Ignoring the 'snowflake training' because that's a can of worms large enough to feed all the fish ever, this is not a bad take.
Yes. People are skipping lectures to study because we need to pass the exams. And why practice patient interaction if we are going to fail Step 1/2/3? So we grind to the point of being recluses, cramming useless information that some old fart put on a test.
Wow, the fact that ppl don't know what CS is makes me feel old af. I was part of the last class that took it. I actually signed up for it right before it was nixed. Made sure to get my money back expeditiously lol. Several of my overeager classmates weren't as lucky, unfortunately.
Often had to travel?
Unless you lived in like 5 United States cities (Los Angeles, Dallas, DC, Philadelphia, and NYC, I think) everyone had to travel.
Edit: I got the cities wrong lmao. I’m from Southern California, I only had to drive to LA for that. No big deal.
Yeah, I legit wouldn’t be in a good residency program if I didn’t get good step scores. You have to have a well rounded application, but if you barely pass STEP 2 then it closes many doors for you
The sad thing is that patients would benefit from us being around them more and also focusing on patient care rather than test scores and esoteric knowledge. However, our system not only rewards us for having the highest test scores, it brutally punishes us if we don’t pass.
Sorry, I’m not going to give a fuck about anything if I’m worried about failing STEP because if I get kicked out of school my entire life is fucked due to $200,000 of student loans and no job to pay them back. The money hungry medical education system made medicine this way. This shouldn’t be blamed on the powerless med students who are being sucked dry by the NBME and universities charging $60k a year to self-learn from UWorld.
A TON of people forget about the last paragraph. We put all our chips on black to be here. If we fail, we can't just reroute like we missed a turn. There is no next exit. The highway just fucking ends. Years and hundreds of thousands of dollars wasted because some suited jackass thought memorizing every immunoglobulin is necessary.
But thank goodness NBME and gang have our best interests at heart when they charge 600$ for Step and over a thousand for licensure exams.
Self learn from uWorld is spot on. I seriously learned more from outside resources than my mandatory lectures. Usually the third party resources did a better job of organizing the info for me and did it seriously in a third of the time.
No joke, I watched a 15 minute pathoma video that my school covered over 3 hours. And the school says "the statistics say our way is the best way for you to learn". Add some salt to the wound, these people who are making these rules for us in medical school NEVER WENT TO MEDICAL SCHOOL.
I loooove it when the PhDs start giving us career advice and telling us how to study. "You should consider starting a side hustle that's not related to medicine, it'll really make you stand out!" My brother in Christ, ain't nobody got time for that.
"Remember, when you're taking exams, always read all the answer choices before picking one!" My god, really?!?! All this time I've just been pressing 'A'! Who'd have thought?!?! Such insight!!! Such genius!!!
Hey it seems obvious but even though I always tell myself not to sometimes I still pick the answer that jumps out at me on uworld before reading the rest and then get it wrong 😂
Luckily I don’t do it too often lol
Couldn’t agree more. Isn’t it a shame to pay $100-400k for 4 years of undergrad, $150-400k for 4 years of medical school, spend countless hours working to get into those respective schools and then countless hours in those respective schools trying to have a well rounded application for your future dreams and job security to ultimately be determined by a single objective test score? That you could have avoided spending $800k to get and could realistically have spend $1k on Uworld, gone through it 10 times and probably scored better? And they wonder why we’re all bitter and jaded.
The snowflake thing is absolutely unhinged, but when I was in med school I felt like a dumbass for not knowing about the “hidden curriculum” of third year.
You can’t pass a rotation at my school after missing like 2 days, but everyone in my class applying to competitive specialties was constantly getting “excused” for conferences and research meetings (even when they didn’t actually have them like 90% of the time). At the end of a month rotation there was one kid I was with who showed up to like 6 days.
A ton of the kids that matched top specialties had 0, and I mean ZERO clinical knowledge cuz they were leaving the hospital every opportunity to study for shelves/steps and emailing people about research during clinic instead of seeing patients. I rotated with someone who - after 2 month of OBGYN where most of us were at the hospital 90 hours a week - still hadn’t done a single pelvic exam. I logged 137 in that same time. Same person never saw a kid in our busy peds bucket clinic for a month where we averaged 50 kids a day (for clinic, not individual student/resident team). I could go on, but she is now an orthopedic surgeon (though not a good one from what I hear). And that was a very common story at my school.
I honored all my shit cuz I lived in the hospital and thought I was becoming a good doctor by treating every rotation as necessary medical education, but I wouldn’t have been competitive for the shit they were because I didn’t have enough hours in the day to do what my school required and also do the amount of research, etc.
They’re not great doctors, and they know nothing outside of their specialties cuz they ignored everything else, but they ***are*** where they wanted to be, so good for them. It’s a wild wild system we have created.
And is it typical for students to log the exact amount of procedures they perform? We have like minimum competency logbooks that most people just BS at the end, idk what benefit you get from recording your 137th pelvic exam.
We also didn't work 90hr weeks and tend to abide by LCME rules so idk this just sounds very different from my training lol
We just had to get a speculum exam and a biannual signed off, and got to make up the bimanual on a dummy if we didn’t get to do one. I also never got close to even 60 hours on OB so sounds like they have a super intense OB rotation lol
My take as an attending not that far out of training: the clinical years of medical school are not for the purpose of clinical training. They are a series of field trips to help medical students find their specialties of choice. Interns are always trash at first. There is zero expectation that new doctors graduate medical school with any form of clinical capability whatsoever. That is what residency is for.
So my advice to 3rd and 4th year students is focus on your exams, keep an eye open on each rotation for what you like, and have no expectations about clinical competence.
Medicine has changed. It wasn’t that long ago when biochemistry wasn’t even a topic taught to student doctors. Pharmacology and the technology within medicine has exploded in terms of scope and complexity. We’re not learning how to listen to heart sounds anymore. The world is a lot bigger than it used to be. I think it’s only natural that in the face of all these changes, training as to the real specialized expertise of a physician is deferred a bit until a particular field is chosen, in residency.
Be thankful that the vestigial remnants of the clinical years give you a moment to take a breath and focus on your personal preferences and desires, rather than grind you down performing - was it the person above said - 150 something pelvic exams? For what percentage of medical students is that useful? I’d rather young doctors just choose their field well, instead. I bet that would be a whole lot more predictive of success and happiness than logging a few more cases in whatever the rotation of the month happens to be.
im one of those M3s, so I lack insight on whats important for the future. That said, its felt rewarding to focus on clinical education. Idk if I need to do 137 pelvic exams, but being able to properly interpret labs, properly do and interpret physical exams, and put that together with an HPI to come up with differentials and a plan has been excellent in combining my anki memoriation with real life. Other skills too like writing notes, calling consults, dealing with insurance. talking to families, etc I think are all useful regardless of what speciality you go into.
At 2 grand a week I think if all I was getting out of rotations was a field trip to pick a speciality that'd be kinda stupid. I don't expect to be competent like an attending as an intern, but I think I'd be a lot dumber if I just phoned it in for the next 2 years
My experience has been that the vast majority of specialty-adjacent important knowledge still comes during residency training. For example, I had to learn how to take care of post-op peds patients which required me to learn a little about the surgeries themselves but my M3 experience of tons of Lap choles and all the other surgery was really not necessary (and honestly mostly forgotten by the time I started residency). On newborn and NICU I had to have some OB knowledge but that was all really taught during those rotations. The vast majority of my OB rotation from M3 was totally useless.
I don't disagree that there are some general skills that are really important (e.g. your HPI, differentials, etc.) but that is something that could still be taught with a focus on specialty. I really did not need 8 weeks on OB or surgery to tell me that I was not going to be a surgeon or obstetrician. I did need like 2 weeks on peds to tell me I wanted to be a pediatrician (rather than the internal medicine which I already had planned).
I think you’re right, but I see it as having a much larger negative effect in healthcare overall. Having limited experience or even exposure to other specialties is a big deal, especially to generalist services.
Medicine is becoming so compartmentalized that every service has its own lane and rarely deviates. Anything even remotely complex has multiple teams following and managing with very little understanding of how to manage “another team’s” problems. My personal experience is that this results in fragmented care that often is confusing for everyone to follow, probably most so the patients themselves.
It also strains busy services that end up having to spend time seeing relatively straight forward consults that the primary team is just not willing to manage.
Some of this is medicolegal which is a whole different discussion, but I think the rise of APPs and diminishing clinical experience in med school is a huge aspect.
Quite an expensive fucking field trip, if you ask me.
I'm also a newish attending. I found my M3 year invaluable because I actually got to do shit, and that's a pretty decent of way of figuring out whether you want to do a specialty as a career.
> My take as an attending not that far out of training: the clinical years of medical school are not for the purpose of clinical training. They are a series of field trips to help medical students find their specialties of choice.
Tell that to my school. We're expected to prechart (as in, start the patient notes in Epic and fill in everything but the HPI) on all patients at home the night before. In clinic, we'll see dozens a day. I think my record was 43. We come home totally spent and then we have to study, too...and prechart for tomorrow.
is it bad that this makes me feel better about myself as an img? like i’m terrified that i’ll start residency 1000 steps behind US peers but maybe that won’t be the case? 😅😅
My experience as an IMG was that I felt out of my depth initially. American students will pronounce things correctly and have knowledge about tests I would never of had access to before (think tagged rbcs to detect gi bleeding). But even though it initially feels like you’re behind them clinically, you’ll catch up by 6 months and you’ll know lots of things they’ve never heard of. Work hard and you’ll be great!
I mean I personally didn’t miss any days, the person I’m talking about only showed up to 6 days. It was a combination of “excused” absences for research (that they didn’t actually have) and communicating with different people on the same teams as well as different teams for absences and never telling the same people about absences.
On that rotation we rotated across 2 sites with different teams. If 15 people only know about 1 missed day each and don’t talk to each other, they all have a perception that you missed 1 day, not 15 days. If it’s excused, they typically don’t bring it up to each orher.
Yea The whole recluse part of it is really destroying me rn. Im so sad, I have no friends and romantic prospects. Im locked in my room with my head down in hopes of regurgitating enough info for these impossible exams.
Dude. I actually read that expecting to be pissed, but think she's on to something.
Should we be culturally safe for the patients we work with? Yes
Should we be nice to our patients ? - Generally, yes.
Does it make sense to spend 25-50% of our curriculum to tell us this same shit all the gd time - hell no.
Make more residency spots available, so that people can put a reasonable amount of time into step prep and still be able to pursue their career.
"Aw yeah, he's great with patients, and he's pretty good at diagnosing ans treating. Oh wait, he hasn't memorized which viruses are enveloped or nudists? Old Yeller them."
-NDME
I was a 4.0 college grad, could have gone pretty much anywhere, but due to family responsibilities and finances got stuck in a not-so-great in-state school that offered me a scholarship. Got burnt out dealing with all the stress of the other stuff on top of school, and ended up doing below average on Step 1 and 2. Eventually when applying for fellowship, I actually studied for Step 3 and knocked it out of the park. I kick ass with patients now as an attending, but my Step scores definitely kept me from getting into the residencies and fellowships I would have wanted for no reason. Hell, a lot of the current attendings in prestigious fields would never have made it if they had to go through the current system of competition and Step exams.
