The Last Summer for Medical Students

12 01 2012

The summer between first year and second year of medical school is sometimes referred to as the “last summer” since it is the last time students can travel or take off before they start the journey towards USMLE Step 1 and then their third year clerkships.  With the angst building, first year medical students are actively deciding in the dead of winter what they will do over the summer.  One popular decision is to do research – this is not uncommon since residency programs are increasingly competitive and look for students who have a commitment to scholarly work.  However, there are a plethora of other things students could do as well.    As tonight is our “Intro to our Summer Research Program” for Pritzker medical students, I thought I would share some of the most common questions I get about the “Last Summer”:

  • Should I do research in a competitive field?   The answer here is to do substantive research that you are interested in with a “CAPE” mentor (Capable, Available, Project interests you, Easy to get along with).   As my premed advisor once told me, “Mickey Mouse” research is not going to look good to anyone (no offense Mickey).   The key is to find something you are passionate about – after all you have to tell this story on your interview trail of why you choose to do this and the answer “because I wanted to go into ortho” is not really that captivating to anyone (even to an orthopedic surgeon).   Instead, if you do something you are passionate about, like community health work, you can always tie it back to your chosen field.  Most residency program directors don’t expect you arrived in medical school with laser like focus towards their field anyway and expect to hear some type of journey or a-ha moment that drew you to their field.  Because competitive specialties are often reimbursed for clinical work and tend to be smaller departments, they depth of research opportunities may be more limited.  But, don’t forget that neuroscience research is relevant to neurosurgery – and oncology research on head and neck cancer is still relevant for ENT and so forth.  The best research is often interdisciplinary and crosses department boundaries so you should not be afraid to either.  It’s also important to remember that as a first year student, it’s hard to even know if you will be competitive for radiation oncology or associated competitive specialties.  You will need killer board scores, and great clinical grades.  So, while you may think securing the research with the Dept Chair will give you an extra ‘edge’, nothing and no one can make up for a poor performance on high stakes exams or clinical rotations.  So, don’t forget to study!
  • I want to go to country X?  How can I get a global health rotation there?  Well, certainly the urge to travel is strong in anyone (including me).  But, you need to separate your travel bug from a genuine interest in global health.  Most global health rotations are not a vacation – and may not be what you think of as “tourist” destination (despite the short-lived popularity of Off the Map).   Maybe your stars are aligned and your school or a nearby affiliate you know has a program near your hot spot of interest.  Usually, however, it is not that easy and you should consider how strong your affinity is for a specific country or location versus your interest in getting the best global health experience possible.  Global health programs that fund medical students are not easy to come by.  So, if you are genuinely interested in global health, it is always better to go with an established program and mentor to get the most substantive experience even if it’s not in the exact country you are interested in.  The other thing to remember is while this may be your last summer for a while; it is not your last vacation!  You will have time to plan a vacation to your designated hot spot if you can’t work it in this summer.
  • Do I have to do anything?  The answer here is easy – no, you don’t have to do anything per se with your ‘time off’.  Many students find themselves on the hamster wheel of endless extracurricular activities.  The real question is what is your goal? If it is to go home and see family and friends, there is nothing wrong with that!  The key is to ensure that you are doing something with your time off that will make you feel ready to face the second year of medical school.   It is easy to forget that there is a lot of time to participate in extracurricular activities at various other points in your medical school career.   The key is that if you will regret not spending time with your friends or family this summer, then you need to make time to do that.
  • What if I want to do everything because I don’t want to close any doors?  This is not an uncommon feeling for medical students. However, its important to remember that your summer work is not choosing a specialty! There is essentially nothing you can do over the summer that will ‘close a door’ – there may be some things that allow you to put your foot further into the doorway but that does not mean another door will close.   The only doors you close are the ones in your mind.   Most students decide on their specialty after their third year rotations and will often fine-tune their experiences in research in that area in the fourth year.   Another thing to consider is to do research in a cross-cutting area like ethics that could apply to everything.  Sometimes the angst you may be feeling is about making a choice that is wrong for you.  However, the truth is that as long as you are genuinely interested in the opportunity, you cannot make a wrong choice since it will be an easy story to tell no matter what you do.  Since everyone is different, it is always good to get individualized advice from a faculty advisor at your school who can comment on your specific career and research goals.

Finally, no matter what you do with your last summer, don’t forget to make sure you enjoy it!

