Early clinical courses make me grumpy

Just 6 months ago, I was interviewing at medical schools, and there was an interesting lack of trend in opinions about curriculums:  what pre-meds are interested in has no correlation to what medical students are interested in.  But it’s the pre-meds with multiple acceptances who make the decisions (who wants to go to a school where you learn absolutely nothing pathological, and see no patients, until 2nd year?  I mean, are we paying $70,000 to feel like doctors or biochem grad students, amirite?), so there seems to be an epidemic of a “new curriculum!” at schools, I bet at least partially to accommodate this.  (No, I have no evidence.  But I don’t think you can go ever wrong in assuming that money is at the bottom of most major decisions.)

Despite the fact that I actually really like these new curriculums (.. curriculi?), the running joke on the interview trail is how the Dean at every single school proudly announces their “unique new curriculum” which features “early patient contact – from the first week!” (UVa proudly announced “starting on day 1 of orientation!”, which I think means they win.  Unless there’s another med school that has patients present on move-in day.) and “integrating pathology with normal physiology”.  (Except for you, UPenn.  Way to stubbornly keep it old school.)  I mean, everybody does this now.

But while early clinical classes about doctor-patient relations sound AWESOME to your average pre-med, they sound ridiculous to medical students – which always struck me as weird, seeing as how one turns into the other.  But now that I’m actually here, I’m beginning to see what the med students I’ve talked to are getting at:  In the first year, patient contact is largely worthless – because we know nothing. They weren’t just saying, “Oh, we know a little medicine, but we’re not real doctors so this is worthless.”  No.  First years know NOTHING.  I get it now.   (Yes, it’s true that the humanistic side of medicine is just as important – but I’d argue that 1st year medical students don’t need help establishing empathy with patients.  We are idealistic, empathetic, and wide-eyed.  It’s knowing the scientific side of medicine and and being paid to concentrate on it that makes empathizing sometimes hard.  I mean, right now, I couldn’t ignore the patient and treat the symptoms if I wanted to.)

Finally, a moment I witnessed that accurately encapsulated why I’m not sold on this:

Patient:  Do you think the headaches have anything to do with my stomach ache?
MS1: Um, maybe.  The doctor will be here any minute now.  I’m just here to get experience.
Patient:  Well, do you think it’s diverticulitis?  My sister has diverticulitis.
MS1: … diver-what?
Patient: …
MS1:  Um.. was that emotionally difficult, dealing with your sister’s div… illness?

This class is referred to occasionally as the “So, You’re All Socially Incompetent!” class, which I think is about right.  I’m sure it will be really helpful once we start knowing things, but right now, any class that features lectures on eye-contact and how to relate to people is bound to be – well, “waste of time” seems awful judgemental – so I’m going to go with “not particularly ‘high-yield’.”

To be fair, it does beat memorizing the ligaments of the talocrural joint.  Hard to argue about that.

7 thoughts on “Early clinical courses make me grumpy

  1. I totally agree that interviewing patients early in first year is probably not that useful. We did have a clinical medicine course in my second term of first year, where we learned to do interviews and I do think it was kind of nice.

    However, what I did find really helpful was having patients tell their stories in lieu of lectures. I don’t remember my med school lecture on MS, but I remember the woman they brought in who had MS telling us about how she was diagnosed. I could still quote large parts of her story.

    • That sounds great. We’ve had a few patient presentations, and they’ve all been fantastic – most, especially the ones with small children, have been pretty emotionally intense. (They’ve also all been a part of our biochemistry course.. go figure!)

  2. I’m a 2nd year and our clinical medicine class was my favorite part of first semester- i loved getting to interview patients- I think that learning how early on really helped- especially once we learned the physical. Yes, I didn’t know any medicine last year, but I thought learning how to take a good history was really valuable 🙂

    • Thanks for the comment! That’s awesome that you guys started doing all of that early on. Right now we’re mostly talking to patients in waiting rooms “just to start understanding the patient’s point of view”, which sounds better on paper than it does in theory, I think. (Nobody wants their soap opera interrupted by a med student.) Hopefully we’ll move onto taking histories soon! 🙂

  3. Interesting argument. Certainly over here (Australia) there is a heavy focus put on those ‘progressive’ schools offering early clinical exposure.

