Twenty Questions for Dr. Bear (Part the Second)

Any advice for aspiring medical students?

Not much. Everybody is going to have a different experience in medical school depending on their expectations, their past experiences, and their willingness to modify their ideals to conform to the realities on the ground. I’m trying to get away from giving advice in favor of relating some of my experiences and opinions and letting the reader make of them what he will.

But I guess the basics are the most important, that is, to study hard, keep your eyes and ears open, and try not to get so caught up in what is, once you strip away the self-congratualtion, just a somewhat difficult professional school. Medical school doesn’t have to consume you and it is possible to have other interests. This is not to say that there won’t be periods when you will have time for nothing else but you do get to go home. The subject matter is very interesting but it ain’t that interesting all of the time. If it was more people would show up to embryology lectures.

I’d also like to add that, if you consider that most medical students do not work while in school and that you can skip what are generally useless lectures at will, with a good course syllabus there should be ample time to both study and master the material. I was not the best student being something of a slacker (and I should have studied a lot harder) but I comfortably passed everything. There is time enough in the day. With a little self-discipline you should have a low-stress first and second year and still make good grades.
In other words, keep up with your studies and you can avoid the desperate all-night study groups that blossom like nervous flowers, the tattered petals of highlighted index cards strewn over the tables in the library, as your disheveled peers try to cram a few weeks of material into a frantic string of all-nighters. I never could pull all-nighters. I lack the stamina and, as I may have mentioned once or twice, mightily dislike going without sleep.

But do what works. I’m just suggesting that there is no need to panic like many of you new first years are probably doing right now. Don’t sweat it. Keep plugging away. It is going to get easier and by the middle of second year you are going to be able to cover three times as much material in a third of the time and laugh, yes laugh, that some punk-ass biochemistry course ever intimidated you.

What’s the biggest shock for many medical students?

Not being as smart as you think you are. Let’s face it, most of you have until now been at the top of your class in high school and college. You’ve studied hard and received both excellent grades and frequent validation that your hard work and discipline has set you apart from the lumbering proles who go to college for the chicks and the parties. It’s not as if you become stupid on the day you matriculate into medical school but, as everything is relative, on that day you will find yourself surrounded by a hundred other highly intelligent people getting hosed down with a tremendous volume of information, wondering if you are going to be able to keep up. And you will look around and see your peers apparently effortlessly mastering the material while you desperately struggle for a barely passing grade on the first test. That first “72” chills your spine, especially if you are used to “high honors.”

When I was in college, I had to take a ridiculously easy Art Appreciation course to sastisfy the distribution requirements for my major. Easy as it was, I was surrounded by students who were really sweating it including a couple of guys in the back regularly formulating cheating schemes whereby they could scrape by with a “D.” Many of you will feel like those guys after the first exam.

Traditional Lecture or Problem Based Learning?

Traditional lecture. No question about it. If you are accepted into more than one medical school and can pick between a lecture-based curriculum or Problem Based Learning, flee as if from the Devil himself the PBL school.

For those of you who don’t know, Problem Based Learning is a fancy word for “Seminars.” Instead of sitting in a traditional lecture following a rational plan of study, you will be divided into small groups and, under the supervision of a faculty member, teach youself the material through the highly inefficient process of self-discovery. It sounds good on paper and the medical schools that have embraced it will try to sell it as if it were going to replace sliced bread. In practice however, it can be a nightmarish voyage into a sea of ignorance on a ship full of clueless people who all want to be captain.

Problem-based learning is an admission by medical schools that most of first and second year is self-study. Instead of following this admission to its logical conclusion, that people should study on their own, Problem Based Learning was devised to justify both freeing up faculty to concentrate on their real interests and to not provide lectures while still collecting tuition. If you look at it like that it almost makes sense because otherwise you would have to believe that many highly intelligent people devised an intricate solution to a non-existent problem.

The fierce partisans of PBL (who make Mac users seem tolerant by comparison) will sneer at the traditonal lecture curriculum which they say “spoon feeds” the student. The implication is that those of us who prefer lectures to seminars are a bunch of big fucking babies. Maybe lecture is “spoon feeding” but Problem Based Learning is like throwing the jars of baby food at the baby and laughing as he struggles to open them. Actually, I don’t accept the metaphor. Like I said, it’s all self-study. Many people don’t even go to lecture but study efficiently on their own which is hardly spoon-feeding. The difference is that a lecture curriculum has a rational plan, starting with the basics and working up to more complex topics which is the ideal model for a curriculum. Why this isn’t obvious only shows that the faculty at many medical schools have mutated to a level of intelligence where their giant brains have crowded out the common sense lobe.

