Graduation date TBD

Over the past several weeks, I have been studying for re-certification with the American Board of Pediatrics.

It is every bit as super-fun as you would imagine.

The method I used to study for the board exam last time was to do a ton of practice questions.  Indeed, the American Academy of Pediatrics (not the same as the ABP!) publishes a set of practice questions every year, which one can purchase for a reasonable fee.  God willing and my small children consenting, I will get through two years’ worth of questions before I sit for my exam in a few weeks.graduation_greeting_cards_package

The set of questions I tackled last night included one about the management of a yeast infection on an indwelling venous catheter in a patient in the neonatal intensive care unit.  Test-takers were asked the pick the most appropriate anti-fungal medication for the patient’s infection.  I am pleased to report that I got the question right employing a “pick the answer you’ve heard of” strategy.  Sadly, the strategy is not 100% effective, and is wholly worthless when you have heard of none of the answer choices.

Now, the chances that I will ever be called upon to manage a central line infection for a patient in the NICU are fleetingly small.  Should that ever come to pass, something has gone Seriously Wrong somewhere.  The people who should be making that call are neonatologists, and I am perfectly happy to never ever make management decisions along those lines, just as I’m relatively confident that your average neonatologist would be pleased as punch to get a lifetime exemption from ever having to diagnose ADHD or pelvic inflammatory disease.

The American Board of Pediatrics does not care.  Its apparent goal is to ensure that, in the event of a zombie apocalypse in which I am the sole pediatrician survivor, I will be able to manage an intensely ill neonate’s central line yeast infection while also prescribing chemotherapy for osteosarcoma and ascertaining if a preschooler’s stutter is developmentally normal.  Drop me onto a desert island with a tongue depressor, an electron microscope and a can-do attitude, and I’ll take on any syndrome, malady or injury the kids there can throw at me.

That seems to be the thinking, in any case.

All of this sprung to my mind as I read this essay at WBUR’s Cognoscenti blog about the length of medical education.

[M]edical school education is actually much more variable. Most schools keep students in the classroom for two years, and in clinical sites for another two. Some, however, compress and rearrange material, creating unique requirements. As a result, some learners gain broad exposure to clinical areas while others receive almost none. Some trade clinical electives for research or international experience. Many have extended periods of free time. None graduate with the exact same expertise or experience.

I actually went to a non-traditional medical school that combined undergraduate and medical studies into six years.  It was not without its flaws (believe me), but one area where it was very strong was in the clinical skills it developed.  I actually had a full three years of clinical rotations, which is more than you will get in almost any traditional four-year school.  I got a lot of very hands-on patient care experience.

But no matter how many years of clinical experience I got in medical school, nothing really can mitigate the challenges that come with being a competent practicing physician over time.  When I was graduating from medical school, HIV was only just becoming a chronically-manageable illness through the advent of HAART regimens.  The overwhelming majority of AIDS patients I managed could expect to die of their disease within the span of a few years, which is (mirabile dictu) not at all the case now.

[T]ailored training marks every profession — except that the body of medical knowledge continues to grow exponentially. This is partially because biomedical science is generating discoveries more rapidly than ever before. Between advances in areas like genetics, radiology, and biomaterials, modern doctors must know far more than their predecessors.

This is undoubtedly true.  Even in the relatively short period of time since I finished my fellowship, things have changed significantly.  Much of what I learned in my training as a subspecialist in adolescent medicine dealt with managing abnormal Pap smears.  That information has been rendered almost entirely obsolete thanks to the HPV vaccine and new clinical guidelines.  Expertise I developed over three long years, gone the way of the dodo in less than a decade.

As I said, I went to a medical school that offered a full additional year of clinical rotations compared to the norm.  I think that added year was a real asset.  But whatever advantage it conferred has long since been swept away by ever-more-rapid discoveries, revisions and advances.  As a resident I occasionally prescribed medications that, if I see them prescribed today, serve as a marker of a provider who doesn’t know what he’s doing.

Medical school should be as long as necessary to have every student rotate through core specialties to determine which she wants to pursue, and preferably a handful of electives to deepen her knowledge and round out her education.  It should provide enough time to give graduates a firm grasp of the anatomy and physiology of the human body.  And that’s about it.