Vineet Arora MD





Transforming Medical Education: Trust, Time, Teams & Technology

28 11 2011

This past Thanksgiving, I was able to reflect on the always jam-packed and inspiring Association of American Medical Colleges 2011 Meeting that took place earlier this month in Denver.  The theme of the meeting was transformation.  It was certainly an interesting theme with the undertones of economic recession and the GME funding crisis- and that was before the failure of the Supercommittee to reach a resolution.  So, how does medical education need to transform?  In more ways than one, it turns out.  So here are just 4 that were the recurring themes of the meeting and being a fan of alliteration, they all begin with “T”.

  • Trust – it was clear that we need to restore the Americans people trust in physicians and in the medical education process.  While students enter medicine to make a difference, something that they see in their journey to becoming a physician makes them jaded and they sometimes lose sight of their initial intention. Is it debt, burnout, role models…Or likely some combination of the 3? It does not matter, because we have to restore their faith in teaching– yes teaching.  Teaching is the heart and soul of our medical education and it is sometimes the easiest to lose in an academic health center focused on NIH dollars or US news world report rankings.  In addition to teaching our students, it is time to teach another constituency, our patients and Congress about the critical need for medical education.   And in fact, advocacy is something we need to be teaching our own trainees so they can engage in the dialogue regarding the future of healthcare.
  • Time- perhaps the most radical proposal advanced was by Victor Fuchs who suggested that we radically redesign medical school to have medical students specialize 2 years after medical school and enter specific pathways like they do in many other countries and in other fields.  I’m all for shortening dwell time for our medical trainees, but I am not so sure that young people are ready to make a serious commitment about what they want to do at such an early age.  There has to be a middle ground since at the same time, one of the most well attended sessions was “who cares about the 4th year of medical school?” which included many insightful comments about the need for reflection and consolidation of core skills.  So, clearly not all time is easily tossed to the waste side.
  • Teams- given the projected shortage of over 90,000 physicians by 2020, it is important to reorganize care into teams.  While there is a lot of controversy about what to call nurses who have PhDs, that was not the focus of the meeting. It was about how can you encourage everyone to practice to their highest level of certification.  Team based competences have actually been developed by several groups and have been advanced by many schools with inter professional learning.  One difficulty we face at home is that we don’t have allied health professions, but we are brainstorming how to involve actual nurses and pharmacists in training medical students.
  • Technology -there was a lot of discussion about technology to boost medical education.  There was even a technology in medical education abstract session moderated by @motherinmedicine and including podcasts, iPads, and social media in medicine.  Perhaps the most interesting speaker was Chuck Friedman at the University of Michigan who is the former technology czar of the US and eloquently highlighted the need for moving medical education from wrote memorization to a distributed knowledge where the most important information future physicians will need to know is not what the information is off the top of their head BUT how to access information.  He went so far to say testing would move to “unassisted testing” followed by “cloud-supported testing” which would then merge into a pass or fail based on performance on both.  I know all of us who certified or recertified recently would welcome assistance from the cloud- it is after all the closest approximation to real medicine.  However, my hands down favorite moment of this session was when someone astutely asked what about these physicians when the power goes out or when the computer system fries.  His response was simple and so spot on… “Dont get me started on the state of IT in our teaching hospitals”.
So, while we just celebrated a holiday and accompanying ritual to give thanks, it is now time for medical educators to transcend the traditional status quo and instead test novel techniques to transform medical training — not only to restore public trust but so we can also train the trainees who will treat us in the future.
–Vineet Arora MD




Differences Between Real & Fake Patients

9 10 2011

Each morning this week, I am rounding on a busy inpatient general medicine service in an academic hospital seeing real patients.  Each night this week, I am also studying for the internal medicine recertification exam where I am doing countless MKSAP questions which present the diagnostic and management conundrums of “fake patients.”   While there are a variety of things I could say about the process, one thing is clear- the real patients don’t ever come as neatly wrapped and easy to figure out as the pithy and succinct questions based on fake patients in the prep questions!   Perhaps the most distinct differences are that real patients suffer from real problems that plague real people…and that is of course why one of the most important lessons for our medical students is that being a good doctor is more than just how well you do on a standardized exam.  It is knowing how to mobilize a team and resources to tend to all of these problems in the same patient.   Here are just a few ways in which the real patients we see differ from testable “patients.”

