Med School Confidential

by Robert H Miller

  There are also a number of alternative approaches you can take that will make school virtually free. Consider a military appointment with promised service after graduation, or a National Health Service Corps grant with a commitment to placement in an underserved area once you’re in practice. Such avenues are there for the taking, and with a little research, ingenuity, and careful planning, they can eliminate the onerous debt burden associated with obtaining your medical degree.

  What about my life and my family?

  Make no mistake—the demands of med school are very real. In order to pursue your education and your training you will, quite simply, be required to forego most nonessential aspects of your life in favor of more time and focus to study. Hobbies go largely by the wayside, and time off becomes a rare and precious commodity. Personal relationships will be continually strained by your workload.

  It’s not all gloom and doom, though.

  Remember that hundreds of thousands of others have endured and survived this experience before you. Striving for a balanced life is a key survival tool—and one you’ll constantly need to call on as a doctor. Recognizing when you need time to get away from work is crucial, and having family, friends, and loved ones who understand the demands on you and have pledged to support you along the way will be a big help. Many people end up getting married and even having children in the midst of their medical training. The only limitations are ones you impose on yourself.

  In the end, no one but you can assess your true fitness and commitment to pursue medicine. The key is making your decision an informed one.

  “My only words of wisdom are to know yourself fully before going into the ordeal of medicine,” Pete counsels. “Those who do not know what they are seeking from the outset are unlikely to find satisfaction in today’s health-care world. Realize ahead of time whether you are someone who loves knowing the most about a small subset of information or if you want to know a little about a wide range of health issues. Recognize as well the type of life you want: if you are looking for the 2.3 kids, the big house in the suburbs, the SUV, and the Wednesdays improving your golf game, those are still attainable, but you have to sacrifice much to get there. Knowing yourself is equally important for those who pursue the inner city or rural primary, grassroots-driven care of the underserved. In deciding whether or not to go into medicine, as with any other career, the key is in knowing not what you want to do, but what kind of person you want to become.”

  CHAPTER 2

  A Road Map of the Med-School Education Process

  By three methods we may learn wisdom:

  first, by reflection, which is noblest;

  second, by imitation, which is easiest;

  and third, by experience, which is the bitterest.

  —CONFUCIUS

  IF YOU’RE STILL with us, you’ve presumably reflected on your fitness to pursue a medical degree and emerged undeterred or, even better, reassured. To most, however, med school and the experience you’ll have there are shrouded in mystery. As such, the next order of business is to dispel some myths and lay bare the process with a general overview of medical education. There are many steps, many variables, and many years to the process, and this chapter will provide a blueprint for each phase of your preparation and training.

  In general terms, the journey to physicianhood includes about two years of premedical prerequisites, four years of medical school, one year of internship, and at least two years of residency training before you become eligible for a specialty board certification. Understanding this road map will be key to understanding the later chapters in this book and applying its teachings to your own education. Feel free to return to these pages periodically if you find yourself lost in the maze later on.

  PREPARATION AND PREREQUISITES

  In order to apply to medical school you will need a bachelor’s degree from an accredited college or university. You can complete any major you choose, but you also have to demonstrate your successful completion of prerequisite courses in biology, chemistry, physics, and calculus. This course work will prepare you for the Medical College Admissions Test (MCAT). The specific course requirements and a guide to the premed process are presented in the next chapter.

  MED SCHOOL: FOUR YEARS, 125 Flavors

  The first medical school in the United States was the College of Philadelphia Medical School (now known as the University of Pennsylvania School of Medicine), founded in 1765. Students enrolled for anatomical lectures and a course on the “Theory and Practice of Physik.” Over time, the breadth and depth of medical knowledge grew, and by 1900 American medical schools had a relatively standard four-year curriculum followed by an internship and/or a residency. Since 1990, however, we have seen dramatic innovations in the way medical-school curricula are structured, to the point where each of the 125 currently accredited medical schools in the United States now takes its own unique approach. An overview of the different curricular formats and general philosophies of medical education follows below.

  Traditional format

  Today there are numerous variations in curricular structure and format in U.S. medical schools. Most, however, are still a variation on what we’ll call the “traditional format.” In this system, the first two years are spent almost solely dedicated to classroom course work, while the second two years are devoted to clinical work on the wards. The preclinical, didactic phase of years one and two is typically broken down into normal anatomy and physiology the first year, followed by abnormal, or diseased, physiology and therapeutics the second year. Thus, typical first-year classes might include Anatomy, Physiology, Microbiology, and Embryology, whereas typical second-year classes would include Pathology, Pathophysiology, and Pharmacology. In the latter two years of the traditional curriculum you leave the classroom almost totally behind and receive hands-on education by rotating through the wards. Year three typically involves core rotations in internal medicine, surgery, pediatrics, obstetrics and gynecology, and sometimes various subspecialties like anesthesia. In year four, you begin to focus on the specialty in which you anticipate applying for residency. The first half of your fourth year is spent finishing prerequisites and doing acting internships in your field, often both at your home institution and at some key residency sites. You apply to residency in the fall of your fourth year, interview throughout the winter months, and spend your fourth-year spring finishing off requirements, taking elective and vacation time, and pretty much waiting with bated breath for Match Day—where you find out where you will serve your internship.

  Integrated formats

  Until the late 1980s, the traditional approach was the predominant format. More recently, however, medical educators and practitioners have begun to propose a more integrated didactic and clinical sequence to medical school, and as such a new era of curricular innovation has been spawned. Today, even schools with fairly traditional curricula are emphasizing some basic clinical exposure early on and throughout the four years. Additionally, instead of monolithic, didactic courses presenting a longitudinal view of a single subject across all the body’s systems, there has been a push to alter the approach of the didactic curriculum as well. Some schools have turned to a systems format in which the course work is organized around a single body system. For example, a lecture block on the cardiovascular system would encompass its anatomy, physiology, pathophysiology, and pharmacology all at once.

  Other schools have completely abandoned the pure didactic approach in favor of problem-based learning (PBL) in small-group environments. In this approach, a small group is presented with a clinical scenario by an instructor and, as a group, works through identifying the clinical issues, researching the pertinent data, and formulating an approach to the clinical problem. Thus, for example, a group presented with a patient who is hypertensive and recently had a heart attack might recognize they need to read about cardiac anatomy and physiology, the pathophysiology of infarction, as well as the interaction of heart, kidneys, and blood vessels in hypertension. Th
ey will need to understand not just the basis for disease and how it alters the normal structure and function of the body but also how drugs and other therapeutics are tailored to combat the diseases. In schools employing this approach, the complete spectrum of didactic knowledge is covered by the careful structuring and sequencing of these clinical scenarios.

  These are just a few examples of the various versions of integrated curricular structures and formats operating in American medical schools today. While most schools offer some blend of traditional, integrated, and problem-based didactics, most schools also emphasize a particular approach to learning. As such, in developing your list of med schools during your application process, consider which format best suits your learning style. Do you need the structure and rigor of large classroom lectures, or are you better in small, creative, selfdirected groups? With sufficient research, you can find the perfect curriculum to suit your preferred learning style.

  M.D. VERSUS D.O. PROGRAMS

  It is worth pausing here to clarify the distinction between the two different types of medical schools in the United States and the different degrees they offer. The majority of U.S. medical schools feature the traditional allopathic curriculum, covering the spectrum of human pathology and its treatment via surgery, medicines, and therapeutics. These schools award the M.D. (Medical Doctor) degree. Osteopathic medical schools offer an alternate and complementary approach providing the same training and experience in medicine, surgery, and therapeutics while also featuring specialized training in manipulative techniques. These therapeutic techniques are more closely aligned to chiropractic manipulations and seek to treat both musculoskeletal and physiologic disease by adjusting the skeletal structure of the body, thereby returning it to normal, functional alignment, relieving symptoms and restoring health. These medical schools award the D.O. (Doctor of Osteopathy) degree. All medical specialties accept both M.D. and D.O. physicians, and D.O. physicians are fully trained and accredited in all aspects of traditional allopathic medicine.

  Since the vast majority (approximately 94 percent) of physicians are graduates of allopathic schools, this has traditionally been the more competitive route through medical school. Yet osteopathic students also attend school for four years and then typically either matriculate into a standard residency or do an additional year of osteopathic clinical training before beginning residency. There are some osteopathic-specific residencies, but most residencies accept both M.D. and D.O. candidates, though not always with equal enthusiasm.

  “I learned about osteopathic medicine by working in a clinic that was staffed by both M.D.s and D.O.s,” Kate explains. “I found that D.O.s had a little something extra to offer to their patients—namely, a whole body philosophy and manual manipulation. I learned more about this technique and the theories behind it while working at the clinic. This provided me with the exposure that I needed to make the decision to pursue an emergency-medicine career as a D.O.

  “As a D.O. in the emergency department, I often find that I do not have time to perform manual manipulation. This is disappointing, but I do educate my patients on what they can do for themselves to help their recovery from their musculoskeletal complaints. Empowering patients is just as important as treating them.

  “Prior to entering my allopathic EM residency, I chose to complete a Traditional Osteopathic Rotating Internship. This was essentially a prelim year (medicine, pediatrics, ob, surgery, emergency medicine, etc.) with osteopathic manual manipulation entwined throughout the year, allowing me to develop my manual manipulation skills. I think this is very important if you are a D.O. who ends up in an allopathic residency program. Not only did it help me develop my osteopathic skills, but it allowed me to mature as a clinician. As an emergency physician, you are expected to know a little bit about everything. This extra year has helped me to do just that—which benefits not only my education but more importantly my patients.”

  Although unfounded, there is a fairly pervasive perception in the allopathic community that osteopathic training is somehow inferior. Allopathic medical schools do tend to be more difficult to get into, and hence osteopathic schools are considered by many to be a second-tier alternative. Fair or not, it is important to be aware of this perception in advance, because when it comes time to pursue residency and career options, osteopaths can find themselves at a competitive disadvantage in the marketplace.

  M.D./PH.D. PROGRAMS

  For the truly stout of heart, many schools offer an M.D./Ph.D. track. The M.D./Ph.D. is primarily a research-focused program in which the graduating candidate will earn both a Doctor of Medicine and a Doctor of Science degree. Typically, the curriculum is modified such that you take some additional classes in research methodology during your first two preclinical years and then take at least a year between the preclinical and clinical phases to focus solely on a major, doctoral-level research project and dissertation. An M.D./Ph.D. is an exceptional degree and offers entry into the hallowed community of high-level academic and clinical research. There are, of course, many active researchers who do not have Ph.D.s, but possessing the joint degree clearly defines you as a specialist in your field.

  “THE MATCH” AND APPLYING TO RESIDENCY

  The process of applying to residency is drastically different from applying to medical school. All institutions in the United States that offer medical residencies belong to the National Resident Matching Program (NRMP). This body links residency applicants to residency programs. The system tries to match the strength of your desire for a program with the program’s desire to have you as a resident.

  Here’s a thumbnail sketch of how it works:

  In the fall of your fourth year of medical school, you will apply to residency programs in your chosen field. Residency programs vary in structure and format, but are universally composed of at least one initial year of internship followed by some number of years of residency thereafter. Some institutions integrate the internship, or first year, into their residency program, such that you will start on day one as a member of that program and graduate the requisite number of years later from the same place. Other residency programs start in postgraduate year two (PGY-2), meaning that you’ll be required to apply to, match to, and complete an internship elsewhere before matriculating into the residency program you’ve selected.

  Once you’ve chosen your field of specialty, done your research, selected your programs, and applied, you wait for an invitation to be interviewed. In February of your fourth year of med school, once the interviewing process is complete, you submit your match list to the NRMR On this list you will sequentially rank the programs that interviewed you from your first choice to your last choice. Around the same time, all the residency programs in the country assemble a similar match list, listing in sequential order the candidates they would most like to have as residents. A giant computer at the NRMP uses a complex algorithm to sort through these lists and match candidates to positions.

  On or around March 18 of your fourth year of medical school you will receive notification from the NRMP of your match. This match represents a binding contract, so where you match, you go. In many fields and many programs there are more candidates than positions, meaning that you may or may not achieve your number one choice. Careful construction of your match list will help ensure that you match somewhere you want to go.

  If all of this has just devolved into a big blur for you, don’t worry. Remember that this chapter is just an overview of the entire experience. We’ll tell you everything you need to know about applying to residency programs and surviving the match in part five of this book.

  INTERNSHIP, RESIDENCY, AND BEYOND

  Most doctors cite their internship as the most memorable year of their medical training. Not only will your year as an intern likely be one of the busiest of your life, it will also represent your rite of passage from book-toting, bewildered medical student to competent clinician. It is for most people an exciting, terrifying, exhausting time. That said, in the current c
limate of work-hours reform and concern for physician wellness, internships across the country are increasingly focused on providing a less hellacious and more manageable experience.

  So what is this thing called “internship,” anyway?

  As an intern you will, for the first time, assume primary responsibility for patient care. As with each stage in the training process, the biggest transition in an internship will be a new and significantly higher level of patient-care responsibility. As a third-year medical student, you will have struggled to figure out how to complete a thorough history and physical exam (H & P) and write a decent chart note. As a fourth-year medical student during your acting intern rotation, you will have been asked to take on a larger portion of the care of a few patients at a time. During your internship, however, you will be expected to carry a significant daily patient load, to crosscover entire services of patients you may not be familiar with while on call at night, and to report directly to senior residents and attending physicians on your clinical assessments and therapeutic plans. It’s a big step up in responsibility and workload. But the reality is that you have a team of senior residents and attendings who are prepared to support and shepherd you through the process. Furthermore, you’ll also have talented nursing staff at the bedside—people who will teach you a great deal and save you from yourself during those late-night crises when a patient goes into a death spiral and it seems like you’re the only one around!