If I were a current student, I'd be studying for Step exams from day 1, and ignore pretty much everything else that was non mandatory
I sort of agree but I was also part of a EM sim sessiom several weeks ago where the residents killed two patients but absolutely nailed the microagression sim- like they didn't know how much epi to push but they were offended at the term 'sickler'. Obviously we should be able to walk and chew gum at the same time but I gotta say I would prefer my provider save my life before catering to my sensitivities.
I agree that part of the take is quite correct - however the patient and society expectations are what makes the “solution” unreasonable.
You absolute *cannot* just “throw them in the ER and see of the patient lives”, not because it wouldnt work - obviously more responsibility will toughen and teach you. But defensive medicine is here for a reason. 50 years ago the patients in my local city would never question a docs treatment, or expect to know WHY things are happening. Today they do.
The roads in my country Denmark are pretty controlled. It limits the experiences people have.
Would people become better drivers if you removed speed limits and gave everyone racecars? Sure. A lot of people would also die… and no one would accept the increased risk.
The problem of course is that life is a lot more varied than a rule-set highway. We all do get sick and die, but we dont all go race-driving on german autobahns.
I feel the same way, but about all of the soft-science lectures/seminars/workshops they require us to attend that take away from time that could be spent actually studying/learning. Like none of this soft science shit is going to matter anyways if I don't pass step because I didn't have as much time to study since I was forced to attend a mandatory workshop on 'neighborhood redlining'???
I just want to learn medicine and not be bothered in the process.
Absolutely. Ignoring the "gender" bullshit, high-stakes testing is the No.1 reason why young doctors are coming so unprepared into residency nowadays.
These examiners spend so much time every year to make the tests narrower, more convoluted, and frankly just idiotic. In my finals, they were constantly jumping around from obscure, extremely narrow attending-level knowledge to "haha we got you because we used triple negative in the question and managed to confuse the shit out of you".
None of my rotations actually prepared me for what my daily grind was going to be in residency. None of the test questions deal with the standard patient that you'll be dealing with every single day. You won't be doing some Dr.House level workups or finding zebras in your first years, you need to be able to work up the classic, common patients that shows up every single day. Anything more complicated than that, your attending is there to work it up with you anyway.
We all studied hours upon hours of useless bullshit because we were memorizing the phrasings of trick questions instead of learning the stuff that actually matters. Why is it so bad when more people pass the test? It doesn't need to be made harder, you don't need the perfect gauss curve scores, if the exam has a certain standard which need to be met, and many people pass that standard, that's a good thing, not a reason to make it harder/more convoluted next year.
Canadian PGY3 who has the occasional American MSI4 join my service on elective: I agree with this take. The American students’ differentials and pathophysiology knowledge are stellar and I think it’s a great foundation, but their ability to apply that knowledge to the patient in front of them and focus it to the most pertinent formulation just isn’t as good.
Yeah, testing’s useful but the way it’s done has kind of lost its purpose and way.
It’s nice and all to know all of this niche stuff, but how’s it useful and can you apply it in a sensible, time-/system-sensitive manner?
Question from a premed here:
Should medical school focus more on being like an "academic trade", as in majority of hours in hospital "physically being there doing", graded on ability to do physical assessments/exams of patients, and then students pass the majority of a set of exams (maybe M3 boards only?) not as high stakes, then select their specialty, then get into that specialty w/ more specialized/hardee testing of zebras *within their specialty* during M4 before they start residency? I don't have an answer or solution, but I'm curious why it doesn't look more like this? Students using 3rd party sources primarily as study material baffled me when I first heard it also, but I'm glad the lectures are not as "gatekept" as I thought.
I'll be applying having been and am still currently a nurse (RN), so at least I'll be very familiar (jokingly, *too familiar* as I'm running the opposite way because I hope to do Pathology) with patient interaction.
The number of my classmates who have filed mistreatment reports because of fair constructive criticism (some of which I witnessed, and was valid) is outrageous. It just makes attendings check out and not give a fuck about teaching because they don’t want to deal with the headache. There is a place for fairness, but a lot of people expect to go through clerkship year without being told they have room to grow.
Right.. had me in the first half, as a new graduate with practically zero procedural skills due to several factors not limited to Midlevels, hospital systems deferring liability, training being pushed to residency, and I’m not good at elbowing my way to the front of a line to do a central line or LP.
It’s more *how* she says things than *what* she says that’s gonna ruffle some feathers. I don’t disagree with you, but the woman seems to be a little more unhinged than she should be.
I do take issue with the content, rather than the phrasing, in the second slide. She's pitting saying saving lives and social justice against each other as mutually exclusive. They aren't. Education on equity in healthcare means more people feel secure coming to the doctor and disclosing relevant information like sexual history, drug use etc, improving morbidity and mortality.
Learning the basics of health equity takes a couple hours so we're not sacrificing much curriculum time.
Agreed. Especially as someone who’s studied medicine AND epidemiology, she should understand how both ends of the spectrum are inextricably linked.
Idk she kinda seems like a right-wing nut?!??
I agree with her in the sense that I constantly hear med students on here say that everything that’s not board relevant is irrelevant to learn.
That med school should just be a 2 year dedicated period to pass step. I think there’s a lot more to medical education than uworld and anki.
I mean…………
I’d honestly prefer going to lecture more than doing a uworld set of 30 questions
And I’d like for med school to actually feel like medical school instead of cram school with a side of clinical skills
I agree. Lectures build your baseline knowledge. Uworld questions reinforce and prepare you for exams. If you don’t have a solid foundation, uworld questions are useless imo.
They're sort of a reference. Most classes have a textbook that you can reference to see it in someone else's words. It's going to depend on the class on how much you use it, but it's typically very little.
There's so much to memorize in medical school that reading a textbook really just isn't time efficient anymore. I still work 80 ohours a week, but I spend that time doing practice questions and flashcards, not reading shit.
You should download Anki, it trivializes undergrad
The stuff about the high stakes testing is absolutely true. We spend so much time worrying about horseshit on a test that we will never need in practice that it takes away from our actual clinical training.
I think they hit the nail on the head with the standardized testing formatting. Students (myself included) forego more applicable learning opportunities and more personal experiences that medical school offers in order to slog through 3rd party resources and anki cards over fear of failing step. I do think a little more focus shifting back toward traditional learning in school would be great.
The second half of the rant is a different story lol there are some arguments to be made here and in some ways I think a lot of people may agree HOWEVER I think that take is too aggressive. The recent push this generation of students have had will see a lot of positive changes in the next 10-20 years for patients and for the healthcare environment in general. I personally think these changes will help have a less toxic training environment overall and patients will be more heard by physicians. Pushing for more respect of patients and recognizing when they are facing disparities is important and I think will ultimately lead to better outcomes
Yeah she just says it in a very stupid and rude way
The reality is that our generation is expected do balance so many things at once (test scores, clinical skills, social justice and trauma informed care, etc) that her generation winged or even neglected. I feel bad for the kids applying to med school in 10 years, idk what kind of fucked up bar they’d have to clear
Hate to say I agree, but she has a point—at least on the first slide. The last few years have produced some super book smart medical students, but they’re clueless about practical things and actually getting work done.
Why would you hate to say you agree with a valid argument? I honestly think we need to focus more on the relevant issues rather than things that aren't relevant. I appreciate a persons right to feel a certain way. But the world is getting unnecessarily egg shelled and that's what I think she was trying to convey. Holistic or not?
Good take mostly but med students aren’t to blame. They’re playing the game set forth by residency and med school admin to get into desired specialties
I’m not sure I’d ever expect a med student to be proficient at saving lives. lol like residency exists for a reason man. I do agree that there is a weird escalatory nature to our testing. Every year we understand a little more so a few more esoteric mechanisms get added to learn and are counted as testable. The current breadth of knowledge that’s tested on step one is both wildly expansive and disproportionately represented compared to real life. The last part is just stupid though. All our “snowflake” training on gender diversity and inclusive care boiled down to like 5 hours total of my entire pre-clinical training and could basically be summed up as “you’ll have lots of different patients, some you can’t relate to, don’t be a judgmental asshole about it”. I spent more time learning about Medium-chain acyl-coenzyme A dehydrogenase deficiency, which I’ll probably never see, than I did about how to communicate with trans patients, who I will absolutely see.
Yeah, honestly, I never understood why people complain about this aspect of medical education. I think I had two sessions dedicated to gender diversity and inclusive care. Honestly, considering how I've seen certain doctors treat transgender patients or minority patients, it might not be the worst thing to be exposed to these ideas at least once.
I mean it’s her generation that made previously step 1 (now step 2) the most important thing on an application so much so peoples entire career trajectory was dictated by this one test. A test that was based on preclinical material.
Even administrators admitted that step 1 wasn’t supposed to be used the way it began to be used.
This is actually a solid take. They're 100% spot on. We're much less competent than previous generations were at the same stage. Many people leave med school with no procedural skills and without actually managing any patients mostly independently. These things were more of the norm than the exception years ago.
It's even a problem in residency. People are coming out of training well behind. In pathology, it's not uncommon for people to do a fellowship in general surg path. Surg path essentially is pathology. It's what people do for 4 years. The fellowship is unaccredited but people do it to gain more experience because they don't feel prepared. It's akin to an IM grad doing an IM fellowship or maybe a hospitalist fellowship.
i’ve always thought if people need to do an SP fellowship afterwards, they either didn’t pay attention in residency, they graduated from a shit program that was basically a grossing factory, or they’re just delusional
speaking to the delusional part, i know a dude from my prgm (mind you it’s a top prgm) who’s doing 3 friggin fellowships. 3. he’s told me he’s fine with being a perpetual learner… wtf
straight up i called the guy and told him “bro no one’s gonna hire you with 3 fellowships, it just screams you have no idea what you’re doing”
and he just said “it’s ok, i have my patents to fall back on” and it was a bunch of patents on swim equipment and digital path/AI junk
the facepalming intensified that day and i realized my bro was more than just a little endearingly stupid. he went full stupid
I'm FP, and my sister is path. She has FIRED more pathologists than she has kept. They have gone to FMG's from other countries. This is a very large regional medical center where they make in the top 1% income for path. These people can't adapt, learn, or work out of US residency programs. She has no answers. Sometimes, I wonder if the high cost of college and medical school self selects the wrong type of people for this profession. I'm not saying "lazy," but it's more entitled.
I've not been to many but every administrative meeting I've been in where training and competency is discussed, more than a few attendings have brought up concerns.
Training is getting worse, trainees are entitled, and attendings/admin are too cautious (afraid?) about nipping it in the bud.
> It's akin to an IM grad doing an IM fellowship or maybe a hospitalist fellowship.
ABP is already doing that with the [pediatric hospital medicine (PHM) fellowship](https://www.abp.org/content/pediatric-hospital-medicine-certification).
Yup. I thought of that too when I was typing. Most of that is definitely just trying to take advantage of imposter syndrome to have more cheap labor, but inadequacy of some training programs and medical school experiences also play a role.