What every graduate should know as he grips his diploma, however, is that he’d better be used to studying.  My fellow residents and I would roll our eyes at the crusty old community pediatricians who’d admit their patients to our hospital and whose clinical skills had long ago calcified into outmoded forms.  What I didn’t fully appreciate is how rapidly that process can happen.  Every brand new doctor should realize that all too quickly his hard-earned body of knowledge can become the professional equivalent of two vast and trunkless legs of stone.

But enough of this.  I should be studying.

Please do be so kind as to share this post.

18 thoughts on “Graduation date TBD

  1. > management of a yeast infection

    Television leads me to believe that douching is the answer.

    Am I right in saying that you think there should be fewer clinical rotations and more of the basic coursework since knowledge conferred by the former will soon be out of date?

    If so, why did your program provide that extra year? And why did you feel it was a real asset at the time? Do you mean it helped get you a better placement? If so, does that mean residencies place too much value on a candidates clinical rotations? And if that’s true, do the medical schools even have the ability to change without negatively affecting their graduates?

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    • Douching will make your yeast infection worse. Don’t douche, Vikram.

      I actually don’t think there needs to be much change in how medical school itself is structured. I think a good foundation in basic science is essential (and an area where my school was, at least when I was there, not as strong), but I don’t think the average medical school is deficient. Honestly, if there were something I’d suggest adding to medical education, it would be schooling on the dry but necessary bits of medical practice, things like coding and understanding how insurance works.

      I think the strong clinical skills I got in medical school prepared me well to be an effective resident from the very beginning. Students at my school were expected to function on essentially the same level as residents, so I was used to doing all the clinical work that was expected of me as a resident upon arrival.

      I landed my decent but not awesome residency slot by working really hard at my electives and getting really good letters of recommendation. (Sorry for the bragging, but… well, that’s what I did.) I would have had a better shot at a more awesome residency had my USMLE Step I score not been in the barely-passing range, and in hindsight I wish I’d included a better explanation of the mitigating circumstances with my applications.

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      • Bah. Next you’ll be saying that the best way to treat amnesia isn’t to hit your head again in the same manner as caused the amnesia.

        Your linked post would probably have made a great explanation with little modification. I marvel at how daunting I once found application essays and now how easy it is to write a thousand words about pretty much anything.

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      • I try to avoid spending time mired in regret, since stewing about the past is pretty useless.

        But if I had to pick a handful of things I regret, near the top of the list would be my failure to explain my shit-ass USMLE score. I had a “let’s hope nobody pays attention to this part of my application because that will be good enough to distract them.” I’m pretty sure it didn’t work, especially when someone interviewing me at one residency (which, for the record, seemed pretty crappy and which I declined to put on my rank list) said outright that my score probably cost me a number of interviews.

        Given that I had a pretty decent explanation for why it was so lousy, it was stupidity (coupled with embarrassment about even acknowledging it) in the extreme not to include it.

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      • People tend to overweight objective indicators of performance. Test scores definitely qualify.
        Just probing out of curiosity: do you think you might have a pattern of behavior that includes not relying on excuses even if they are legitimate? I am asking, because if I look back at my life, I have done that at times and I now puzzle as to why I was unwilling to just relay my excuse. I think it must be some sort of inclination that I didn’t want to be the kind of guy who relied on excuses.

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      • I don’t think I’m totally averse to offer explanations or excuses if I feel they’re truly legitimate. But usually if I feel in any way responsible for an outcome, I’m going to own up to it.

        In the case of my USMLE score, I actually discussed deferring the exam until the next available test date with the professor assigned to mentor me. (Another of my school’s strengths was the clinical mentoring relationship it fostered between professors and students.) As much as I admire the man, he gave me lousy advice and told me to just go ahead as scheduled, since the worst that would happen is that I’d fail and just retake it later anyway. In reality, the worst that could happen is what did happen, which is that I got a crap but passing score. (You can’t retake it if you pass.) As delighted as I was to have passed a ridiculously hard exam without studying, it would have been in my best interest to have deferred and actually studied.

        But it was my own damn stupid decision to take it, so I owned the score that resulted.

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  2. All of this studying and keeping up with new developments does not sound like it either is any fun, nor is it something that (directly) generates income. Yuck!

    Your regimen of mandatory education for maintenance of professional certification sounds a good deal more rigorous than mine.

