global health

The Last Summer for Medical Students

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


Whittling Costs in White Coats

At the beginning of last week, I was excited to be invited to take part in the ABIM Foundation Summer Forum, where the who’s who in medicine convened to discuss how to create a sustainable healthcare system, where costs are controlled and quality of care is preserved.   We heard some bold vision and ideas, many of which were focused on badly needed policy levers or system redesign.  However, as I ended my week on Sunday with investing Pritzker’s new medical student class with their white coats, I was wondering how we can teach and empower individual trainees to do their part.  As our speaker highlighted so eloquently, the most powerful thing about the white coat is what and who is in it…and also the learning that takes place in it.  So, in that vein, here are some thoughts for what students and residents can do.

  • Read up on the topic – some excellent resources I heard about at the meeting
  1. Physician Stewardship of Health Care in an Era of Finite Resources– a recent article in JAMA by Drs. Chris Cassel and David Reuben regarding the various levels of stewardship
  2. Personal Reflections on the High Cost of American Medical Care – a recent article in Archives of Internal Medicine by Dr. Steven Schroeder
  3. The Pricing Of U.S. Hospital Services: Chaos Behind A Veil Of Secrecy – a classic by noted economist Uwe Reinhardt
  4. Less is More Series – a great resource in Archives of Internal Medicine edited by Rosemary Gibson and others.
  • Listen to the patient  Of course, this sounds simple…but the truth is that more times than not, the answer is in the patient history.   With duty hours and workload, taking a detailed history sometimes takes a backseat to reviewing the electronic iPatient.  One approach is to start with two open questions:  (1) Tell me about yourself; and (2) What are your healthcare goals?   Often, the key is to try to understand the baseline.  I once took care of an older patient who had abdominal pain and had received over 40 abdominal CTs over the past several years.  When we were able to gather more information from the patient and her family, it turns out that she has had bad abdominal pain for over 30 years that would come and go!   By working this information into her discharge summary and plugging her into primary care, our hope was to have her avoid future costly and harmful workups.  As I’ve mentioned before, students often have more time with patients than residents or attendings and can often take the most helpful and detailed history!
  • Learn the physical exam Often times, we rely on tests since we do not trust our physical exams.   It is too easy to get an echo when you are wondering if you are truly hearing a murmur.  The lore here is that you need to  listen to a lot of normals to be able to detect the abnormal.  Because of this, when I am on service, I usually invite the third year student to examine every patient with me so they can see a lot of exams.  Usually by the end, they are more confident in their ability to detect crackles or murmurs.  As stated by our white coat speaker, the stethoscope is indeed a powerful tool.  Interestingly, with the infectious increase in global health experiences among medical students and residents, working in resource poor settings requires ingenuity and reliance on the lowest technologically feasible solution.   Closer to home, volunteering in a free clinic is likely to provide one with the same experiences.
  • Don’t just check boxes but ask why the test is indicated Trainees can ask the difficult question – why are we ordering this test or medication?  Is it indicated?   An even better question to research is whether there is a CHEAPER (we can’t shy away from using that word anymore) alternative that would provide the same information?   For example, before every PE protocol CT or Doppler to rule out DVT, I always ask my team to calculate the Wells score so we understand if the test is indicated and what our pretest probability is.  In addition, every study has a downside, whether it be hospital-acquired anemia from phlebotomy or incidentalomas and pseudodisease from excessive imaging.  It is easy to check boxes, it is harder to question why you are checking them.
  • Try to find out how much the test costs While the answer is elusive, the goal is to start the conversation in your own backyard.  There are anecdotal reports of residents going back over 10 years who have tried to work with their hospital billing departments to find out how much things cost.  Moreover, greater knowledge of costs will change practice patterns as we’ve discussed before.
  • Counsel patients One impressive thing about the ABIM Foundation Forum was the representation of patient advocacy groups who were willing to partner with physicians and physician groups to reduce the costs of care.  While the image that may immediately come to mind most is of a patient coming in to request a test that is not indicated, engaged and informed patients expressed the desire to work together and that less is more.   In some communities, there is a lot of distrust of the medical care system and these conversations have to start one patient at a time.