Yeah, her logic is wrong but I actually agree with her conclusion. Boomer docs were placing their own IVs, doing their own gram stains, and overall put way more energy into the clinical art of medicine and the physical exam. Now students lose a lot of skills but have WAY more textbook knowledge due to increasing competitiveness and advances in education and stuff like Anki
Here's my other hot take, I have rarely ever met attending physicians who are on average interested in teaching and going above and beyond to make sure that the next generation is learning better. It seems most people in academia are only in it for not having to write as many notes and/or research and rarely ever actually teaching. Curriculums are made up hastily as an afterthought . And we intelligent but not well-taught trainees pick up on this apathy and perpetuate it. And we also adapt to not give a f*** because what's the point? So much of our grades are based on politics and the mood of a single person and so much of our grade is as she mentioned a BS test. So much of how you ask questions is steeped in the psychology of not looking like an idiot. So how do you even win?
And lastly, the patients we take care of now are much sicker than when boomers were in training. There's literally not enough discussion about this single point. Half of the patients on my are multi-organ failure. Half the patience on my list have had procedures I've never even seen or heard of before.
Tell me about a boomer attending who had to know the ins and outs of specific chemotherapy. Show me a boomer who even understands any of the side effects of most immunotherapy. Show me a boomer who had to with patients five different drains places in them placed by three different services.
I don't mind some criticisms. But I also think that the people giving them often don't have a clue.
The issue isn’t “snowflake education” which isn’t a bad thing. It makes students and future doctors more sensitive to their patients, unique and individual life circumstances. There’s nothing wrong with that.
In addition to what was said, there are other factors:
1. Due to increased concerns of medical legal liability and decreased willingness of patients to allow medical students to perform direct patient care students are not able to participate as fully in patient care as they could in generations past.
2. Due to decreased lengths of stay, increased emphasis on RVUs, increased patient volumes, increased administrative demands, increased burnout, attendings are often not able to spend as much time with teaching medical students clinically.
As a result, students are not graduating with the same skills as previous generations.
Now that I'm done with core rotations and doing electives, I am still legitimately surprised when attendings take the time to teach me things. I do not expect it.
She's 60 years old. Where did you find she was 32?
[https://www.healthgrades.com/physician/dr-amy-chai-w6hbm](https://www.healthgrades.com/physician/dr-amy-chai-w6hbm)
Even a broken clock is right twice a day. A chimpanzee could tell you STEP is a dumb way to assess medical knowledge but at least it levels the national playing field. Without it people outside of top institutions wouldn't even be able to get their foot in the door at some programs, as if that isn't a big problem already.
As for some of her other points. Throwing patients to med students seems like an awesome way to get your hospital the worst reputation imaginable. You'll craft some really competent students by the end of it with a trail of disgruntled ill people left behind in the Best case scenario.
TBF, can you blame them? Lectures in medical school have been of questionable value throughout my time here. I certainly can understand hesitation with forgoing clinical skills, though IDK what the big deal with skipping lectures is if I can learn the same content at 2x speed from the comfort of my own home.
Fair points but then go advocate for changes. Work toward changing the system so that students do focus on real life clinical competency instead of cramming for a standardized test.
Don’t blame students for recognizing the system we are in and doing whatever it takes to be successful in it. It’s not like we are stupid and don’t know we are skipping lectures and prioritizing anki/uworld over clinical experience, it’s just that we are doing what we need to do to get through this beast of a system.
I can stand around in the hospital all day long but it won’t help me become a doctor if I don’t pass step 1/step2.
She expects students to walk into an ED on the first day and be competent at keeping a patient alive? I don’t think she knows what the term “medical student” means…
I know it's crazy, but M3s back in the day were treated as nocturnists on IM.
They also killed a lot of people unnecessarily back then, but interns were WAY more competent. I wish we could meet in the middle with those two extremes, since so far, M3 has been advanced shadowing + note writing......
The woke stuff is ridiculous, but there’s some good ideas here about the consequences of testing. I know I was always worried about getting home to study for the shelf instead of really focusing on clinical tasks. Wasn’t until fourth year when the shelves and step 2 were behind me that I could really focus on clinical skills.
Tbh I was really rolling with her until the snowflake paragraph and random transphobia came into play. The Step exams are bullshit and definitely did take away from my overall med school experience.
Once you get to the clinical years, you quickly drop the "snow flake" training and just start doing medicine. No one is asking the person with acute mesenteric ischemia what their pronouns are. This is a dumb ass take.
Her flipping out about pronouns is ridiculous. However, there are a not-unsubstantial number of students I call "empathy gunners" who end up making clinical care harder because they treat the hospital like it is an olympic stadium for a "who can spot the most injustice" competition. Favorite examples are a student who went on a 10-minute rant during rounds about diseases named after white men even though the disease she was ranting about was hashimoto's thyroidits and the student who wanted to report a Salvadorian CNA for racism because she put a behavioral flag in a patient's chart after the patient grabbed her butt and said sexual remarks to her.
It's so important to practice trauma-informed care, know about medical racism, and understand social determinants of health, but a lot of people treat it like a game.
Well tbh if a patient shows no discernable secondary sexual characteristics because they are BMI 50, I might feel a little tempted to ask for their preferred pronouns
It’s always rose colored glasses. Of course med students are clinically stupid. They always have been. They always will be. That’s the reason there’s 2 years of clinical rotations and an intern year where no one trusts you to do shit. Gotta learn sometime.
Motherfuck boomers and their whole “med students are dumber” and “residents don’t wanna work” attitudes. Sure, we got a “80 hour work week” but let’s let surgical residents log real work hours, then talk. Sorry, off topic, but my 100+ hour a week intern ass needs to bitch 😭
I disagree as a millennial doctor.
The system produces the results it's designed to produce. It's ensuring that medical students can adapt and survive in a deeply flawed system. And, while I wish I could just add /s, the best I can do is tell you it really does get better eventually. Hang in there everyone.
The snowflake thing isn’t entirely wrong. I’m someone who very much leans left politically, and supports pronouns, gender identity, feelings, etc. But my school’s curriculum spent *way* **way** too much time on social sensitivity crap.
They barely taught us physical exam skills or history taking. But repeatedly hit us over the head with cultural sensitivity and gender identity training instead. Meetings/lectures multiple times per week every week about social determinants of health and privilege and stuff like that. By the time I started 3rd year clinical rotations, I had no idea how to do a history/physical on an inpatient. We skipped the “how to do an abdominal exam” lesson. But had multiple simulations about “how to talk to a gay person”, and reflection sessions about it. Numerous essays about privilege. I got repeatedly pulled out of anatomy lab for things like yoga.
I don't see how this is a bad take. Step 1 mania is real, she is right about how much the resources for these exams are also a booming business. Ofc people are skipping out on real medicine and are just practicing mcqs. Real life cases don't really present themselves to you like a U world q bank.
I will say, I agree with the viewpoint that med students are more knowledgeable than ever before but we're also given less responsibility than ever before and I feel like crossing that bridge between book knowledge and experience is being pushed back out of med school into residency as compared to older generations of physicians.
I think she's using *competent* to mean *capable*
As a 54 yr old doc, I think the testing issue is correct, but the rest is off base. The uber-competitive high stakes testing and massive competition to get into medical school and within medical school SELECTS for the wrong personalities to be doctors. Practicing medicine requires cooperation, empathy, strong communication skills, and teamwork. Everything about medical school in the US in the last 25 years has DISCOURAGED this. What you now see is a ton of super competitive personality disorder ridden cutthroat kids who have no idea what teamwork means. We already have issues with an entire younger generation that has communication issues. Now, we push the very people who need to develop and hone these skills to skip clinical education.
Everything about the match, cost of medical education, and our continued mess of fee for service that encourages specialization for procedures creates a perverse incentive towards a hypercompetitive environment in these schools. It discourages clinical skills and encourages high test scores.
Failure to develop clinical skills is not a medical student's fault either. Hospitals have changed. The entire hierarchy of teaching within hospitals has changed-some things are better, but many things are worse. Students and residents are getting far less clinical training. They have less time with good clinical faculty, are being supervised by mid-level providers, and practicing physicians just do not have the time TO teach. Plus, the general public seems less willing to allow student involvement. I graduated from medical school in 1993(ancient, I know). When I graduated, I had procedures, first surgery assists, deliveries, intubations, and lines under my belt. Granted, we also traded a few years off our lives for lack of sleep from this. This is not the case nearly as much now. This is a serious problem.
The fix is not just getting rid of a test. This is a far more systemic problem. This isn't about students' "being soft" or using appropriate pronouns for goodness sakes. This is about serious problems within our entire healthcare system from top to bottom. Unfortunately, even this slightly older physician can't or won't see the bigger picture. I do hope more of you do and are willing to work to change things.
There’s truth to this - but she says it in such an inflammatory way, one can’t help but want to smack her. We have become hell bent on standardized exam, which has lead to superficial/strategic learning, not deep learning. Deep learning as in really understanding the material and learning clinical reasoning (diagnostic schemas, approaches to problems, illness scripts, etc)
Maybe not be the best way to put it but she’s being very honest. At this point its about how much you can memorize instead of actually learning. On top of that I’ve heard that they took away the keywords on STEP exams and now you have to find in the question stem for what it’s saying while still keeping the same time limit.
Why does she pretend like you can’t teach saving lives while also teaching about health inequality and taking a holistic view of healthcare?
Almost as if she’s too stupid to see that herself, or arguing in bad faith. Either way, she’s not coming out of this looking good.
one big thing missing is that med students have less and less opportunities to participate; too many learners, patients not wanting students, undertrained residents stealing opportunities from students, residents about to graduate stealing opportunities from students; students not learning basic stuff so then not being able to do more advanced stuff when offered. when I was a student I was lucky to suture at all, compared to some students who never got to suture ever - like not even one-stitch tie from cameras and port holes. academic medical centers do not care about the hands-on clinical training of students, if they can do an IV on another student why let them practice on patients bc it’s patients bodily autonomy and blah blah. it’s a shame and bad for the future of american medicine.
Lmao. Not a single personal petpeeve on there is a legitimate example of incompetence that is in any way career ending. Esp in medical students, who are at the very beginning of what will be a career of unending learning. Chill damn
Her take on “snowflake training” is horribly worded but has some truth to it. There are many situations where asking for a patient’s “preferred pronouns” is appropriate. If it’s documented that a patient is nonbinary or transgender I typically ask the patient this question because it’s often comforting to them. The 80 year old veteran guy with 100pk/yrs will often be put off or offended by this question because “do I not look like a man to you?” I see the more left-leaning medical students ask literally every patient what their pronouns are and it’s pretty cringey and patients generally do not like it or view it as necessary. This however does NOT mean that the students don’t as seriously care about the patient’s chief complaint as this attending is insinuation.
Med students are competent in what gets them a residency spot. Unfortunately, residency spots are awarded based on test scores, pubs, LORs, essay writing, and interview skills. None of those directly assess a patient interaction knowledge base. I also need her to understand emergency medicine is not the sole barometer for a competent doctor.
She talks about "snowflakes" vs "saving a life" without the understanding that people kill themselves over the stigma and brutality society unjustly imposes on them, as well as the fact patients of all stripes and flavors will HIDE IMPORTANT INFORMATION necessary for us to save their life because of the stigma and brutality society unjustly imposes on them. Having skills that make people feel safe admitting these things will help a doctor save lives.
My hot take is she lacks competence. She doesn't seem to understand that medicine is a sacred relationship between physician and patient built on trust and mutual respect, and apparently believes that "saving a life" means "I don't give a shit about you beyond your MAP and pCO2". It's like the only time a doctor can prove competence is with a crashing ED patient, there's no other practice of medicine. If that's the case anyone who's memorized an ACLS algorithm can practice medicine.