What’s the bottom line? Studying in a group is highly inefficient, often highly annoying, and puts you firmly on somebody else’s schedule for a significant portion of the day. Instead of just studying you are asked to become an active participant in someone else’s group dynamic masturbatory fantasy. My medical school dabbled in Problem Based Learning and by the end of a typical three hour group session I was ready to shoot myself in the head.

I cannot say enough bad things about Problem Based Learning. Almost everybody despises it.
Podunk or Top Tier?

I am immensely grateful to those who pursue careers in academic medicine, careers that advance the science of medicine and train future physicians, and I am second to none in admiration for the most excellent faculty at my program. With that being said, I have no desire to teach, conduct research, or to become involved with academics once I finish my training. Neither do most physicians for that matter. So with this in mind, what really is the difference between going to your inexpensive, relatively unknown state medical school and a major academic powerhouse?

Not much if you just want to practice clinical medicine. I’m not discounting the value of prestige however. If you want to do a cardiology fellowship at Harvard a medical degree from Yale and a residency at Duke will put you way ahead of some rube coming out of the medical sticks. On the other hand, I rotate at a hospital that most of you have never heard of and probably couldn’t find on a map but it has a cardiology program that turns out first rate cardiologists who have no trouble finding jobs or patients. You just have to know what you want and what you are paying for it. All other things being equal, the more prestigious the program the worse the medical students and residents are treated and the more time you will spend as somebody’s entourage. Consider carefully then your choice. If you know that you want to work at medicine like a regular job it makes no difference where you go and location and lifestyle should trump all other considerations (except for Problem Based Learing).

In the end, it just comes down to what the t-shirt is worth.

Like any rotations?

Sure. I like working in the ICU. I didn’t always, of course, as the ICU is probably the most intimidating rotation for medical students and interns. The patients there are horrifically, almost obscenely, sick and the comforting medical paradigms on which you rely seem to be turned on their heads. This is not, for example, a rotation where you can usually have a polite conversation with the patient and explore, in perfect order, the history and the review of systems. In the ICU the patients often come in with nothing but a vague transfer note and an incomplete list of medications. They can’t talk and there is not always a family member to fill you in on the patient as they head south before your eyes, possibly for the last time.

It is a rotation where you have to do something big, and soon, for most of your patients and this kind of decisiveness is something that doesn’t come naturally. You have to learn, in short, to be the kind of doctor that goes into the patient’s room when something goes wrong, not the kind who leaves the room to get help. Emergency medicine residents tend to like their ICU rotations because this kind of thing is right up our alley. In turn our ICU nurses apparently really like to have the Emergency Medicine residents rotating because we’re not afraid to make decisions and don’t have to call a synod of attendings and residents to do a lumbar puncture or intubate.

How do you feel about pharmaceutical sales reps?

I’m working on an article about pharmaceutical reps. The short answer is that I don’t take gifts from them, don’t need their crappy pens, and as I eat for free at my program don’t need to eat their lunches even if I wanted to (which I don’t). Part of my antipathy is my dislike for bad salesmen which most drug reps are. Give me a good salesman selling a good product in which he believes and with him will I gladly do business. Drug reps however, tend to be smarmy glad-handers peddling products which they do not understand using questionable statistics and glitzy marketing. It’s embarrassing and I cringe to watch a typical drug rep present his little spiel before a noon conference to which he has provided food.
(To be continued…)

21 thoughts on “Twenty Questions for Dr. Bear (Part the Second)

  1. Dear Panda,

    I am currently a FP attending, will be going back to do a diagnostic rads residency next June. Just wanted to let you know that I appreciate that someone as articulate as you are telling the new guys like it is.

    Anyway, I went to a school with a PBL curriculum, and was actually in the first class after they switched. What a royal CF. I would have killed for a lecture based format. Anyway, I survived. But your line about a “group dynamic masturbatory fantasy” is classic, and sadly very true. There were many times in small group when someone just wouldn’t get a topic we were discussing, and then the whole group would lurch to a halt while we got that person up to speed. I have always been a self-directed loner when it comes to studying, so wasting my time because someone else doesn’t get it really pisses me off.

