Some reactions on step 1 and the first 2 years


Category : Medical Rants

Victor Maitland wrote:

Let’s not forget the real significance of Step 1. Yes, passing the exam is necessary to gain licensure. However, students do not dread the exam because they worry that they will not become licensed physicians. Students dread the exam because Step 1 scores are the first thing (and if they are not high enough, the only thing) that residency directors look at when evaluating applicants.

And perhaps much of the material that Step 1 covers is not important for practicing physicians. Nonetheless, the traits required to obtain a high score (for example, a willingness to ignore friends and family to spend tremendous amounts of time performing menial tasks) are very similar to the traits required to become obedient and dutiful intern.

Victor is correct that many residencies use step 1 as a first cut. If you scores are substandard your chance of even getting an interview is greatly diminished. He is wrong to correlate high scores on step 1 with being a good intern. Rather he champions obedient and dutiful interns.

While those may be traits desired in some specialties, I would argue that those are not the traits we should champion. Being an excellent physician requires a wide range of attributes. Step 1 really does not test any of those traits. We need medical knowledge, medical reasoning, bedside manner, integrity, and judgment – to mention a few attributes.

Step 1 scores predict other randomized test scores. These scores give us an incomplete picture of a candidate.

I love this comment:

I think the typical basic science approach also reduces the number of medical students who aim for a primary care career. Everyone who teaches a student in the first two years is a hyperspecialist, with a deep spike in knowledge of a very narrow area. They are excited by the tip of the spike, which they have spent many years getting out to, but the students are starting at the very base. This has two problems: 1) the hyperspecialist often loses touch with what it was like to start at the base, and the lectures are a hodgepodge of facts pulled from all levels of specialization, not just the basic ones; and 2) the hyperspecialist often does not know conceptually related information that is ‘horizontal’ to his/her field and thus cannot teach it.

It is just this broader, ‘horizontal’ understanding that generalists must develop, yet there are no role models for that type of learning. Instead, medical students develop a bunch of ‘mini-spikes’ scattered throughout the fields of instruction, with broad areas of fundamental knowledge about relationships among these concepts totally missing.

The 3rd and 4th years are somewhat better, but in most medical training, even the clinicians are specialists, not primary care generalists. A specialist is going to take, and teach, a fundamentally different approach to a given problem, because in most cases potential diagnoses that are outside of their expertise have been (or are assumed!) excluded by a previous generalist evaluation.

By the end of all this training, a medical student is going to internalize a world view in which deep specialized knowledge is more accomplished and of higher status than generalist and integrative knowledge and skills. And it doesn’t help that specialists are paid more to boot.

This comment makes my points better than I have. We need subspecialists. They are important in research and in caring for unusual disease. We also need the perspective of generalists. Our approach adds an integrative function.

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Comments (1)

I could not help being struck by this discussion, and others taking place on the web, concerning doctor training and the US military, never served. Painting with a broad brush. Starting in the 1940’s and continuing through the 80’s different branches had to periodically remove a group of DI’s for behavioral reasons.

These were the typical bad movie stereotypes of the DI abusing the recruits. There battle cry was: In the day or When you have been in battle this will seem easy. This seems to be the same attitude of some doctors when it comes to teaching medicine. Long hours and abusive relationships seem to be justified by the need to reach a standard that does not exist.

Medicine, like the military, appears from the outside to be a team effort. The days of the lone doctor sitting at the bedside are gone, replaced with a hospitalist and staff of specialist. Much like the young recruit of today, doctors need to be computer literate, as well as possessing hands on skills. There is a different skill set needed to be competent and a “go it alone” attitude will not complete the mission.

Medicine needs to take a page from the military and take a hard look at the training system. The current system is not producing doctors with the desired traits. Many of the old guard will not like to see their sacred cows pushed aside in favor of newer methods. Money will be an issue as time on call will be measured against the time frame where learning stops and a person is just functioning.

The military today has many training safe guards, and we in the public hear when they fail. The reality is they turn out thousands of well rounded people ready to perform to excellent standards. While no system is perfect, one does not need to reinvent the wheel when looking for better educational models.

Steve Lucas

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