Unfortunately, whittling healthcare costs is not as easy as teaching trainees.  As long as our systems and the faculty within them promote costly workarounds such as misrepresenting tests as urgent to expedite them, ordering tests as fast as possible for fear of discharge delay, or wasteful lab testing, trainees will be reprimanded for NOT doing something.  Therefore, to truly make change in our teaching hospitals, we must also ask that our faculty reach deep into their own white coats and find the courage to say “Don’t just do something, stand there.”

–Vineet Arora, MD

Bleeps and other Medical Lessons from the Emerald Isle

I recently spent a week in Ireland, taking in the sights and spirits sometimes even together (see Dublin Literary Pub Crawl and the view from the top of the Guiness Factory).  I was actually there for work too – visiting the University College of Dublin and the Mater Miserecordia Hospital – or the original Mercy Hospital as they refer to it.   As the future of primary care, residency work hours, and the healthcare insurance system continue to cause angst in the US, we often find ourselves referencing what our European colleagues do.  Well, there’s nothing like asking the people and observing for yourself.  For example, the first time I heard the word “bleep”, I thought they were politely avoiding colorful language in front of me.  But in fact, to page someone is to bleep them and you’re always afraid your bleeper will go off.  While this is a small difference, there are quite a few substantial differences in their medical education system.

  • Residency work hours?  I was expecting that the European Working Time Directive was in effect, where all workers are to work only a maximum of 48 hours.  What I learned is that each country has determined its own ‘solution’ and really ‘style’ in managing this constraint.  In Ireland, to preserve some aspect of continuity, they have in effect argued for dividing educational hours from ‘service hours.’  Therefore, all junior doctors can work 48 hours of ‘service’ and have an additional 12 hours of ‘education’ for a total of 60 hours per week.  The residents do still have a culture of staying until the work is done.  But, they are on the cusp of change since this years interns are now limited to 24hour shift maximums creating some concern that they will not have the same experience and learning as the seniors before them got.
  •  Supervision?  The team model of inpatient care was in full effect but with slightly shuffled roles.  Interns did mostly cross cover for large numbers of patients.  Admitting was done predominantly by residents (aka Senior House Officers or SHO).  Also in house is a registrar, who is a physician who has completed at least 3 years of post graduate training and is available for supervision for the intern and senior house officer and is spending another 4 to 6 years in training in a clinical subspecialty at this level.  Consultants (aka attendings) come by for rounds less frequently since the registrar is quite capable having in fact completed their training.
  • Cost of medical school?  Indeed, medical school in Ireland is free for EU citizens, but only if you continue to pass so there is a strong incentive to pass.  Entry into medical school can be from high school but also can occur as a graduate of the college.  In fact, there is quite a diverse generation of students that are all in training together simultaneously.  Moreover, the tuition from foreign students (non EU that is) is what the medical schools thrive on, which was similar to my experience in China.  The foreign students come from all over, but quite a few come from Malaysia.
  • Access to care?  While healthcare disparities are not focused as much on race as they are on income.  Those that are rich are able to buy private insurance and ‘jump the cue’ so to speak to get a consultation with a specialist.  If you don’t have private insurance, you’re relegated to the public insurance system where it could take several months at least to see a rheumatologist or orthopedic surgeon.   Seeing a general practitioner (primary care doctor) also costs quite a bit of money so people don’t visit the doctor unless they have to.  Interestingly, in Northern Ireland, which is still under British rule, citizens can see their GP for free.  In certain rural areas of Ireland, Gaelic may be exclusively spoken by patients so doctors in those areas need to have a strong command of the native language of Ireland. 
  • Competitive specialties?  While I explained to my colleagues what the ROAD was, they speculated it would be the O’s for them– Opthalmology, Orthopedics and OB/GYN.  While the first 2 are understandable, I had to ask about OB.  Obstetric care is insured in Ireland guaranteeing a decent salary (they also don’t face the high malpractice premiums). Also, primary care is not devalued since Irish docs actually enjoy becoming GP’s since they get more autonomy and entry into specialty training is heavily restricted by the number of positions and is tied to the hospital limiting jobs, since a ‘consultant’ post at a hospital may or may not be available upon completion of specialty training.  Workforce planning seemed to be a hot topic while I was there, as there were commissions that were deciding the future of the numbers of training posts in Ireland. 