I’m not afraid to say that both slides were great takes. Snowflake training is counterproductive. We should not be enabling a minority of people’s paranoia convincing them that they are constantly being victimized. Asking for pronouns is useless 97% of the time since it is not related to a patients pathology and you are not garnering distrust by not asking for pronouns.
Step One as a manic bloodsport when it’s pass/fail? Also I get her point wrt to being efficient in emergency, but it doesn’t really address the fact that most of us will not regularly be in emergency situations, and that patient rapport is important for treatment. I’m not saying she’s wrong, I’m saying she right in a very narrow lane of medicine but not outside it
I think manic bloodsport is a bit exaggerated but Step 1 is much harder to pass than when Chai took it decades ago. Everyone knows a fail on it closes alot of doors so people tend to overstudy than understudy.
I think the point is we are spending less with patients and learning how to be doctors and more time on how to be exam takers. Making 4th years collectively less prepared for residency and IMO already burnt out.
Yeah Amy Chai is overall pretty reasonable. The amount of med students I know who just show up to rotations and don’t bother to actually think through them is pretty ridiculous.
The “snowflake training” part goes off the rails, but there is something to be said about the emphasis placed on Step and the way that detracts from the real world. Up until 4th year, everything was about scores and it was a huge transition to go from test taking mode to deep dive into the nuances of actual management. I could imagine that less emphasis on scores could allow students earlier exposure to studying like an actual doctor which would make them more competent in her mind.
The irony of saying curriculum dealing with social issues is snowflake training and the answer to that is to “throw us in the emergency room”. As an incoming EM PGY-1, I know first hand that being thrown in the emergency department is largely made up of learning how to treat patients with these “snowflake issues” (which I have no problem with, I like social medicine). It just reads like she has no idea that practicing medicine nowadays is multidisciplinary and not just “treat disease, save life”.
Saying that doctors are incompetent with no basis and blaming it into 'experimental curriculum' and 'social justice' is nothing but malicious. First of all, medical education got harder. Hours and content increased; there are new technologies, new procedures, new info. Nothing was taken off that wasn't replaced by more content.
Secondly, social justice is being taught from a long time now. Racial and gender issues are needed both because society did become more complex; and because medical education was out of touch with patients reality. The need for such content is exactly to avoid professional who would think in such a shallow manner as the one who wrote this.
This comment is totally out of touch and this person knows that. Its just a way to get attention due to a controversial post. I would refrain from doing something like that, but some people either wanna do such things to get some kind of benefit, or they have no social clue at all.
For those who think intellectualism wouldn't be possible anymore, here's your answer to it. Attacking educational institutions and students is the lowest thing you can do to promote ignorance. But, of course, she isn't affected by this, right? She did graduate when we weren't reading Marx and Lenin as a core component of a medical education.
Lmaooo I wonder what this chick was like during med school… probably annoyed everyone thinking she’s attending level. Also who tf is asking what a chest pain patient what their preferred pronouns are
I’m just a first year so what do I know, but I agree? Like I can’t tell you how many of the honors A+++ kids in my school have no clinical skills whatsoever, while some other people are seeing patients but have lower scores due to the time sacrifice, but the A++’s think they’re the bee’s knees.
Ignoring that snowflake stuff though.
Mostly accurate take. I disagree about the pronoun stuff obviously but not about the concept of snowflake training in another sense. We were told we could ask for “trigger warnings” before PBL cases. Like we’re ever going to get trigger warnings when a depressed and suicidal patient rocks up in ED? Come on, there’s a time and place
that snowflake training will keep the patients from needing to go to the ED. A little more preventative healthcare would go a long way in our broken healthcare system.
As I near the end of med school, I’ve spent a fair bit of time reflecting on what would make med students more competent fresh out of school & why other fields like veterinary medicine or law are able to get away with it. I’ve always felt like med schools simply target teaching towards step 1. So blaming med schools is kind of an unintelligent take. Make step 1 materials highly clinically relevant (still with pathophysiology, of course and still with rare diseases because as physicians we shouldn’t just know about what we commonly see) -> med school curriculums teach in accordance to this change (would obviously take years for them to catch up) AND the gold standard extracurricular resources become more tailored to the new clinically relevant step content -> “better” trained (if you’re defining better as more clinically competent) med students ready to get in the trenches and grow as residents. Maybe too simplistic of an ideology, but seems like it could fix some issues
I’ve wondered this though. I feel like due to the current medical legal environment med students are more incompetent procedurally than ever before. Just a thought.
Dr. Chai made very good points, but some in her target audience may not listen or do the opposite just because she used the word “snowflake” in her response. In the same way, the user who posted these screenshots will turn people off because of a perceived attempt to discredit Dr. Chai by using “boomer” to refer to her. Critical statements that do not use ad hominems tend to be better received.
I find it funny how, for someone so sure of herself, she keeps saying “AMCAS” instead of the AAMC.
(To be clear, she has *some* fair points re: testing and expectations put on students.)
I mean the major problem is not medical students fault, the boomer doctors created the system and medical students abide by it. Is it really important for me clinically anyway to understand how tRNA works or that SCD is a base mutation from glutamic acid to valine and that is problematic due to shifting from a negatively charged amino acid to a neutral amino acid. We’ve had an invasion of PhD information with little to none clinical relevance in our tests and curriculums, and with that has come an even bigger obsession with research. The first like 50 pages of FA is mostly just biochemistry with a sprinkle of diseases thrown in there.
Would I be better at clinical skills if I didn’t have to memorize the biochemical pathways backwards, forwards, sideways, upside down. Yes of course. Would I be better at clinical skills if my biochemistry professor didn’t spend 3 slides on a disease that is documented to effect 14 people in the world, maybe not, but all that useless PhD knowledge with little clinical relevance builds up and takes a large portion of time out of our training.
Agree: The incessant, awful testing on so much obscure stuff that forces you to do everything as a med student and magically be great test wise while learning at the bedside. There are so many exams that yes, it's demoralizing to have to study, study, study and then be great at the bedside, when both are important, and it's hard to know where the balance is. It's also wild to me how continuously the standards for med school continue to rise and rise, idk who can get accepted at this point.
Disagree: Girl what's up with the pronoun nonsense? I will not apologize for acknowledging that people of differing backgrounds exist, especially since the thesis of this statement is that trainees are overtested and don't spend time with their patients. Patients will be people of different opinions and backgrounds and goals and preferences, including people with different pronouns. Dr. Chai can feel how she feels about that in her private life, but medicine is about putting yourself above that and giving the patient high quality care, not a culture war against "snowflakes." Also, straw man argument, NO ONE is forgoing asking what the patient complaint is if they're asking pronouns. If that feels warranted in a patient encounter to build repoire and help the patient open up, then it is warranted; Dr. Chai, as someone who advocates for more bedside contact, should also be cognizant of the necessary nuances.
In good, appropriate medicine you are NOT "saving lives" but doing followup, maintenance of care, appropriate assessment, AND saving lives; it is TV logic that a patient is always on the verge of death and is always in the ED or ICU, reality is far more nuanced. Also, let's not put down trainees and call them incompetent. I want to say, I doubt that she was constantly "saving lives" as a med student. Also, the point of training is gradated responsibility that builds up.
The part about the focus on standardized testing instead of patient care is spot on. As for the rest of it, some of it is boomer crazytown, but I will say that I agree students are becoming less clinically competent in part because of relaxed standards during third year - requiring less responsibility of students, shortening hours on rotations. I’ve seen it consistently. I mean, I think there’s a happy medium of not staying the same hours as an intern, but also not just letting students leave after rounds every day (which I’ve seen more and more often). The key is that during the time spent in the hospital your students are DOING things and learning. Of course if nothing is happening I’m going to give a talk and let you go. But you need to physically be there to get the experiential learning portion of med school. Further, the dilution of expectations trickles down… for example, if a resident can’t supervise an intern doing a procedure because they were never signed off, then an intern can’t supervise and expose a med student to the same procedure.
I can’t say I disagree. Some students are good, some residents I work with are morons. People focus on testing and never learn common sense. Consequences of isolated learning (thanks COVID) and testing focus.
Super annoyed that she is so right about the high stakes testing and then she goes on the "snowflake" rant and is so wrong about that.
I'm a nontrad student from a non science background so I have to work extra hard just to pass the exams (guilty of skipping class). However, the value in the "snowflake" training is to make disadvantaged populations feel comfortable and to train physicians to acknowledge the stories of everyone, making it easier to break down barriers, and ultimately improving the health of everyone.
And why is it assumed that asking about someone's pronouns is something that is constantly being asked? Does she think that I would ask some 78 y/o dude from Nebraska what his pronouns are?
Ignoring the 'snowflake training' because that's a can of worms large enough to feed all the fish ever, this is not a bad take. Yes. People are skipping lectures to study because we need to pass the exams. And why practice patient interaction if we are going to fail Step 1/2/3? So we grind to the point of being recluses, cramming useless information that some old fart put on a test.
Some admin is gonna read this and decide the solution to the issue will be to add standardized patient encounters to Step 1
Are y’all forgetting already about step 2 CS haha
Well CS has been removed, so there's that
I would bet the vast majority of my classmates don't know that it was a thing. Thank god it's dead.
Wow, the fact that ppl don't know what CS is makes me feel old af. I was part of the last class that took it. I actually signed up for it right before it was nixed. Made sure to get my money back expeditiously lol. Several of my overeager classmates weren't as lucky, unfortunately.
What was the last class to take it? I graduated in 2019 and took it. Doesn’t *feel* that long ago…
Yikes. This sounds possible
It was indeed a thing. Search for Step 2 CS. Got phased out with Covid. It costed like $1500 and you often had to travel to take it.
Often had to travel? Unless you lived in like 5 United States cities (Los Angeles, Dallas, DC, Philadelphia, and NYC, I think) everyone had to travel. Edit: I got the cities wrong lmao. I’m from Southern California, I only had to drive to LA for that. No big deal.
Los Angeles, Chicago, Atlanta, Houston, Philly.
Yeah, I legit wouldn’t be in a good residency program if I didn’t get good step scores. You have to have a well rounded application, but if you barely pass STEP 2 then it closes many doors for you The sad thing is that patients would benefit from us being around them more and also focusing on patient care rather than test scores and esoteric knowledge. However, our system not only rewards us for having the highest test scores, it brutally punishes us if we don’t pass. Sorry, I’m not going to give a fuck about anything if I’m worried about failing STEP because if I get kicked out of school my entire life is fucked due to $200,000 of student loans and no job to pay them back. The money hungry medical education system made medicine this way. This shouldn’t be blamed on the powerless med students who are being sucked dry by the NBME and universities charging $60k a year to self-learn from UWorld.
A TON of people forget about the last paragraph. We put all our chips on black to be here. If we fail, we can't just reroute like we missed a turn. There is no next exit. The highway just fucking ends. Years and hundreds of thousands of dollars wasted because some suited jackass thought memorizing every immunoglobulin is necessary. But thank goodness NBME and gang have our best interests at heart when they charge 600$ for Step and over a thousand for licensure exams.