  • Social problems trump medical problems – Many of the patients we see suffer from poor health literacy, lack of insurance, access to safe housing, affordable healthy food, and access to healthcare outside of the hospital that prevents optimal care and treatment of their medical conditions.  Understanding how to bring up and address these problems is equally important to design a customized care plan for a patient that will ensure their most optimal recovery and health outside of the hospital.
  • Caregiver support- Many older patients who are chronically ill are cared for by family members who suffer a lot of stress.  This stress manifests in different ways and sometimes you see that sigh of relief when they come to the hospital since they are in need of as much care and support as their family member.  Arranging home services and providing and ensuring caregiver support is a key part of hospital care these days.
  • Insurance compatibility – Most patients require services that go beyond hospital discharge, such as home IV antibiotics or short-term rehabilitation stays after hospitalization to recover.  In addition, patients often require close follow up after hospitalization. Unfortunately, arranging such things for patients who are uninsured or underinsured is increasingly difficult.  Perhaps this is one thing that we can hope to change with the implementation of the Affordable Care Act- lets at least hope so.  But for now, it’s sometimes a guessing game how to piece together the most logical plan that will also be optimally covered.
  • Medical necessity – These days, patients can’t stay in the hospital to “recover” unless it meets strict criteria for inpatient admission.  This process is audited by private contractors so hospitals are required to follow strict guidelines or face harsh penalties from Medicare.  The challenge is that for a variety of social issues documented above, patients may not be ready to go home (caregiver not ready, patient lacks understanding regarding illness, etc.) but they have to go home or be faced with footing the bill for their stay.   Given that rock and a hard place, it’s a difficult position for any doctor to be in.

Because medicine does change and evolve very quickly, we refresh our medical knowledge every 10 years by testing our clinical acumen through ‘caring’ for fake patients on a written exam.  But, a written exam can only go so far…Given the sea changes occurring on a daily basis in our healthcare delivery system, it is equally important to stay up-to-date on systems-level changes that influence how we can actually provide care for real patients.  After all, both are necessary for good doctoring.

Vineet Arora, MD





Rising Above the Sea of MacBooks: “Edu-tainment” and Other Tips

12 09 2011

Although Steve Jobs has stepped down as CEO of Apple, his legacy for physicians-in-training is very palpable. Or should that be visual – As I looked into the auditorium of eager and bright incoming medical students this Summer, I saw a bunch of Apple’s staring back at me – sleek, silver and unmistakably MacBooks.  This is the millennial generation so why would I be surprised?  Maybe because it is more ever-present than before this year.  Could it be that the entering class of 2015 had more millenials?  Actually, another hypothesis has also been put forth that is equally if not more plausible…our medical school auditoriums were installed with new desks and chairs.  While these were well received, the desks served as an inviting surface just beckoning for the MacBooks to be placed there.    As a result, you’re never sure if you’re competing with Facebook, the worldwide internet, or even email messages that appear more interesting than your class.   Since lecture capture technology has made it possible for people to view lectures from home, it’s important to make attending lecture in person worthwhile.  Well, here are some tips for medical educators who ‘lecture’ in this new age.

1.  Engage in “edu-tainment” – As Scott Litin at Mayo refers to it, “edu-tainment” is the goal – entertainment via education.  How does one incorporate entertainment into lecture style?  Well, the easiest way is through humor.  This is difficult since not everyone is funny by nature so it may be that you have to inject humor in odd ways.

2. Play games – Games are inherently fun and interactive can stimulate a lot of learning and discussion.  While you may be thinking about computer games, easy games can often stimulate learning.  One of our research ethics faculty played 20 questions with the group of students to teach about landmark research ethics cases.

3. Turn into a talk show – There is nothing more boring than watching the same person for an hour give a talk.  It is much more interesting to watch a panel of people tell a story about themselves – whether it be a patient, another physician, or another student.  I still remember medical school lectures with invited guests that had this talk show appeal due to the lack of power point and focus on the story.  While I’m not suggesting a Jerry Springer approach, who doesn’t love Oprah – at least Chicago has several role models to choose from.

4. Showcase video – Video is one of my favorite teaching tricks.  One well made video can communicate a thousand research articles.  In our week of Scholarship and Discovery, our faculty used videos from Xtranormal (no it was not the famous orthopedics vs anesthesia) but a similar one.  One faculty who could not attend taped a welcome introduction, and another used a clip from “Off the Map” which is now off the air but is still an effective reminder of how NOT to perceive global health.

5. Use audience response – Use of Turning Point clickers can result in instant feedback and engagement with students as they see the results of their poll immediately. It also tells you how many people who up to class!  The only problem is that passing out the clickers and collecting them can be rather time consuming.  So, another possibility is to issue them at the start of class which is done in some colleges and used as a way to count attendance (until a brilliant undergrad brings in a bunch of clickers to class to vote for their lazier friends!).  Here Steve Jobs can help again – Turning Point has audience response systems for iPhones and iPads that can be used and automatically identify people- but it would require that everyone have a smartphone and purchase a license to the software.

6. Refer to the internet– Given that students are on the computer, you can take advantage of it and ask them to visit internet resources in class by showing them urls or web pages that are of use.  Sometimes you may actually refer to your own course website like we do.