    By the way, thanks for your service. I have brother currently in the Corps as well.

  2. “I rotate at a hospital that most of you have never heard of and probably couldn’t find on a map but it has a cardiology program that turns out first rate cardiologists who have no trouble finding jobs or patients.”

    Good point.

    Which hospital is this? I’ve been in academia for too long; I don’t know anything except the big names 🙂

  3. About the lecture format: Amen. I recently stopped going to all but our required lectures, and it’s heaven. Yesterday I got days ahead in readings, and I didn’t lose the middle half of the day sitting in class. Between listening to recorded lectures (played back at high speed) and the extra review time, I understand the material much better.

    One of our deans asked me about PBL. They’re considering the change because *nobody* goes to lecture. I told her that everyone has their own learning style and to keep it. When I see her next, do you mind if tell her the “jar at the baby metaphor?”

  4. Dissenting opinion on PBL here. My school, as I thought most did, had a hybrid version. We did mostly lecture, maybe 20% PBL depending on the course.

    I thought it had a couple advantages. For one, it made the basic science stuff a bit more clinical, which I was hungry for at the time. Our PBLs were all clinically based.

    But more importantly for me, it mixed things up. I got fatigued of the lecture-study-lecture-study pattern, and this was a break to my brain.

    Looking back, I have more memory of the PBLs than the lectures. But I have a crappy memory for anything further than a couple years back. And there were certainly those stab-me-in-the-eye-with-a-pencil-to-put-me-out-of-my-misery moments…it wasn’t all roses.

    I can’t IMAGINE doing 100% PBLs, as a couple schools I applied to were doing. Do schools still do that now?

  5. My school recently switched over to an entirely PBL curriculum. All courses, including physiology, are now PBL. I can’t imagine what a disaster having bio majors teach themselves math is going to be like.

  6. Studying in a group is highly inefficient, often highly annoying, and puts you firmly on somebody else’s schedule for a significant portion of the day. Instead of just studying you are asked to become an active participant in someone else’s group dynamic masturbatory fantasy. My medical school dabbled in Problem Based Learning and by the end of a typical three hour group session I was ready to shoot myself in the head.

    Sounds like a socialist dream, depriving people of self-sufficiency and replacing it with the “collective.”

    Remember: it takes a village to raise a child!


  7. Dittos, Dittos, Dittos on every topic you touched.

    I would have gone postal if my school did PBL. I was completely perplexed by the strange folk that formed study groups and stayed up all night drinking coffee and studying in martyrdom. In general, these were not the top tier of students. The best students went to the important classes and otherwise studied effeciently on their own and were playing basketball or surfing while the future primary care doctors of America were just getting started their all night “group dynamic mastubatory fantasy”.

  8. Thank you for your insight in every instance. In particular PBL; My story: My school spent a great deal of money to introduce a PBL style review for our final semester before the boards. They were concerned because 2 or 3 students always seemed to fail and they wanted to offer a review. They developed a mandatory attendence course–8 hours a day for 5 weeks as all classes were finished save path II. Students screamed and were threatened and finally submitted. I considered suicide after the 4th day but became torn by a desire to shoot several in my “working group”. The result? Failures skyrocketed to an unprecedented over 10% of (my) class. They quickly scrapped the course. This was many years ago but I still think back on that time with anger.

  9. I thought PBL worked OK as a small integrated part of a curriculum that was primarily based on lectures. We did an “expiramental” module in rheumatology last year that was part lecture and part PBL. For the clinical modules (in a modern curriculum) this helped consolidate the lecture material. It would have been a DISASTER if that was all we did however. Also, too much in a week is too much. One or two sessions tops seems to work. Also, we had a lot more control over who was in our groups, so it was atleast more like a divisioin of labor than outright academic communism.

  10. I go to an all PBL school, and while a lot of your criticisms are valid, some are not. It’s true that you have a huge douchebag contingency that hate being told they are wrong and need to shut up, but it is also nice that you only are in group for about 6-8 hours a week. So it’s not like you’re spending all day gnashing teeth and then have to go home to learn. And you definitely don’t study in a group unless you want to. It’s more like a “morning report”, working through the workups and what not than totally unguided. That said, the criticism about faculty not having to do squat and still collect tuition dollars is spot-on.