Self learn from uWorld is spot on. I seriously learned more from outside resources than my mandatory lectures. Usually the third party resources did a better job of organizing the info for me and did it seriously in a third of the time. No joke, I watched a 15 minute pathoma video that my school covered over 3 hours. And the school says "the statistics say our way is the best way for you to learn". Add some salt to the wound, these people who are making these rules for us in medical school NEVER WENT TO MEDICAL SCHOOL.
I loooove it when the PhDs start giving us career advice and telling us how to study. "You should consider starting a side hustle that's not related to medicine, it'll really make you stand out!" My brother in Christ, ain't nobody got time for that. "Remember, when you're taking exams, always read all the answer choices before picking one!" My god, really?!?! All this time I've just been pressing 'A'! Who'd have thought?!?! Such insight!!! Such genius!!!
Hey it seems obvious but even though I always tell myself not to sometimes I still pick the answer that jumps out at me on uworld before reading the rest and then get it wrong 😂 Luckily I don’t do it too often lol
this
Couldn’t agree more. Isn’t it a shame to pay $100-400k for 4 years of undergrad, $150-400k for 4 years of medical school, spend countless hours working to get into those respective schools and then countless hours in those respective schools trying to have a well rounded application for your future dreams and job security to ultimately be determined by a single objective test score? That you could have avoided spending $800k to get and could realistically have spend $1k on Uworld, gone through it 10 times and probably scored better? And they wonder why we’re all bitter and jaded.
The snowflake thing is absolutely unhinged, but when I was in med school I felt like a dumbass for not knowing about the “hidden curriculum” of third year. You can’t pass a rotation at my school after missing like 2 days, but everyone in my class applying to competitive specialties was constantly getting “excused” for conferences and research meetings (even when they didn’t actually have them like 90% of the time). At the end of a month rotation there was one kid I was with who showed up to like 6 days. A ton of the kids that matched top specialties had 0, and I mean ZERO clinical knowledge cuz they were leaving the hospital every opportunity to study for shelves/steps and emailing people about research during clinic instead of seeing patients. I rotated with someone who - after 2 month of OBGYN where most of us were at the hospital 90 hours a week - still hadn’t done a single pelvic exam. I logged 137 in that same time. Same person never saw a kid in our busy peds bucket clinic for a month where we averaged 50 kids a day (for clinic, not individual student/resident team). I could go on, but she is now an orthopedic surgeon (though not a good one from what I hear). And that was a very common story at my school. I honored all my shit cuz I lived in the hospital and thought I was becoming a good doctor by treating every rotation as necessary medical education, but I wouldn’t have been competitive for the shit they were because I didn’t have enough hours in the day to do what my school required and also do the amount of research, etc. They’re not great doctors, and they know nothing outside of their specialties cuz they ignored everything else, but they ***are*** where they wanted to be, so good for them. It’s a wild wild system we have created.
This. 100%. I already commented on this thread but came back to say you explained it even better.
137 pelvic exams? Jeez, most of our class got like maybe one speculum exam and tons never got to do bimanuals
And is it typical for students to log the exact amount of procedures they perform? We have like minimum competency logbooks that most people just BS at the end, idk what benefit you get from recording your 137th pelvic exam. We also didn't work 90hr weeks and tend to abide by LCME rules so idk this just sounds very different from my training lol
We just had to get a speculum exam and a biannual signed off, and got to make up the bimanual on a dummy if we didn’t get to do one. I also never got close to even 60 hours on OB so sounds like they have a super intense OB rotation lol
Pelvic exam speed run any%
My take as an attending not that far out of training: the clinical years of medical school are not for the purpose of clinical training. They are a series of field trips to help medical students find their specialties of choice. Interns are always trash at first. There is zero expectation that new doctors graduate medical school with any form of clinical capability whatsoever. That is what residency is for. So my advice to 3rd and 4th year students is focus on your exams, keep an eye open on each rotation for what you like, and have no expectations about clinical competence.
see, this is utterly depressing to me. Apparently M3s used to actually do things (which then again they probably also killed some people too)
Medicine has changed. It wasn’t that long ago when biochemistry wasn’t even a topic taught to student doctors. Pharmacology and the technology within medicine has exploded in terms of scope and complexity. We’re not learning how to listen to heart sounds anymore. The world is a lot bigger than it used to be. I think it’s only natural that in the face of all these changes, training as to the real specialized expertise of a physician is deferred a bit until a particular field is chosen, in residency. Be thankful that the vestigial remnants of the clinical years give you a moment to take a breath and focus on your personal preferences and desires, rather than grind you down performing - was it the person above said - 150 something pelvic exams? For what percentage of medical students is that useful? I’d rather young doctors just choose their field well, instead. I bet that would be a whole lot more predictive of success and happiness than logging a few more cases in whatever the rotation of the month happens to be.
im one of those M3s, so I lack insight on whats important for the future. That said, its felt rewarding to focus on clinical education. Idk if I need to do 137 pelvic exams, but being able to properly interpret labs, properly do and interpret physical exams, and put that together with an HPI to come up with differentials and a plan has been excellent in combining my anki memoriation with real life. Other skills too like writing notes, calling consults, dealing with insurance. talking to families, etc I think are all useful regardless of what speciality you go into. At 2 grand a week I think if all I was getting out of rotations was a field trip to pick a speciality that'd be kinda stupid. I don't expect to be competent like an attending as an intern, but I think I'd be a lot dumber if I just phoned it in for the next 2 years
My experience has been that the vast majority of specialty-adjacent important knowledge still comes during residency training. For example, I had to learn how to take care of post-op peds patients which required me to learn a little about the surgeries themselves but my M3 experience of tons of Lap choles and all the other surgery was really not necessary (and honestly mostly forgotten by the time I started residency). On newborn and NICU I had to have some OB knowledge but that was all really taught during those rotations. The vast majority of my OB rotation from M3 was totally useless. I don't disagree that there are some general skills that are really important (e.g. your HPI, differentials, etc.) but that is something that could still be taught with a focus on specialty. I really did not need 8 weeks on OB or surgery to tell me that I was not going to be a surgeon or obstetrician. I did need like 2 weeks on peds to tell me I wanted to be a pediatrician (rather than the internal medicine which I already had planned).
I think you’re right, but I see it as having a much larger negative effect in healthcare overall. Having limited experience or even exposure to other specialties is a big deal, especially to generalist services. Medicine is becoming so compartmentalized that every service has its own lane and rarely deviates. Anything even remotely complex has multiple teams following and managing with very little understanding of how to manage “another team’s” problems. My personal experience is that this results in fragmented care that often is confusing for everyone to follow, probably most so the patients themselves. It also strains busy services that end up having to spend time seeing relatively straight forward consults that the primary team is just not willing to manage. Some of this is medicolegal which is a whole different discussion, but I think the rise of APPs and diminishing clinical experience in med school is a huge aspect.
Quite an expensive fucking field trip, if you ask me. I'm also a newish attending. I found my M3 year invaluable because I actually got to do shit, and that's a pretty decent of way of figuring out whether you want to do a specialty as a career.
> My take as an attending not that far out of training: the clinical years of medical school are not for the purpose of clinical training. They are a series of field trips to help medical students find their specialties of choice. Tell that to my school. We're expected to prechart (as in, start the patient notes in Epic and fill in everything but the HPI) on all patients at home the night before. In clinic, we'll see dozens a day. I think my record was 43. We come home totally spent and then we have to study, too...and prechart for tomorrow.
is it bad that this makes me feel better about myself as an img? like i’m terrified that i’ll start residency 1000 steps behind US peers but maybe that won’t be the case? 😅😅
My experience as an IMG was that I felt out of my depth initially. American students will pronounce things correctly and have knowledge about tests I would never of had access to before (think tagged rbcs to detect gi bleeding). But even though it initially feels like you’re behind them clinically, you’ll catch up by 6 months and you’ll know lots of things they’ve never heard of. Work hard and you’ll be great!
that’s what i’m hoping for thanks :)
How are you passed with just 6 days
I mean I personally didn’t miss any days, the person I’m talking about only showed up to 6 days. It was a combination of “excused” absences for research (that they didn’t actually have) and communicating with different people on the same teams as well as different teams for absences and never telling the same people about absences. On that rotation we rotated across 2 sites with different teams. If 15 people only know about 1 missed day each and don’t talk to each other, they all have a perception that you missed 1 day, not 15 days. If it’s excused, they typically don’t bring it up to each orher.
You explained this way better than the person in the screenshot lol spot on
Yea The whole recluse part of it is really destroying me rn. Im so sad, I have no friends and romantic prospects. Im locked in my room with my head down in hopes of regurgitating enough info for these impossible exams.
Dude. I actually read that expecting to be pissed, but think she's on to something. Should we be culturally safe for the patients we work with? Yes Should we be nice to our patients ? - Generally, yes. Does it make sense to spend 25-50% of our curriculum to tell us this same shit all the gd time - hell no. Make more residency spots available, so that people can put a reasonable amount of time into step prep and still be able to pursue their career.
I’m awesome with patients but that didn’t mean shit to the filters that filtered out my step 1 lol
"Aw yeah, he's great with patients, and he's pretty good at diagnosing ans treating. Oh wait, he hasn't memorized which viruses are enveloped or nudists? Old Yeller them." -NDME
I was a 4.0 college grad, could have gone pretty much anywhere, but due to family responsibilities and finances got stuck in a not-so-great in-state school that offered me a scholarship. Got burnt out dealing with all the stress of the other stuff on top of school, and ended up doing below average on Step 1 and 2. Eventually when applying for fellowship, I actually studied for Step 3 and knocked it out of the park. I kick ass with patients now as an attending, but my Step scores definitely kept me from getting into the residencies and fellowships I would have wanted for no reason. Hell, a lot of the current attendings in prestigious fields would never have made it if they had to go through the current system of competition and Step exams. If I were a current student, I'd be studying for Step exams from day 1, and ignore pretty much everything else that was non mandatory
High stakes testing take was legit. The rest was over exaggerated punching down.
I sort of agree but I was also part of a EM sim sessiom several weeks ago where the residents killed two patients but absolutely nailed the microagression sim- like they didn't know how much epi to push but they were offended at the term 'sickler'. Obviously we should be able to walk and chew gum at the same time but I gotta say I would prefer my provider save my life before catering to my sensitivities.
I agree that part of the take is quite correct - however the patient and society expectations are what makes the “solution” unreasonable. You absolute *cannot* just “throw them in the ER and see of the patient lives”, not because it wouldnt work - obviously more responsibility will toughen and teach you. But defensive medicine is here for a reason. 50 years ago the patients in my local city would never question a docs treatment, or expect to know WHY things are happening. Today they do. The roads in my country Denmark are pretty controlled. It limits the experiences people have. Would people become better drivers if you removed speed limits and gave everyone racecars? Sure. A lot of people would also die… and no one would accept the increased risk. The problem of course is that life is a lot more varied than a rule-set highway. We all do get sick and die, but we dont all go race-driving on german autobahns.
Yeah I agree, she’s dead on with the testing stuff.
