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Med Student Burnout

05 September 2008 in medical education, undergraduate education | No comments

A study recently published in Annals of Internal Medicine explored the relationship between student burnout, quality of life, and thoughts of suicide at several US medical schools. Not surprisingly, their results were not encouraging: half the students reported burnout, and a little more than 5% had considered suicide within the past year. The investigators’ analysis showed that burnout and poor quality of life were independent predictors of suicidal ideation. What’s even worse is that this study is only the latest in a series of alarming reports of poor mental health and quality of life among medical students and residents.

Is this problem intrinsic to medical education, or is it a consequence of poor educational methodology? It’s certainly possible that the American system of educating physicians - first requiring an undergraduate degree, then medical school - exacerbates student burnout by increasing the number of years spent in school, increasing average debt, and increasing the number of exams and application cycles. And the traditional medical school curriculum is, without a doubt, demanding and dry. But what is the alternative? Should we be content with physicians educated less stringently, with less grounding in the basic science underlying clinical decision-making? I don’t have a complete solution, but I don’t think that’s the best approach. Rather than making medical school less demanding, the process of arriving at medical school should be less stressful - beginning with increasing the number of US medical schools and relaxing application standards. We need more physicians, especially primary care physicians, and we need to make the years of education preceding medical school tolerable enough that our best and brightest don’t begin their medical training already on the verge of burnout.

Inbred Kids, Bad Sex, and the Pill

14 August 2008 in medicine, news | No comments

Not surprisingly, this story has gotten enough press that even the local hip-hop DJs are talking about it. A new study from the UK suggests that oral contraceptives alter women’s perception of pheromones, leading them to prefer (in the Biblical sense) men with genes similar to their own. This is the opposite of the usual situation, in which women are drawn to the scent of men with different genes, especially at the loci controlling MHC expression (remember the classic sweaty-shirt experiment?). Of course, this makes sense (in a hand-waving sort of way): women prefer mates whose genes will give their children the widest arsenal of immune responses. But the catch is that pregnant women prefer the pheromones of closely-related men, possibly because we’re hard-wired to seek the protection of family in vulnerable times. It shouldn’t come as any surprise that the pill, which roughly mimics pregnancy hormonally, also switches pheromone preference.

What does this mean? Has a generation of sexually liberated women consigned itself to relationships with the (genetically speaking, at least) wrong men? Do women who get married and then stop taking the pill have a higher divorce rate? Maybe. But there’s something critical being lost here: I think most women would much rather have wonky MHC radar than end up with an unplanned pregnancy. I mean, ending up attracted to, and possibly married to or in a relationship with, a man whom you can’t stand when you’re off the pill is certainly bad. But having four children before your peers are done with college is way, way worse. Get a grip, people.

As a side note, I’m interested to see which oral contraceptives the researchers decided to use. I wouldn’t be surprised if the newer low-dose or progesterone-only OCPs have less of an effect on pheromone perception.

NYC Hospitals Train Caribbean Grads for Profit

12 August 2008 in medical education, news | No comments

The New York Times recently ran an article on the controversy surrounding the NYC public hospitals’ decision to train Caribbean medical students for profit. US medical students spend two years doing clinical clerkships in various fields of medicine; these clerkships last anywhere from a few weeks to a few months and are designed to both inform students’ career choices and provide a broad foundation in clinical medicine. Traditionally, hospitals either provided this training gratis or charged a nominal fee. The recent uproar is over the NYC Health and Hospitals Corporation’s decision to sign a contract with St. George’s University School of Medicine (located on the Caribbean island of Grenada) to train hundreds of medical students in exchange for fees many times the usual rates. Obviously, the physicians in these hospitals can only support a certain number of medical students without compromising the quality of the teaching provided; just as obviously, this contract is likely to increase the price of the remaining slots, potentially making it difficult for local medical schools to place their own students. But throughout the article and the comments, the real outcry is over the perception that the city is legitimizing (and even encouraging) the import of inferior medical students who will eventually become inferior physicians.

But why are institutions like St. George’s flourishing in the first place? An education at St. George’s is just as expensive as training at the most expensive private medical schools in the US, and the school offers less financial aid and fewer scholarships. The school has large classes and little clinical training in the first two years, virtually no active research on-site, and (until the recent contract) clinical clerkships scattered across the country with little faculty coordination. Nevertheless, its graduates generally pass the US licensing exams and often become fantastic physicians. Consider the following:

  1. There aren’t enough primary care physicians or specialists in most non-urban areas of the US.
  2. The quantity of available physicians is directly linked to the number of medical school graduates produced each year.
  3. The number of medical schools in the US, and the number of students they can train, is regulated by a centralized professional organization.
  4. Admission to a US medical school is difficult to get, and increased demand for spots has raised admissions standards over the past few decades.
  5. Of the students who fail to gain admission to US schools, a significant proportion go to medical school abroad, pass the US licensing exams, and practice in the US.

There seems to be an obvious disconnect here - even though we need more doctors (at least in a number of areas), we deny admission to a number of applicants only to re-admit them to the profession after they complete their schooling abroad. The immediate solution, then, is to lower admissions standards to US medical schools and increase the number of available positions to meet the demand for physicians. Or is it?

The crux of the problem is the public perception (and the perception of most US physicians) that doctors must be both budding scientists and well-educated humanists by the time they’re in their early twenties. This is, quite simply, an impossible expectation - there simply aren’t enough qualified undergraduates to meet our need. Just as we’re comfortable relegating certain tiers of care to nurses, therapists of one stripe or another, and nurse practitioners, we should also accustom ourselves to the notion that not all physicians need to have da Vinci’s breadth of expertise. Not every physician needs to be interested in research, the latest advances in medical science, or the details of medical policy. For at least a portion of our physicians, it should be enough that they are attracted by a life of service and that they meet our licensing standards.

Flat Dysplasia: Ninjas of the Colon

12 August 2008 in medicine | No comments

Ninja Face

Flat dysplastic lesions are the ninjas of the colon: they’re deadly, they’re hard to find, and nobody really knows how common they are. My last hurrah in medical school (for two years, at least) was a presentation on flat colonic dysplasia at the colorectal surgery/gastroenterology conference. Whether you’re planning on a career in general surgery or primary care, these lesions are important - they have a higher rate of malignant transformation than normal polyps and are difficult to locate using standard endoscopic techniques, so you should know enough about them to counsel your patients about appropriate surveillance and therapy. Without special training or chromoendoscopy, most American endoscopists miss these lesions! That newfangled CT colonography is also terrible at picking them up. If you’ve just got to know more, the best recent reference I found is Soetikno’s 2008 paper in JAMA.

Management of Hypothermia

12 July 2008 in cardiology, medicine, wilderness | No comments

Another day, another presentation: this one’s from a brief talk I gave at the VA morning report in February. It covers some basic definitions and clinical strategies for management of hypothermia and includes references to a few relevant papers. One of the chief residents gave a separate talk on Osborn waves and other hypothermia-induced arrhythmias, so my talk doesn’t cover those aspects of care in much detail. Good references were surprisingly hard to find; though I didn’t end up including it in my talk, there’s a slide at the end of the presentation discussing the challenges to good hypothermia research. If you’re interested in wilderness medicine or healthcare for the homeless, this is a good talk to give.

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