 Thanks especially to all my wonderful hosts at the University College of Dublin and Mater Misericordia Hospital for their generous hospitality and putting up with all my questions! 

 -Vineet Arora MD

Lost in Translation..but the Familiar Language of Medical Education

Grey’s Anatomy, Scut Work, Burnout, & Rural Shortages in China too…

My husband and I recently traveled to Wuhan Medical School in the Hubei Province in central China.  Our medical school has partnered with Wuhan to help inform their curricular reform efforts.  We spent 4 days touring the hospitals and teaching facilities, meeting students and faculty, going on rounds, and giving talks.  Although the language barrier was challenging, we had incredible translators who worked to translate every slide we spoke into Chinese.  We also had the opportunity to observe and talk to students, residents, and faculty through translators to better understand their experiences. 

Preclinical Student Education  Interestingly, the preclinical students told me they watch Grey’s Anatomy and House and wonder if that is what medicine is like.  I told them that US medical students and premeds have wondered that too!  And just like our preclinical students, these students are very excited to get to the wards and desire earlier exposure to patient care.  Fortunately, Wuhan has already started instituting reforms for a pilot group of preclinical students through a more integrated block style curriculum that focuses on incorporating clinical medicine into the preclinical teaching.   They also have state of the art simulation to help students practice clinical medicine.  As one attending said, “the book is book, but practice is practice.”

One big difference is that Chinese medical students are a lot younger – starting right after high school and have little understanding about a medical career.  A standardized national exam in high school dictates whether students will get to go to medical school.  The default pathway for students that don’t get into medical school is often nursing school.  Therefore, many of the nursing students are disengaged.  Once in medical school, the standard pathway is the 5 year option, with smaller 7 and 8 year options for select few who desire more clinical training and research.   Wuhan also has a foreign medical student population that include students from India, Canada, Africa and even the U.S. who spend 4 hours a day studying Chinese on top of their preclinical studies so they can eventually interact with Chinese patients.  And yes, they don’t have Facebook or Twitter and use Baidu instead of Google. 

Rounds and Clinical Rotations Probably the most fascinating part of our trip was observing teaching rounds in 2 Chinese hospitals.  The patients were three to a room and were wearing their own clothes instead of gowns.  It is cold in the hospital since the buildings are not heated (I was wearing my winter coat the whole time).   In both hospitals we were in, the clinical students did not ‘follow’ patients but worked as a group (4 to 5) with one attending physician to see all the patients. 

Through the long streams of Chinese, we could make out the terms “COPD” in a lung ward or “Framingham” when observing a cardiologist teaching medical students.  Students who were thirsty for clinical teaching were furiously taking notes in little books.  The familiar tradition of the attending ‘pimping’ the students was also observed.  Students did not ask a lot of questions, which is consistent with more of the passive learning style documented in Chinese medical education –one thing that Wuhan very much wants to reform.   Students were also carrying all the charts for the rounds and expected to do other clerical tasks. When I explained the term ‘scut work’ to our Chinese medical student translator, she told me that this work is actually part of their ‘cooperation score’ on the evaluation symbolizing teamwork.  

Residency and Clinical Practice There is currently no required residency training but formal residency training is on the verge of starting across China.  Currently, some graduating medical students will do an internship at the hospital underneath a senior doctor.  One of the interns we met with said that she lives at the hospital (in a dorm) working 6 days a week with one day off working roughly 70-80 hours per week taking overnight call once a week.  Since not every department has an intern every year, the attendings sometimes have to take call weekly too. As a result, the doctors we met with reported being fatigued and burned out and wondering how to balance work and life (sound familiar?).  And lastly, as described in several articles in this week’s issue of Academic Medicine in the US, there is also a major shortage of Chinese doctors in rural areas since everyone wants to live in urban areas.   

Even though we were there to teach, we ended up learning that we had a lot in common.   A special thank you to all of our hosts at Wuhan Medical School who went above and beyond to make us feel welcome!

Vineet Arora, MD