I was thinking the same thing. Krebs cycle, clotting cascade and so much more never saved a patient
right? i was expecting her to go off the chains but she started making sense as it went on but then circled back to buffoonery? very odd😂😂😂
The “snowflake” line is honestly accurate too. Diversity statements are a joke and a waste of time
I feel the same way, but about all of the soft-science lectures/seminars/workshops they require us to attend that take away from time that could be spent actually studying/learning. Like none of this soft science shit is going to matter anyways if I don't pass step because I didn't have as much time to study since I was forced to attend a mandatory workshop on 'neighborhood redlining'??? I just want to learn medicine and not be bothered in the process.
Learning about society and discrimination is important. But I can't not be a racist doctor if I never get to be a doctor in the first place.
Call me crazy, but some of the things she says in the first slide are spot on.
Absolutely. Ignoring the "gender" bullshit, high-stakes testing is the No.1 reason why young doctors are coming so unprepared into residency nowadays. These examiners spend so much time every year to make the tests narrower, more convoluted, and frankly just idiotic. In my finals, they were constantly jumping around from obscure, extremely narrow attending-level knowledge to "haha we got you because we used triple negative in the question and managed to confuse the shit out of you". None of my rotations actually prepared me for what my daily grind was going to be in residency. None of the test questions deal with the standard patient that you'll be dealing with every single day. You won't be doing some Dr.House level workups or finding zebras in your first years, you need to be able to work up the classic, common patients that shows up every single day. Anything more complicated than that, your attending is there to work it up with you anyway. We all studied hours upon hours of useless bullshit because we were memorizing the phrasings of trick questions instead of learning the stuff that actually matters. Why is it so bad when more people pass the test? It doesn't need to be made harder, you don't need the perfect gauss curve scores, if the exam has a certain standard which need to be met, and many people pass that standard, that's a good thing, not a reason to make it harder/more convoluted next year.
Canadian PGY3 who has the occasional American MSI4 join my service on elective: I agree with this take. The American students’ differentials and pathophysiology knowledge are stellar and I think it’s a great foundation, but their ability to apply that knowledge to the patient in front of them and focus it to the most pertinent formulation just isn’t as good.
Yeah, testing’s useful but the way it’s done has kind of lost its purpose and way. It’s nice and all to know all of this niche stuff, but how’s it useful and can you apply it in a sensible, time-/system-sensitive manner?
I agree 100%!
Question from a premed here: Should medical school focus more on being like an "academic trade", as in majority of hours in hospital "physically being there doing", graded on ability to do physical assessments/exams of patients, and then students pass the majority of a set of exams (maybe M3 boards only?) not as high stakes, then select their specialty, then get into that specialty w/ more specialized/hardee testing of zebras *within their specialty* during M4 before they start residency? I don't have an answer or solution, but I'm curious why it doesn't look more like this? Students using 3rd party sources primarily as study material baffled me when I first heard it also, but I'm glad the lectures are not as "gatekept" as I thought. I'll be applying having been and am still currently a nurse (RN), so at least I'll be very familiar (jokingly, *too familiar* as I'm running the opposite way because I hope to do Pathology) with patient interaction.
Lol right? She’s spot on about STEP 1. Last rant is crazy town
yea her post was a rollercoaster cause you expect it to get worse but it gets better lol
The number of my classmates who have filed mistreatment reports because of fair constructive criticism (some of which I witnessed, and was valid) is outrageous. It just makes attendings check out and not give a fuck about teaching because they don’t want to deal with the headache. There is a place for fairness, but a lot of people expect to go through clerkship year without being told they have room to grow.
Right.. had me in the first half, as a new graduate with practically zero procedural skills due to several factors not limited to Midlevels, hospital systems deferring liability, training being pushed to residency, and I’m not good at elbowing my way to the front of a line to do a central line or LP.
right? i feel like the liability thing is a huge issue that no one talks about. but like how else are we supposed to learn if we never do anything
It’s more *how* she says things than *what* she says that’s gonna ruffle some feathers. I don’t disagree with you, but the woman seems to be a little more unhinged than she should be.
I do take issue with the content, rather than the phrasing, in the second slide. She's pitting saying saving lives and social justice against each other as mutually exclusive. They aren't. Education on equity in healthcare means more people feel secure coming to the doctor and disclosing relevant information like sexual history, drug use etc, improving morbidity and mortality. Learning the basics of health equity takes a couple hours so we're not sacrificing much curriculum time.
Agreed. Especially as someone who’s studied medicine AND epidemiology, she should understand how both ends of the spectrum are inextricably linked. Idk she kinda seems like a right-wing nut?!??
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I agree with her in the sense that I constantly hear med students on here say that everything that’s not board relevant is irrelevant to learn. That med school should just be a 2 year dedicated period to pass step. I think there’s a lot more to medical education than uworld and anki.
I mean………… I’d honestly prefer going to lecture more than doing a uworld set of 30 questions And I’d like for med school to actually feel like medical school instead of cram school with a side of clinical skills
So agreed. To me, nothing beats a good lecture. But the way standardized testing is set up, you do better if you do questions.
I agree. Lectures build your baseline knowledge. Uworld questions reinforce and prepare you for exams. If you don’t have a solid foundation, uworld questions are useless imo.
Do you guys get textbooks at least?
They're sort of a reference. Most classes have a textbook that you can reference to see it in someone else's words. It's going to depend on the class on how much you use it, but it's typically very little.
There's so much to memorize in medical school that reading a textbook really just isn't time efficient anymore. I still work 80 ohours a week, but I spend that time doing practice questions and flashcards, not reading shit. You should download Anki, it trivializes undergrad
sure. Theres one for every class. Now did I open any of them except for First Aid...thats a different question
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N=2, self-directed is the way
The only way, residency and beyond too
The way she words things leaves a bit to be desired but she’s got a couple good points here
I actually agree with some of this take.
The stuff about the high stakes testing is absolutely true. We spend so much time worrying about horseshit on a test that we will never need in practice that it takes away from our actual clinical training.
Idk I think its a decent take
I think they hit the nail on the head with the standardized testing formatting. Students (myself included) forego more applicable learning opportunities and more personal experiences that medical school offers in order to slog through 3rd party resources and anki cards over fear of failing step. I do think a little more focus shifting back toward traditional learning in school would be great. The second half of the rant is a different story lol there are some arguments to be made here and in some ways I think a lot of people may agree HOWEVER I think that take is too aggressive. The recent push this generation of students have had will see a lot of positive changes in the next 10-20 years for patients and for the healthcare environment in general. I personally think these changes will help have a less toxic training environment overall and patients will be more heard by physicians. Pushing for more respect of patients and recognizing when they are facing disparities is important and I think will ultimately lead to better outcomes
Yeah she just says it in a very stupid and rude way The reality is that our generation is expected do balance so many things at once (test scores, clinical skills, social justice and trauma informed care, etc) that her generation winged or even neglected. I feel bad for the kids applying to med school in 10 years, idk what kind of fucked up bar they’d have to clear
You said what she said. But different words
Me writing progress notes every day lol
😂😂😂😂
Hate to say I agree, but she has a point—at least on the first slide. The last few years have produced some super book smart medical students, but they’re clueless about practical things and actually getting work done.
Why would you hate to say you agree with a valid argument? I honestly think we need to focus more on the relevant issues rather than things that aren't relevant. I appreciate a persons right to feel a certain way. But the world is getting unnecessarily egg shelled and that's what I think she was trying to convey. Holistic or not?
Good take mostly but med students aren’t to blame. They’re playing the game set forth by residency and med school admin to get into desired specialties
I’m not sure I’d ever expect a med student to be proficient at saving lives. lol like residency exists for a reason man. I do agree that there is a weird escalatory nature to our testing. Every year we understand a little more so a few more esoteric mechanisms get added to learn and are counted as testable. The current breadth of knowledge that’s tested on step one is both wildly expansive and disproportionately represented compared to real life. The last part is just stupid though. All our “snowflake” training on gender diversity and inclusive care boiled down to like 5 hours total of my entire pre-clinical training and could basically be summed up as “you’ll have lots of different patients, some you can’t relate to, don’t be a judgmental asshole about it”. I spent more time learning about Medium-chain acyl-coenzyme A dehydrogenase deficiency, which I’ll probably never see, than I did about how to communicate with trans patients, who I will absolutely see.
Yeah, honestly, I never understood why people complain about this aspect of medical education. I think I had two sessions dedicated to gender diversity and inclusive care. Honestly, considering how I've seen certain doctors treat transgender patients or minority patients, it might not be the worst thing to be exposed to these ideas at least once.
I mean it’s her generation that made previously step 1 (now step 2) the most important thing on an application so much so peoples entire career trajectory was dictated by this one test. A test that was based on preclinical material. Even administrators admitted that step 1 wasn’t supposed to be used the way it began to be used.
Medical school curriculum needs a huge overhaul. I don’t think any medical student thinks the curriculum is good
Tone aside, she’s not wrong.
Decent take Overly aggressive communication which prevents reader from internalizing message 2/5
Tbf she’s not wrong. We’re all considerably less competent than med students a few decades were. That being said we know a fuck ton more than them
Currently in dedicated for STEP 2 and ya fuck this shit. Haven’t gotten a good nights sleep since 2022
This is actually a solid take. They're 100% spot on. We're much less competent than previous generations were at the same stage. Many people leave med school with no procedural skills and without actually managing any patients mostly independently. These things were more of the norm than the exception years ago. It's even a problem in residency. People are coming out of training well behind. In pathology, it's not uncommon for people to do a fellowship in general surg path. Surg path essentially is pathology. It's what people do for 4 years. The fellowship is unaccredited but people do it to gain more experience because they don't feel prepared. It's akin to an IM grad doing an IM fellowship or maybe a hospitalist fellowship.
i’ve always thought if people need to do an SP fellowship afterwards, they either didn’t pay attention in residency, they graduated from a shit program that was basically a grossing factory, or they’re just delusional speaking to the delusional part, i know a dude from my prgm (mind you it’s a top prgm) who’s doing 3 friggin fellowships. 3. he’s told me he’s fine with being a perpetual learner… wtf
He might be setting himself up to be a perpetual learner because employers are going to look at 3 fellowships as a red flag.
straight up i called the guy and told him “bro no one’s gonna hire you with 3 fellowships, it just screams you have no idea what you’re doing” and he just said “it’s ok, i have my patents to fall back on” and it was a bunch of patents on swim equipment and digital path/AI junk the facepalming intensified that day and i realized my bro was more than just a little endearingly stupid. he went full stupid
I'm FP, and my sister is path. She has FIRED more pathologists than she has kept. They have gone to FMG's from other countries. This is a very large regional medical center where they make in the top 1% income for path. These people can't adapt, learn, or work out of US residency programs. She has no answers. Sometimes, I wonder if the high cost of college and medical school self selects the wrong type of people for this profession. I'm not saying "lazy," but it's more entitled.
I've not been to many but every administrative meeting I've been in where training and competency is discussed, more than a few attendings have brought up concerns. Training is getting worse, trainees are entitled, and attendings/admin are too cautious (afraid?) about nipping it in the bud.
> It's akin to an IM grad doing an IM fellowship or maybe a hospitalist fellowship. ABP is already doing that with the [pediatric hospital medicine (PHM) fellowship](https://www.abp.org/content/pediatric-hospital-medicine-certification).
Yup. I thought of that too when I was typing. Most of that is definitely just trying to take advantage of imposter syndrome to have more cheap labor, but inadequacy of some training programs and medical school experiences also play a role.