  11. Hahahahahahahahahahahahahah
    Classic post! (wipes tear from eye)

    My school was mostly lecture- but was trying to transition to PBL (all the rage- late 90’s). As a consequence, they tacked on PBL sessions to an already full day- sometimes 11 hour days (not kidding) All I learned was what a bunch of tools I had chosen to surround myself with, and what it is like to have your time truly wasted.

    Seriously, as the famous quote goes- we all stand on the shoulders of giants. Meaning generations ahead of you owe it to you to show you past mistakes and give you insight and knowledge. This, as applied to a professional school, implies a solid cirriculum and thoughtful lectures. I honestly see this as a baby boomer product. “F*** these kids, I am not spoon feeding them MY knowledge. They need to figure it out on their own. (I am still gonna need that increased tuition rate though)”

  12. Thank goodness PBL only constitutes 30% of our curriculum. I’ve been lucky with my group so far (not too many douchebags), but part of the problem we’ve had is the uneven quality of preceptors between sections. You can have a great one that actually teaches you something, or a complete dick who gets off on cutting people down. Plus, to a certain extent I agree that you could just read the clinical scenarios yourself and get as much out of them.

    As for the sales reps, I haven’t been bothered by them yet, but I totally understand your innate mistrust of any type of sales person. I always assume they are lying to me (be it while buying a car, or a new pair of shoe). I have no reason to assume that drug reps would be any different.

  13. “I was not the best student being something of a slacker (and I should have studied a lot harder) but I comfortably passed everything. There is time enough in the day. With a little self-discipline you should have a low-stress first and second year and still make good grades.”

    Beautiful. I’m a first-year scrambling to learn the ropes and your tenet of “low-stress yet good grades” (with efficient study technique) is my motto.

    My particular campus does not use much PBL at all; the times I’ve been in a group-study session have been awful, and I much-prefer studying on my own. The material is all right there; plugging away at it on my own forces me to learn much faster than hearing some super-gunner in the medical-student lounge rattle off the rotator-cuff muscles and innervations (loudly…purposely) like nobody’s business.

    The herd-mentality is high at my school; we have a big class and there is a lot of mental and group “masturbation” as you call it. Awesome post – worth 10 minutes away from anatomy 🙂

  14. I have to disagree on the biggest shock–at least for me. I guess I was some sort of dewy-eyed naif who really believe all of my classmates and I had sterling motives in going to medical school to become doctors–that we were going to help people first and foremost. I discovered that my classmates were a cross-section of the general population in terms of morals, motives, and common sense, at least. Yes there were plenty of brainiacs, but also some raging personality disorders, egotistical SOBs and back-stabbers. I’m just glad medical school ended!!!

  15. Old-school loyalty obliges me to say that, for a person who always hated review sessions and study groups, and still learns best in a corner with a book, I was pleasantly surprised by my school’s use of PBL: one or two afternoons a week with a quiz format to go over material previously covered in lecture. Once we got past on truly horrible teacher in first year, these were almost always enjoyable and profitable sessions. I really think that they are a valuable opportunity to learn to work through problems with a team – which is what healthcare today consists of. One member of my team had an ER background, and knew what to do next in the emergency scenarios. One had been a biology researcher, and helped us understand the very abstruse science. I knew what to do with the pathology slides. And so on. I hate socialism, but since the group always did better on the quizzes than the individuals did, I can’t object. It just depends how much time the school spends on PBL. 30% is plenty.

  16. Are there any white men in medicine today? I am MS1 and it seems that more than half the class is Indian (subcontinent)? The rest is a combo, white, asian, and 1 or 2 blacks and hispanics? What is this about?? Also, I am male + I think I would like to do OB/GYN but it seems that this is all female these days. Can men still do OB/GYN?

  17. Sure. Plenty of white boys, at least in my neck of the woods. But as Indian and Asian families traditionally embrace education, it is not surprising that their children are over-represented. That’s the beauty of America. Immigrants flock here for a shot at a better life for themselves and their children.

  18. Ha, this was funny. Because not only am I interviewing at an entirely PBL based school, but I’m also a Mac user. PS – I’m excited by the prospect of PBL.

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