7. Provide fancy color handouts – While handouts may sound like they have gone by the waste side, there is nothing like a fancy color brochure or handout to create a “buzz”.  It’s almost like a souvenir of their hard journey to class that day.  If you ever want to provide someone with a ‘leave behind’ that looks important, lamination is key.  A color laminated leave-behind is even better.  Pocket cards are some of my favorites.

Is there any guarantee these tips will work?  Of course not.  But, what’s the harm in trying?  While some professional schools have gone so far as to block wireless in lecture halls, the truth is that current medicine is augmented with the help of computers and online resources- so we should figure out how medical education can be too.

–Vineet Arora, MD





Becoming a Medical School Memory Champion via Cartooning

11 06 2011

Congratulations to all of our MS2 who recently took the dreaded USMLE 1 Exam!  Unfortunately, much of medical school is about memorization – and believe it or not, there is a science to memorization.  I learned this from one of our students—who describes her experience meeting a ‘memory champion’ and picked his brain for some memory tricks for Step 1 including cartoon images.   As I’ll be speaking at the upcoming Comics in Medicine conference here in Chicago this weekend, it seemed fitting to describe her journey.

Right around the time I was beginning an epic five-week studying stint to prepare for STEP 1 of the Boards, Joshua Foer happened to be a guest on The Colbert Report (my go-to 20 minute study break).  Joshua Foer is this ridiculously young and talented journalist who won the US Memory Championships (yes this exists).  If his name sounds familiar you may be thinking of Jonathan Foer, his equally talented older brother who is also a writer.

Anyway, Joshua Foer was promoting his recently released book “Moonwalking with Einstein:  The Art and Science of Remembering Everything.” The book is about memory and his adventures in the world of memory competitions. Apparently there is a small group of people who get together each year and have memory competitions which consist of several memory “events” including faces of strangers, poetry, random words, numbers, binary digits, stacks of cards, etc.  Participants wear noise cancelling headphones and blinders (think sunglasses with two little holes drilled out) to reduce distractors as much as possible.  After attending the US competition as a journalist he wound up being tutored by and English memory master and winning the completion the next year (the US memory scene is not very developed, the Germans are much more serious).

Foer stressed that memory champions are not born with extraordinary powers of memory. They training themselves to use some established memory techniques and are constantly developing new ways on remembering things. This intrigued me since I wondered if I could use some of these techniques to master the overwhelming volume of facts needed for the Boards.  I started reading his book and loved it. It’s very pop-science quick read.   When chatting with one of my best friends who was studying for the Bar, she says, “Oh Josh Foer is giving a talk at this spot in Echo Park this weekend, let’s go pick his brain for ideas.”  (I studied in LA).

So we went… and I managed to get up the nerve to ask him for any advice.  In the most bizarre coincidence, he tells me that his wife is a also second year medical student studying for the boards (bet she’ll do just fine!).   Since visual mnemonics are big in the memory world, he explained that when making a visual aid, the funnier, scarier, raunchier, and stranger it is, the easier it is to remember. He recommended trying to enrich the image with as much detail as possible. He also explained that, though these images help you remember, thinking up good ones takes a lot of creative energy and can be exhausting. That’s one of the things you work on developing when training for a memory championship – the capacity to conjure up rich, creative images really quickly.  He signed my First Aid for the Boards, and I went home and started using that idea by making cartoons (a la Micro Made Ridiculously Simple).

He was right…creative effort is draining.  Sometimes, it took forever to think of something that would stick – but the stuff I made cartoons for is in the vault! Here is an example of a visual aid I made myself for a mucopolysccharidosis, Hurlers. In this image there is a gargoyle (Hurler’s causes gargoylism) hurling a ball (Hurler’s).  He has a dark spleen and liver (spleno- and hepatomegaly) and rain clouds for eyes (clouded corneas). He is also panting and gasping because of airway obstruction.  What I love about this picture is that if I can remember one part of the image (one thing about Hurler’s) the rest of the image (the rest of the facts) come back to me. The other nice thing I noticed is that on a lot of Boards questions you narrow it down to two answers, but it’s been a while since you looked at that material and you are 70% sure you picked the right answer. If I made a picture like this I was sure, clouded cornea’s goes with Hurler’s, not the related Hunter’s disease.  I used some other techniques from the book: the “memory palace” for biochemical pathways; the “major system” to remember lab values.   While memory tricks don’t lend itself to everything, it was really helpful for stuff that is difficult to reason through (lysosomal storage diseases, embryology).

–Gabrielle Schaefer, MS2

Thanks to Gabrielle for describing her experience!  And who said doodling in class never got you anywhere?








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