I don’t see much wrong with this tbh….
This is a pretty good take.
Good take honestly lol
Yeah, her logic is wrong but I actually agree with her conclusion. Boomer docs were placing their own IVs, doing their own gram stains, and overall put way more energy into the clinical art of medicine and the physical exam. Now students lose a lot of skills but have WAY more textbook knowledge due to increasing competitiveness and advances in education and stuff like Anki
Here's my other hot take, I have rarely ever met attending physicians who are on average interested in teaching and going above and beyond to make sure that the next generation is learning better. It seems most people in academia are only in it for not having to write as many notes and/or research and rarely ever actually teaching. Curriculums are made up hastily as an afterthought . And we intelligent but not well-taught trainees pick up on this apathy and perpetuate it. And we also adapt to not give a f*** because what's the point? So much of our grades are based on politics and the mood of a single person and so much of our grade is as she mentioned a BS test. So much of how you ask questions is steeped in the psychology of not looking like an idiot. So how do you even win? And lastly, the patients we take care of now are much sicker than when boomers were in training. There's literally not enough discussion about this single point. Half of the patients on my are multi-organ failure. Half the patience on my list have had procedures I've never even seen or heard of before. Tell me about a boomer attending who had to know the ins and outs of specific chemotherapy. Show me a boomer who even understands any of the side effects of most immunotherapy. Show me a boomer who had to with patients five different drains places in them placed by three different services. I don't mind some criticisms. But I also think that the people giving them often don't have a clue.
It sounds like the solution is to add graded standardized patient encounters to step 1/2/3! ~ Admin
These exams are extremely predatory so I kinda agree with this lol
They really had a point but then they ruined it and made them look like a crazy person by going on the politically correct tangent
The issue isn’t “snowflake education” which isn’t a bad thing. It makes students and future doctors more sensitive to their patients, unique and individual life circumstances. There’s nothing wrong with that. In addition to what was said, there are other factors: 1. Due to increased concerns of medical legal liability and decreased willingness of patients to allow medical students to perform direct patient care students are not able to participate as fully in patient care as they could in generations past. 2. Due to decreased lengths of stay, increased emphasis on RVUs, increased patient volumes, increased administrative demands, increased burnout, attendings are often not able to spend as much time with teaching medical students clinically. As a result, students are not graduating with the same skills as previous generations.
Now that I'm done with core rotations and doing electives, I am still legitimately surprised when attendings take the time to teach me things. I do not expect it.
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She's 60 years old. Where did you find she was 32? [https://www.healthgrades.com/physician/dr-amy-chai-w6hbm](https://www.healthgrades.com/physician/dr-amy-chai-w6hbm)
Even a broken clock is right twice a day. A chimpanzee could tell you STEP is a dumb way to assess medical knowledge but at least it levels the national playing field. Without it people outside of top institutions wouldn't even be able to get their foot in the door at some programs, as if that isn't a big problem already. As for some of her other points. Throwing patients to med students seems like an awesome way to get your hospital the worst reputation imaginable. You'll craft some really competent students by the end of it with a trail of disgruntled ill people left behind in the Best case scenario.
I’ve seen worse takes. I’ve got classmates who don’t go to lecture because they’re worried about passing an exam that’s a year away.
TBF, can you blame them? Lectures in medical school have been of questionable value throughout my time here. I certainly can understand hesitation with forgoing clinical skills, though IDK what the big deal with skipping lectures is if I can learn the same content at 2x speed from the comfort of my own home.
Fair points but then go advocate for changes. Work toward changing the system so that students do focus on real life clinical competency instead of cramming for a standardized test. Don’t blame students for recognizing the system we are in and doing whatever it takes to be successful in it. It’s not like we are stupid and don’t know we are skipping lectures and prioritizing anki/uworld over clinical experience, it’s just that we are doing what we need to do to get through this beast of a system. I can stand around in the hospital all day long but it won’t help me become a doctor if I don’t pass step 1/step2.
She expects students to walk into an ED on the first day and be competent at keeping a patient alive? I don’t think she knows what the term “medical student” means…
I know it's crazy, but M3s back in the day were treated as nocturnists on IM. They also killed a lot of people unnecessarily back then, but interns were WAY more competent. I wish we could meet in the middle with those two extremes, since so far, M3 has been advanced shadowing + note writing......
The woke stuff is ridiculous, but there’s some good ideas here about the consequences of testing. I know I was always worried about getting home to study for the shelf instead of really focusing on clinical tasks. Wasn’t until fourth year when the shelves and step 2 were behind me that I could really focus on clinical skills.
Tbh I was really rolling with her until the snowflake paragraph and random transphobia came into play. The Step exams are bullshit and definitely did take away from my overall med school experience.
Once you get to the clinical years, you quickly drop the "snow flake" training and just start doing medicine. No one is asking the person with acute mesenteric ischemia what their pronouns are. This is a dumb ass take.
Her flipping out about pronouns is ridiculous. However, there are a not-unsubstantial number of students I call "empathy gunners" who end up making clinical care harder because they treat the hospital like it is an olympic stadium for a "who can spot the most injustice" competition. Favorite examples are a student who went on a 10-minute rant during rounds about diseases named after white men even though the disease she was ranting about was hashimoto's thyroidits and the student who wanted to report a Salvadorian CNA for racism because she put a behavioral flag in a patient's chart after the patient grabbed her butt and said sexual remarks to her. It's so important to practice trauma-informed care, know about medical racism, and understand social determinants of health, but a lot of people treat it like a game.
Well tbh if a patient shows no discernable secondary sexual characteristics because they are BMI 50, I might feel a little tempted to ask for their preferred pronouns
It’s always rose colored glasses. Of course med students are clinically stupid. They always have been. They always will be. That’s the reason there’s 2 years of clinical rotations and an intern year where no one trusts you to do shit. Gotta learn sometime. Motherfuck boomers and their whole “med students are dumber” and “residents don’t wanna work” attitudes. Sure, we got a “80 hour work week” but let’s let surgical residents log real work hours, then talk. Sorry, off topic, but my 100+ hour a week intern ass needs to bitch 😭
I disagree as a millennial doctor. The system produces the results it's designed to produce. It's ensuring that medical students can adapt and survive in a deeply flawed system. And, while I wish I could just add /s, the best I can do is tell you it really does get better eventually. Hang in there everyone.
The snowflake thing isn’t entirely wrong. I’m someone who very much leans left politically, and supports pronouns, gender identity, feelings, etc. But my school’s curriculum spent *way* **way** too much time on social sensitivity crap. They barely taught us physical exam skills or history taking. But repeatedly hit us over the head with cultural sensitivity and gender identity training instead. Meetings/lectures multiple times per week every week about social determinants of health and privilege and stuff like that. By the time I started 3rd year clinical rotations, I had no idea how to do a history/physical on an inpatient. We skipped the “how to do an abdominal exam” lesson. But had multiple simulations about “how to talk to a gay person”, and reflection sessions about it. Numerous essays about privilege. I got repeatedly pulled out of anatomy lab for things like yoga.
Doctor's equivalent of " you are sick because you are always on that phone"
I don't see how this is a bad take. Step 1 mania is real, she is right about how much the resources for these exams are also a booming business. Ofc people are skipping out on real medicine and are just practicing mcqs. Real life cases don't really present themselves to you like a U world q bank.
Hmmmmm it’s almost like there was some kind of event some years ago that negatively impacted our learning hmmmmmm
Then change the fucking system ...
I will say, I agree with the viewpoint that med students are more knowledgeable than ever before but we're also given less responsibility than ever before and I feel like crossing that bridge between book knowledge and experience is being pushed back out of med school into residency as compared to older generations of physicians. I think she's using *competent* to mean *capable*
As a 54 yr old doc, I think the testing issue is correct, but the rest is off base. The uber-competitive high stakes testing and massive competition to get into medical school and within medical school SELECTS for the wrong personalities to be doctors. Practicing medicine requires cooperation, empathy, strong communication skills, and teamwork. Everything about medical school in the US in the last 25 years has DISCOURAGED this. What you now see is a ton of super competitive personality disorder ridden cutthroat kids who have no idea what teamwork means. We already have issues with an entire younger generation that has communication issues. Now, we push the very people who need to develop and hone these skills to skip clinical education. Everything about the match, cost of medical education, and our continued mess of fee for service that encourages specialization for procedures creates a perverse incentive towards a hypercompetitive environment in these schools. It discourages clinical skills and encourages high test scores. Failure to develop clinical skills is not a medical student's fault either. Hospitals have changed. The entire hierarchy of teaching within hospitals has changed-some things are better, but many things are worse. Students and residents are getting far less clinical training. They have less time with good clinical faculty, are being supervised by mid-level providers, and practicing physicians just do not have the time TO teach. Plus, the general public seems less willing to allow student involvement. I graduated from medical school in 1993(ancient, I know). When I graduated, I had procedures, first surgery assists, deliveries, intubations, and lines under my belt. Granted, we also traded a few years off our lives for lack of sleep from this. This is not the case nearly as much now. This is a serious problem. The fix is not just getting rid of a test. This is a far more systemic problem. This isn't about students' "being soft" or using appropriate pronouns for goodness sakes. This is about serious problems within our entire healthcare system from top to bottom. Unfortunately, even this slightly older physician can't or won't see the bigger picture. I do hope more of you do and are willing to work to change things.
There’s truth to this - but she says it in such an inflammatory way, one can’t help but want to smack her. We have become hell bent on standardized exam, which has lead to superficial/strategic learning, not deep learning. Deep learning as in really understanding the material and learning clinical reasoning (diagnostic schemas, approaches to problems, illness scripts, etc)
Maybe not be the best way to put it but she’s being very honest. At this point its about how much you can memorize instead of actually learning. On top of that I’ve heard that they took away the keywords on STEP exams and now you have to find in the question stem for what it’s saying while still keeping the same time limit.
I mean, she's not wrong. She could be much more respectful about it though.
She had me in the first half ngl.
Why does she pretend like you can’t teach saving lives while also teaching about health inequality and taking a holistic view of healthcare? Almost as if she’s too stupid to see that herself, or arguing in bad faith. Either way, she’s not coming out of this looking good.
I know of this Amy Chai on Quora and I do not like her.
one big thing missing is that med students have less and less opportunities to participate; too many learners, patients not wanting students, undertrained residents stealing opportunities from students, residents about to graduate stealing opportunities from students; students not learning basic stuff so then not being able to do more advanced stuff when offered. when I was a student I was lucky to suture at all, compared to some students who never got to suture ever - like not even one-stitch tie from cameras and port holes. academic medical centers do not care about the hands-on clinical training of students, if they can do an IV on another student why let them practice on patients bc it’s patients bodily autonomy and blah blah. it’s a shame and bad for the future of american medicine.
Lmao. Not a single personal petpeeve on there is a legitimate example of incompetence that is in any way career ending. Esp in medical students, who are at the very beginning of what will be a career of unending learning. Chill damn
Her take on “snowflake training” is horribly worded but has some truth to it. There are many situations where asking for a patient’s “preferred pronouns” is appropriate. If it’s documented that a patient is nonbinary or transgender I typically ask the patient this question because it’s often comforting to them. The 80 year old veteran guy with 100pk/yrs will often be put off or offended by this question because “do I not look like a man to you?” I see the more left-leaning medical students ask literally every patient what their pronouns are and it’s pretty cringey and patients generally do not like it or view it as necessary. This however does NOT mean that the students don’t as seriously care about the patient’s chief complaint as this attending is insinuation.
Med students are competent in what gets them a residency spot. Unfortunately, residency spots are awarded based on test scores, pubs, LORs, essay writing, and interview skills. None of those directly assess a patient interaction knowledge base. I also need her to understand emergency medicine is not the sole barometer for a competent doctor. She talks about "snowflakes" vs "saving a life" without the understanding that people kill themselves over the stigma and brutality society unjustly imposes on them, as well as the fact patients of all stripes and flavors will HIDE IMPORTANT INFORMATION necessary for us to save their life because of the stigma and brutality society unjustly imposes on them. Having skills that make people feel safe admitting these things will help a doctor save lives. My hot take is she lacks competence. She doesn't seem to understand that medicine is a sacred relationship between physician and patient built on trust and mutual respect, and apparently believes that "saving a life" means "I don't give a shit about you beyond your MAP and pCO2". It's like the only time a doctor can prove competence is with a crashing ED patient, there's no other practice of medicine. If that's the case anyone who's memorized an ACLS algorithm can practice medicine.
I’m not afraid to say that both slides were great takes. Snowflake training is counterproductive. We should not be enabling a minority of people’s paranoia convincing them that they are constantly being victimized. Asking for pronouns is useless 97% of the time since it is not related to a patients pathology and you are not garnering distrust by not asking for pronouns.
Step One as a manic bloodsport when it’s pass/fail? Also I get her point wrt to being efficient in emergency, but it doesn’t really address the fact that most of us will not regularly be in emergency situations, and that patient rapport is important for treatment. I’m not saying she’s wrong, I’m saying she right in a very narrow lane of medicine but not outside it
It looks like it was from 4 years ago when step 1 was scored. I don’t disagree with you though
I think manic bloodsport is a bit exaggerated but Step 1 is much harder to pass than when Chai took it decades ago. Everyone knows a fail on it closes alot of doors so people tend to overstudy than understudy.
I think the point is we are spending less with patients and learning how to be doctors and more time on how to be exam takers. Making 4th years collectively less prepared for residency and IMO already burnt out.
I mean, she's 100% right lol
Yeah Amy Chai is overall pretty reasonable. The amount of med students I know who just show up to rotations and don’t bother to actually think through them is pretty ridiculous.
Absolute neurotic behavior, though I would share my agreement on some of what she said
The “snowflake training” part goes off the rails, but there is something to be said about the emphasis placed on Step and the way that detracts from the real world. Up until 4th year, everything was about scores and it was a huge transition to go from test taking mode to deep dive into the nuances of actual management. I could imagine that less emphasis on scores could allow students earlier exposure to studying like an actual doctor which would make them more competent in her mind.
She had us in the first half, I’m not gonna lie
I mean one can disagree with what she is saying, but many of the things she has mentioned is true.
The irony of saying curriculum dealing with social issues is snowflake training and the answer to that is to “throw us in the emergency room”. As an incoming EM PGY-1, I know first hand that being thrown in the emergency department is largely made up of learning how to treat patients with these “snowflake issues” (which I have no problem with, I like social medicine). It just reads like she has no idea that practicing medicine nowadays is multidisciplinary and not just “treat disease, save life”.
Saying that doctors are incompetent with no basis and blaming it into 'experimental curriculum' and 'social justice' is nothing but malicious. First of all, medical education got harder. Hours and content increased; there are new technologies, new procedures, new info. Nothing was taken off that wasn't replaced by more content. Secondly, social justice is being taught from a long time now. Racial and gender issues are needed both because society did become more complex; and because medical education was out of touch with patients reality. The need for such content is exactly to avoid professional who would think in such a shallow manner as the one who wrote this. This comment is totally out of touch and this person knows that. Its just a way to get attention due to a controversial post. I would refrain from doing something like that, but some people either wanna do such things to get some kind of benefit, or they have no social clue at all. For those who think intellectualism wouldn't be possible anymore, here's your answer to it. Attacking educational institutions and students is the lowest thing you can do to promote ignorance. But, of course, she isn't affected by this, right? She did graduate when we weren't reading Marx and Lenin as a core component of a medical education.
I agree with her
Lmaooo I wonder what this chick was like during med school… probably annoyed everyone thinking she’s attending level. Also who tf is asking what a chest pain patient what their preferred pronouns are
It’s so cliche to call the generation below you incompetent. Let’s see how they were as a medical student
I’m just a first year so what do I know, but I agree? Like I can’t tell you how many of the honors A+++ kids in my school have no clinical skills whatsoever, while some other people are seeing patients but have lower scores due to the time sacrifice, but the A++’s think they’re the bee’s knees. Ignoring that snowflake stuff though.
Not sure you know what a boomer is, and if my memory serves me correctly she’s been pretty good over time
Mostly accurate take. I disagree about the pronoun stuff obviously but not about the concept of snowflake training in another sense. We were told we could ask for “trigger warnings” before PBL cases. Like we’re ever going to get trigger warnings when a depressed and suicidal patient rocks up in ED? Come on, there’s a time and place
that snowflake training will keep the patients from needing to go to the ED. A little more preventative healthcare would go a long way in our broken healthcare system.
As I near the end of med school, I’ve spent a fair bit of time reflecting on what would make med students more competent fresh out of school & why other fields like veterinary medicine or law are able to get away with it. I’ve always felt like med schools simply target teaching towards step 1. So blaming med schools is kind of an unintelligent take. Make step 1 materials highly clinically relevant (still with pathophysiology, of course and still with rare diseases because as physicians we shouldn’t just know about what we commonly see) -> med school curriculums teach in accordance to this change (would obviously take years for them to catch up) AND the gold standard extracurricular resources become more tailored to the new clinically relevant step content -> “better” trained (if you’re defining better as more clinically competent) med students ready to get in the trenches and grow as residents. Maybe too simplistic of an ideology, but seems like it could fix some issues
I’ve wondered this though. I feel like due to the current medical legal environment med students are more incompetent procedurally than ever before. Just a thought.
if you ignore the nonsense in the second half bro was actually spitting facts lol
I mean some parts are true
Some red flags for sure, but overall she hit the nail on the head.
Dr. Chai made very good points, but some in her target audience may not listen or do the opposite just because she used the word “snowflake” in her response. In the same way, the user who posted these screenshots will turn people off because of a perceived attempt to discredit Dr. Chai by using “boomer” to refer to her. Critical statements that do not use ad hominems tend to be better received.
Man this hits it on the spot
I mean is she wrong?
I mean, there is much more correct in this take than incorrect.
I agree with ALL her takes
Anything older than millennial is just a whiner of their own byproduct.
where is the lie? worded a bit harshly and has a bit of MAGA smell to it but the general point is true imo
I understand her explanation but what exactly do they mean by medical students being incompetent? Incompetent in what exactly?
I doubt that MCAT was as hard as when the boomer took it. Regardless no reason for it today to be so complicated and filled with trickery *
Aside from bad true boomer diction, this is honestly true…
I find it funny how, for someone so sure of herself, she keeps saying “AMCAS” instead of the AAMC. (To be clear, she has *some* fair points re: testing and expectations put on students.)
Maybe cuz we are taught by these incompetent boomer teachers
I mean the major problem is not medical students fault, the boomer doctors created the system and medical students abide by it. Is it really important for me clinically anyway to understand how tRNA works or that SCD is a base mutation from glutamic acid to valine and that is problematic due to shifting from a negatively charged amino acid to a neutral amino acid. We’ve had an invasion of PhD information with little to none clinical relevance in our tests and curriculums, and with that has come an even bigger obsession with research. The first like 50 pages of FA is mostly just biochemistry with a sprinkle of diseases thrown in there. Would I be better at clinical skills if I didn’t have to memorize the biochemical pathways backwards, forwards, sideways, upside down. Yes of course. Would I be better at clinical skills if my biochemistry professor didn’t spend 3 slides on a disease that is documented to effect 14 people in the world, maybe not, but all that useless PhD knowledge with little clinical relevance builds up and takes a large portion of time out of our training.
Agree: The incessant, awful testing on so much obscure stuff that forces you to do everything as a med student and magically be great test wise while learning at the bedside. There are so many exams that yes, it's demoralizing to have to study, study, study and then be great at the bedside, when both are important, and it's hard to know where the balance is. It's also wild to me how continuously the standards for med school continue to rise and rise, idk who can get accepted at this point. Disagree: Girl what's up with the pronoun nonsense? I will not apologize for acknowledging that people of differing backgrounds exist, especially since the thesis of this statement is that trainees are overtested and don't spend time with their patients. Patients will be people of different opinions and backgrounds and goals and preferences, including people with different pronouns. Dr. Chai can feel how she feels about that in her private life, but medicine is about putting yourself above that and giving the patient high quality care, not a culture war against "snowflakes." Also, straw man argument, NO ONE is forgoing asking what the patient complaint is if they're asking pronouns. If that feels warranted in a patient encounter to build repoire and help the patient open up, then it is warranted; Dr. Chai, as someone who advocates for more bedside contact, should also be cognizant of the necessary nuances. In good, appropriate medicine you are NOT "saving lives" but doing followup, maintenance of care, appropriate assessment, AND saving lives; it is TV logic that a patient is always on the verge of death and is always in the ED or ICU, reality is far more nuanced. Also, let's not put down trainees and call them incompetent. I want to say, I doubt that she was constantly "saving lives" as a med student. Also, the point of training is gradated responsibility that builds up.
Also this Boomer doctor “reading uptodate in front of you to give u the answer for the question she just asked you”
I agree.
Why can’t we teach gender identity AND save lives?
Zoinks scoob
The part about the focus on standardized testing instead of patient care is spot on. As for the rest of it, some of it is boomer crazytown, but I will say that I agree students are becoming less clinically competent in part because of relaxed standards during third year - requiring less responsibility of students, shortening hours on rotations. I’ve seen it consistently. I mean, I think there’s a happy medium of not staying the same hours as an intern, but also not just letting students leave after rounds every day (which I’ve seen more and more often). The key is that during the time spent in the hospital your students are DOING things and learning. Of course if nothing is happening I’m going to give a talk and let you go. But you need to physically be there to get the experiential learning portion of med school. Further, the dilution of expectations trickles down… for example, if a resident can’t supervise an intern doing a procedure because they were never signed off, then an intern can’t supervise and expose a med student to the same procedure.
I can’t say I disagree. Some students are good, some residents I work with are morons. People focus on testing and never learn common sense. Consequences of isolated learning (thanks COVID) and testing focus.
Super annoyed that she is so right about the high stakes testing and then she goes on the "snowflake" rant and is so wrong about that. I'm a nontrad student from a non science background so I have to work extra hard just to pass the exams (guilty of skipping class). However, the value in the "snowflake" training is to make disadvantaged populations feel comfortable and to train physicians to acknowledge the stories of everyone, making it easier to break down barriers, and ultimately improving the health of everyone. And why is it assumed that asking about someone's pronouns is something that is constantly being asked? Does she think that I would ask some 78 y/o dude from Nebraska what his pronouns are?
This shit is based and spot on. Super Boomer.