today, the dense, gray clouds releasing their water just as the water from the pleural effusion in my dadu’s lungs was drained.

I hope that one day soon, when this rain had cleared, my grandfather will write his own words as he has planned to do. And then he can tell you his story, not I.

Amrapali Maitra is a fifth-year MD/PhD student working towards a PhD in Anthropology. She is interested in the illness experience, the cultural and social basis of health, and practices of care.   Amrapali grew up in New Zealand and Texas, and she studied history and literature as an undergraduate at Harvard. She is a 2013 Paul and Daisy Soros Fellow.  

Photo by Jason Devaun

Stanford Medicine Resources: