Medical Education

The Transition

There are significant differences between attending college, especially a small one, and being enrolled in a medical school. It is thus desirable to first enumerate some of the characteristics of the learning environment in medical school so as to provide a better perspective as to what is involved in making the transition.

Medical school is characterized by:

1. a fast-paced, fact-oriented, and highly impersonal environment, especially during the first two years;
2. the keen competition that usually exists because the students have similar backgrounds as high achievers and are all taking the same required courses. The competition usually involves staying above the median class level, although striving for superior grades obviously exists;
3. the staggering amount of material that is usually presented and must be assimilated in a short amount of time;
4. multi-instructor course teaching, which inherently does not favor the establishment of meaningful student-faculty relationships; and
5. early exposure to human cadaver dissection, and subsequently to dying and death, without adequate preparation.

Retaining Idealism

The special challenge of medical school is retaining the sense of idealism premedical students usually bring with them at the outset of their studies. Medical school is an especially stressful interlude in a young person's life. It is not uncommon to find third- or fourth-year students speaking of the negative impact of the pressures of the first years. Cynicism and apathy appear to be replacing much of the idealism that was present at the beginning of a student's education.

Medical students frequently begin their education with many idealistic interests, strong views on the need for political and economic change, constructive thoughts on increasing the number of general practitioners, and positive attitudes toward medical ethics and eliminating bias. When their studies begin, stress also builds up. During the initial years, students are expected to learn vast amounts of information, besides taking the regular school exams. Students face taking Step 1 of the USMLE, long clinical rotations, and, finally, the challenge of finding a suitable residency. Heightening the existing burden is the anxiety brought on by student loan debt. Consequently, students begin to feel overwhelmed and start to prioritize the distribution of their interest and energy, with little idealism remaining for work to bring about change and progress.

In order to be maintained, idealistic beliefs need encouragement or they dissipate. In theory, sustaining altruism should be a shared responsibility of student, school, and profession. Unfortunately, important fiscal concern for their institution or their constituents distracts school administrators or profession leaders from focusing on this issue. In reality, the responsibility for retaining idealism falls essentially on the students. While some feel that it is impossible to do, many have successfully accomplished it.

The key to nurturing one's sense of idealism as a medical student is to reinforce it. This can perhaps best be done by establishing close relationships with like-minded classmates. In addition, participation in the activities of student organizations, such as the American Medical Student Association, Student National Medical Association, American Medical Women's Association, or the Student Section of the American Medical Association, can be stimulating. The ideals generated and contacts made can serve to sustain one's altruistic impulses.

Domestic or overseas volunteer work in typical social settings can provide another opportunity for enhancing idealistic motives. Taking electives at rural community or similar locations can prove to be an enriching experience that will nourish service attitudes.

Thinking Positively

During the long period of medical school and postgraduate training, many challenges must be faced, the results of which may be quite disappointing. They may include poor results on a major test, an unfavorable evaluation of a clerkship performance by one's superior, a severe reprimand by an attending physician for inappropriate patient treatment, or totally negative patient outcome of therapy. Such disappointments coming on the heels of a time already filled with intense professional and personal demands can, if prolonged, negatively influence your mental health and, in the long run, possibly your physical well-being. We are beginning to gather scientific evidence that suggests that there may be a link between chronic stress and depression with suppression of the immune response and possibly even with some chronic diseases. Cross-disciplinary research is leading to the development of the field of psychoneuroimmunology, which studies the influence of mental attitude on physical health.

There are many individuals who naturally lend to think negatively. For these people there is a need to learn how to reverse such patterns by steering their thoughts in a positive direction. Strategies are available to view expectations in a more favorable light. Maladaptive thought habits are not easily corrected, but attaining lasting results requires a constructive program for thinking and viewing events differently.

By enlisting our conscious mind as an ally in strengthening our immunological status, we can, in turn, protect our physical well-being. Thus, one should operate on the premise that because of the connection between body and mind, positive thoughts can induce positive biochemical changes that enhance the body's well-being and therefore serve as a deterrent to illness.

Negative thought patterns should be promptly challenged by subjecting them to a reality check. Failure in one or even more issues is not a true predictor of a future lack of success. Rather, a lack of success should be taken in the context of the many and consistent patterns of success over one's lifetime. There is a reason to believe that the power of positive thinking can in time deflect negative thought habits and thus protect one's health by enhancing resistance to physical illness. Obviously, sustained negative thinking and repetitive depressive episodes require professional attention.

Coping with Stress

The inherent characteristics of medical school listed earlier clearly lend themselves to stimulating a stressful life for the medical student. This potential is enhanced by the natural insecurity that a major new phase in life can engender. Thus, a significant element in achieving success by a medical student is knowing how to cope with stress.

The ability to cope with stress is dependent upon your personality as well as your prior life experiences. Some people can withstand very intense stress before they feel the pressure, while others have a lower stress tolerance threshold. Mastering the art of coping with stress is essential in order to succeed in medical school.

Coping with stress is also essential in helping you maintain your health. Under stress, your breathing becomes shallow and uneven, your pulse speeds up, and your senses sharpen. Consequently, a stressful day frequently results in a feeling of tiredness. Prolonged stress has been demonstrated to contribute to headaches, skin rashes, or even more serious illness such as ulcers and asthma.

If you have any problems coping with stress, you should seek information about deep breathing, stretching, or regular aerobic exercises that can help you control the feelings generated by pressure. Consulting a physician can also prove useful, especially in severely stressful situations where medication may be indicated.

At the very outset, it should be recognized that, if you have been admitted to medical school, you have already proven that you can probably cope rather effectively with stress induced by educational demands. A successful premedical phase clearly included getting superior grades in college, especially in the science courses, as well as on the MCAT exam, completing an application that was impressive, and effectively facing the challenge of admission interviews. These achievements should serve to strongly reinforce your sense of confidence in being able to cope with stress while attending medical school.

The goal in coping with stress should be twofold: (1) to control the extent of your exposure to stressful situations; and (2) to learn how to respond to stress.

The following seven suggestions may be useful in coping with stress:

1. Maintain your health as optimally as possible. This includes following an appropriate diet and a suitable exercise regimen.
2. Try to meet pending responsibilities one at a time. Tasks and problems should be prioritized and addressed accordingly. When possible, subdivide large problems into small manageable tasks, which in turn should also be solved in a prioritized manner.
3. Utilize your time efficiently. This means budgeting time in an appropriate manner. Don't overextend yourself with an excessive number of scheduled activities, or underestimate the time they may require. Be flexible in meeting needed changes in planned activities.
4. Realize that some stressful situations are unavoidable. These include scheduled examinations, traffic delays, and so on. Since you cannot exercise control over certain potential stress-inducing problems, try to accept them calmly and matter-of-factly.
5. Find a wholesome outlet for stress and frustrations. This can include participation in some sports activities, or the use of a close friend to whom you can verbalize your frustrations and fears.
6. Avoid situations that you know will be stressful. Thus, if last-minute cramming for an exam generates stress, schedule your study time so that you are fully prepared in advance of the test deadline and therefore can avoid cramming. Similarly, if getting to school is an erratic experience time-wise, schedule an adequate amount of time in order to avoid the frustration and stress created by the fear of arriving late.
7. Allow for several short periods of relaxation during the day. These can be taken at mealtimes and for more extended periods on weekends. Periodic holiday vacations can help you to recover from long spells of intense activity.

Looking Ahead

While at the outset of your medical school career it is natural to focus on the courses at hand, it is also important to have a longer-term perspective on your education. One needs to recognize that in its essence the first two years are the essential preparation for the last two-year clerkship training years. It is thus important to master a number of skills during the preclinical phase of your education to be able to satisfactorily cope with the challenges you will face when undertaking clinical service on the wards.

In this regard, a recent report indicated that a significant number of medical students may have an uphill battle during their clinical training. This is suggested from a study that found that between 30 and 50% of clerkship directors reported that medical students are unprepared in six competency areas.

A survey of a significant number of clerkship directors indicates that they believe that improvement is necessary in communication, interviewing, and examination skills, professionalism, and understandings of systems of care and life cycle stages. As a consequence of this situation, some clerkship directors have been forced to provide remediation in one or more of these areas of professionalism, communication, interviewing, and examination skills, because of a deficiency in preclinical preparation. It is thought that preparation for the clinical skills component of the USMLE Step 2 may prove helpful in this area when working on the wards.

First-year Guidelines

Special emphasis deserves to be placed on the freshman year of medical school, where attrition, if it will occur at all, is most likely. Like the first year of high school or college, it marks a year of transition from the triumph of graduation to the lowest rung of the school's hierarchical ladder. It frequently involves relocating and having a new group of peers.

The average freshman begins medical school with unresolved feelings about his or her level of achievement attainable in a new and unproven milieu. The nature of the academic environment, with its large volume of work and the presence of bright and hard-working classmates, makes it difficult to prove oneself and attain one's inner expectations. Students with a high degree of self-worth and those who can gain gratification from intrinsic rewards, such as the satisfaction derived by keeping up with and passing through the curriculum, will best respond emotionally to the existing stressful situation. Providing self-praise rather than seeking external sources of encouragement is helpful.

The special features of the freshman year that deserve to be brought to the attention of prospective medical students are as follows:

1. Students frequently have a wide range of emotional experiences during the course of the year, ranging from exhilaration to anxiety, frustration, and, at times, depression.
2. The academic program offered is usually uneven, with some courses being exciting and others dull. Taken as a whole, the program is exhausting.
3. A key to success is to organize one's time most effectively to meet your specific needs. Allowance should be made in your schedule for a reasonably fulfilling personal and social life.
4. Upperclass students may provide useful insights into the pressures to be faced and methods of coping, as well as helpful study tips. The advice given should not always be taken at face value, but must be adjusted to one's specific needs.
5. While attaining high grades is commendable, developing a competent grasp of the material presented should be the prime goal. This involves developing a priority system of study of the wide-ranging subject matter and the various topics, focusing on understanding concepts, and fitting the details into the conceptual framework so as to facilitate their retention.
6. Development of an objective approach to clinical problems should begin during the first year. This involves beginning to establish a flexible emotional balance between excessive sympathy for patients and exaggerated detachment.
7. It is important to avoid a feeling of complete isolation in an endless sea of information, some of which is esoteric and apparently irrelevant to your specific career activities. To avoid losing one's perspective, it is useful to set aside some free time for clinical observation, such as attending rounds or conferences.
8. Although difficulties and setbacks may occur, they need not necessarily lead to failure. They should be placed in the context of your many successes.
9. Emotional self-care, using such methods as having planned breaks and regular exercise, utilizing preventive stress management techniques, and maintaining personal relationships, as well as providing oneself with rewards, is important.
10. Prompt help should be sought if signs of trouble, in the form of depression, relationship problems, and increased use of alcohol or drugs, become evident.
11. To offset the decrease in overall physical activity due to the considerable time spent in the classroom and laboratory, an exercise schedule, even if at quite a limited level, should be maintained.
12. To help ensure good physical, mental, and emotional health and stamina, proper attention should be paid to nutrition, diet, and getting enough sleep.

Finally, it should be kept in mind that, while there frequently is an increase in stress as the freshman year progresses, there is also a tendency for the ability to cope effectively to improve. Associated with this improvement is a betterment in health and mood. Along with these changes comes a heightened enjoyment of medical school, with feelings of greater competence and reduced uncertainty about entering a medical career.

Second-year Guidelines

The second year marks a turning point on the student's road to becoming a physician. The focus is drastically altered, from what heretofore has been almost exclusively the normal state of the human body, to a consideration of the disease process, its consequences, and modes of therapy. While conceptual thinking continues to be required, the volume and the content of the information presented place a heavy premium on memorization. This year represents an equalization in potential between premeds and nonscience majors.

For obvious reasons, pathology represents the key transitional course from the normal to the diseased. It is usually taught by means of formal lectures, exercises in the laboratory, seminars in clinical problem solving, and autopsy exposure. The interplay of anatomy, biochemistry, and physiology with pathology provides the intellectual challenge inherent in this subject. The linkage of clinical observations with autopsy findings as revealed in clinicopathologic conferences (CPCs) provides dramatic insights into the effects of the disease process.

Pharmacology complements pathology, since the actions of individual drugs and drug families can be learned in the context of the diseases they treat. This course stimulates a review of relevant basic science topics and, while heavy on memorization, also demands conceptual understanding.

A significant course of the upper sophomore semester is physical diagnosis. This is usually taught by formal lectures, at hospital teaching rounds, and by individual hospital assignments. This course provides an invaluable base upon which to build for the coming clinical medical school years and postgraduate training.

The major challenge of the second year is to balance all its demands, namely multiple-coursework, patient responsibilities, and preparation for tests and Step 1 of USMLE in June. The second year thus has all the components to generate a great deal of physical and emotional stress, and it usually does. The advice given as to stress management in the preceding section is obviously applicable for preventing and/or meeting this year's challenges. The survival skills developed during the first year should help ensure satisfactory completion of the second.

Third-year Guidelines

The beginning of the third year marks a major turning point in professional medical education. It represents the onset of a lifelong involvement with the realities of clinical medicine.

The initial impact is reflected by the need to learn how to develop a relationship with patients. In this regard, medical students should clarify to the patient and/or the patient's family their position as being on the first rung in the medical hierarchy. This may preferably be reinforced by referring to oneself as “student Doctor Smith.” This will limit the student's responsibilities to their appropriate level and permit unanswerable patient questions to be referred to the appropriate authority without embarrassment.

Concomitant with the introduction to patient care is the impact it has on the attitude of the medical student toward patients. There generally (and unfortunately) is a change in attitude from being service oriented to being self-education oriented. The goal that should be sought is the ability to view the patient simultaneously as a human being and as a source of biomedical knowledge.

Another special feature of the junior year is the development of a relationship with the house staff. There will be substantial learning opportunities as well as exposure to menial routine or “scut” work. Thus the results can be both exhilarating and rewarding, and frustrating and depressing. The key to a meaningful experience is to determine what the patient's diagnostic or therapeutic plan is so that you can interact as intelligently as possible with the other members of the medical team.

During this year the opportunity to view the bedside manners of different attending physicians will be available, perhaps for the first time. Each will be found to have a distinctive style that can be instructive to the doctor-in-training.

Learning to chart, that is, to prepare a current, clear, concise, and complete record of the patient's progress, is a significant part of the educational experience. Finally, a central element of medical school experience, namely the “workup,” taking a history and performing a physical examination, will be introduced during the junior year. Developing a positive attitude toward hospital work routine and critical skills in achieving a differential diagnosis is the key to professional success. To master the art of diagnosis, one must work out the rationale for every question and organize questions into logical groups. Leads should be followed up by additional questions and a search for specific physical findings. Thoroughness in working up the patient will prove most rewarding for both the practitioner and the patient.

In summary, the junior year represents a relearning of the basic sciences in a clinical setting. Learning the biochemical and physiological bases of disease mechanisms in the context of living patients will facilitate developing the skills to provide therapeutic relief.

The onset of the clinical years is the appropriate time to learn how to avoid making mistakes. The three basic rules in this regard are:

1. Recognize your own limitations. Be prepared to admit when you feel unqualified to undertake an assigned task. Do not try to bluff your way through a challenge or develop an air of bravado that you can do anything.
2. Don't be afraid of new challenges, so long as you feel assured you are being adequately supervised during the course of carrying them out.
3. Do not ignore the advice of residents and nurses. Their experience and judgment can be very helpful in avoiding costly errors or embarassing situations.

A number of schools offer formal training in technical skills such as venipuncture. Such introductory courses most frequently teach “universal precautions,” such as handling needles and wearing protective gear. Existing programs, however, vary from a five-day intensive course to ad hoc training at the hospital.

Fourth-year Guidelines

The fourth year represents the final stages before assuming the responsibilities of postgraduate education. The knowledge and experience acquired during the first three years will be put to use during this year of intensive clinical training.

A number of admonitions are in order as the student now proceeds toward the practice of medicine.

1. The principal goal in practicing medicine should be the satisfaction gained through service to others.
2. The essence of good medicine is to reach a diagnosis on the basis of a carefully secured, complete history and physical examination, supplemented, where necessary, by laboratory findings. The lab results should not be used, however, to negate the results of a good “workup,” nor should they serve per se as a diagnostic tool.
3. Patients tend to place physicians on a pedestal. By recognizing that the majority of illnesses are self-limiting, physicians should realize that often the services they render only provide reassurance and make the patient comfortable. This should promote an attitude of humility that can counteract the ego-stimulating factor inherent in the practice of medicine.
4. While medicine is an inexact science, its practice nevertheless requires one to be as exact as possible. Nothing should be taken for granted; otherwise, unforeseen complications can ensue.
5. It should always be recognized that it is the patient who is ill, and that it is the patient, not the disease, that should be treated.
6. There is a critical need to remain up to date by reading the current literature and attending meetings. This will ensure quality health care and maintenance of an intellectually stimulating quality in the practice of medicine.
7. Responsibility to the profession calls for the practitioner to set the best possible example in appearance, speech, and behavior.
8. The goal should not be solely to gain an education by isolating oneself from world affairs and one's community. By remaining alert to what is transpiring and being as active as possible, one meets the broader responsibilities associated with the title “Doctor.”

Goals to Strive for in Medical School

The premedical college years can, in some cases, have a negative impact because of the competition for a place in the entering class. Those gaining admission are usually achievers of high grades that have been attained by intensive studying. This generates an attitude where learning becomes a chore rather than a pleasure.

The goals in medical school should be associated with the learning process. They should be to:

1. learn how to develop and maintain a love for knowledge;
2. learn to develop and maintain a balanced lifestyle incorporating work, relaxation, rewarding relationships, and varying interests;
3. learn to be receptive to new concepts while at the same time being reserved in making definitive judgments, since not all that appears logical is proved correct in the end;
4. learn to develop a genuine interest in finding out more about people and the best ways to care for them as individuals;
5. learn to use one's imagination and not be overwhelmed by the mountain of information ingested;
6. learn how to acquire a serviceable foundation in the biomedical sciences during the preclinical years and how to secure additional information in each area when needed;
7. learn how to attain a secure knowledge base during the clinical years upon which to build during postgraduate training;
8. learn to accept the fact that practicing medicine requires some personal sacrifice in terms of one's private life, time off, and in other areas;
9. learn that one's goals are not only to acquire knowledge and skill, but also to retain an interest in society and the world; and
10. learn to accept the fact that medicine is a continual challenge and that it brings with it both the joy of triumph and the sorrow of defeat.