    While I wouldn’t say that we are able to do very much, I found it to be an experience that allowed you to see how it is done by ‘the pros’, to (as mentioned by @Fizzy) experience and hear those patient stories that stick with you so much more than another lecture on the Krebs cycle, and generally allowed many students to reconnect with why they wanted to do medicine in the first place, and to keep them going.

    Because we can all admit – med school ain’t easy. And often it’s that patient (or sometimes doctor) who you meet right when midterms are happening, or right when you’re sick of pharmacology to your eyeballs, who has a transformative experience and reminds you that it’s worth all the effort in the end.

  4. Pingback: Bagging 101 (Remedial) « The Notwithstanding Blog

  5. Well, here is a perspective from many years ago. In 1969 I started med school at CWRU in Cleveland. In the first several weeks, I was assigned as “student doctor” to a pregnant woman from the OB clinics. We were really a “health care liaison” rather than any kind of doctor, but for the patient we were a source of continuity in a very disjointed medical care system. We met the patient at the beginning of each clinic visit, took a brief history, and accompanied the patient to the “real” prenatal visit. We made a home visit to take a more in depth social history, but really just to see the patient in a home context. When she went into labor, she called me first and I met her on Labor and Delivery and went through her delivery at her end of the table. Subsequently I played the same patient liaison role for her child’s well child care through the age of one. We met for an hour in groups of 8-10 med students with a preceptor to discuss how it was going.

    From my standpoint, looking back at the experience from the other end of my career, the program had HUGE benefits:

    1. Most important, I learned (and I know from our group that others learned) to say straight out to a patient, “I don’t know that, but I’ll find it out.” Through my medical career I met many physicians who never learned to say that. It was a surprise, but just for a moment, that it was OK not to have every answer for the patient.

    2. I believe it firmly implanted a patient-point-of-view in my way of looking at health care and especially at the system of health care. Routinely in January and February when our patients started delivering, students would come to our small group with some variant of, “You can’t believe how they treated my patient on that OB floor. She was just a number to them and they didn’t even see her as a person.” I acknowledge that some of our first year outrage was unfair because we could not see the whole picture. But some of it absolutely reflected the perhaps necessarily impersonal nature of a large metropolitan hospital, especially one dealing with cultures of race, ethnicity, and poverty that are foreign to the bulk of the providers.

    3. I think early patient contact contributed to both 1 and 2 above partly because it contrasts so starkly with the situation when first real and personal patient contact coincides with third year rotations. The medical student, during third year rotations, can rarely spend much time contemplating the interpersonal points of the doctor patient relationship because of the overwhelming flood of clinical knowledge that must be absorbed. At rounds in the morning, students are grilled not on “how did this illness fit into this patient’s life?” but on “What was that test result, what does it mean, what if it were higher or lower, did you remember it was needed?” I don’ t think I was alone for feeling that “If I don’t know this content, this patient could die at my hands.” My early patient experience allowed me to learn about the meaning of health and illness, patients and doctors and communication” before I was grilled on “Do you know the critical fact about this illness presentation?” Don’t get me wrong. I believe in the importance of what is grilled in hospital rounds. But it does crowd out lots of important aspects of medicine and the doctor patient relationship that were easier to learn with early contact.

    4. Finally, it did make the first two years of medical school lectures and reading much more fun and interesting. I remember Josie, her home in inner-city Cleveland, and her chunky little baby as much as I remember the details of any of my first year lectures, and I am convinced that engaging with her and her family as I began this medical career was as important to the kind of physician I became as any other part of my medical school career.

    Just another point of view.
    Gregg Wright

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