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    • I have no trouble with stringent requirements for physicians to stay educated about standards of care. But yes, between the hospitals where I am on staff, the state board of licensure and the ABP, I am under pretty strict scrutiny re: my continuing medical education. And some of it is stupid.

      One of these days, I’m going to write a post about the one issue where I am totally on Rand Paul’s side, which is the arbitrary and onerous obligations specialty certifying boards have created. It’ll probably just be a bunch of inside baseball (which is why I’ve not written it already, really), but it would feel good to write.

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      • When I took some teacher certification tests (disclaimer: I passed the two tests I took, but remain uncertified as my current job doesn’t require it), I remember thinking that the test was simultaneously too hard and too easy. The “too hard” parts were those which required people to memorize useless bureaucratic details about how the state-level education system works, the sort of information that serves little to no value to an on-the-ground teacher and which seemed largely intended to indoctrinate potential teachers into the entrenched system. The “too easy” parts were the ones that any 3rd grader could have aced.

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  3. Superb post, as usual. I always look forward to your stuff.

    I’m on this HCR data initiative consortium. Worms galore crawling out of the can. Privacy considerations, hosting, interfaces, the Data Hub (absolutely horrible implementation from a security standpoint) — I keep saying, “Guys, where are the physicians? Who’s asking the physicians and administrators what they need? Why is this so badly managed? This is going to be hacked in a heartbeat!”

    Nobody’s listening to me. And why should they?

    Health care is evolving so quickly, the only way I can foresee managing this process is to let the physicians control it. Connecting the guy with the problem to all the other physicians and researchers who’ve dealt with this problem, give them the tools they need to work with the problem domain. What’s working? What isn’t?

    My fellow residents and I would roll our eyes at the crusty old community pediatricians who’d admit their patients to our hospital and whose clinical skills had long ago calcified into outmoded forms. What I didn’t fully appreciate is how rapidly that process can happen.

    Truckers can talk to each other about road conditions. But feedback on developments in medicine —

    4. Thus, what enables the wise sovereign and the good general to strike and conquer, and achieve things beyond the reach of ordinary men, is foreknowledge.

    5. Now this foreknowledge cannot be elicited from spirits; it cannot be obtained inductively from experience, nor by any deductive calculation.

    6. Knowledge of the enemy’s dispositions can only be obtained from other men.

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    • I’m trying to wrap my head around designing a system for end-users without, you know, involving them in the process.

      It is meant to be a tool to help deliver health care, seems like the folk who do the actual delivery might be worth working with.

      But that means you’ve got to sit down and talk to people and let go the IT jargon while learning the medical jargon. Back in the day, when a mainframe was standard and the laptop I type on not yet a glimmer in Steve Jobs’ eye, we called those folks ‘systems analysts.’ Are they vanished from the process now, Blaise? I’ve only been involved with small development projects of late.

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      • Zic,

        My wife works in informatics. Her background is in clinical nursing… bedside care. Her informatics/computing background was limited to time spent interning with the specialists at her hospital, something she did on her own time to help her break into the field. Among the reasons she was hired was because she could speak to the end-user experience. Problem is… so is everyone else in her department. This includes managers and directors and the like. Her department has too much end-user input and not enough technical knowledge or experience, creating a clusterfuck of inefficiency (and that is before I start in on the lacker of leadership or management training amongst the people). It is one reason she wants out of her current hospital. She wants to find a place that has a better balance between the IT side and the clinical side.

        Part of the difficulty is that the field is relatively new. The PPACA put in place new requirements for hospitals, meaning there is a huge demand but limited supply. Few colleges even offer programs in the specialty, meaning most departments are cobbled together with IT people who have no specific medical systems experiences and clinical people who have no IT experience. My wife should be well situated because she has the clinical experience and is tech savvy enough, plus she is willing to go back to school to get the new training, something a lot of the older people are unwilling to do.

        So, yea, it’s all pretty screwy right now, and may get worse before it gets better. Time will tell. Most hospitals are trying to incorporate end-user experience, with mixed results.

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      • Kazzy, the field isn’t new, they just invented a new name for a part of the larger field: biostatistics. My husband worked in that, years ago, in oncology research. When he started, there was a binary measure of a clinical trial, for instance: does the patient live or die? By the time he left the field, it had progressed to quality of life measurement, and was just beginning to analyze qualities of care for statistical impact.

        For what you wife’s facing, I agree, more technical knowledge is required. From what BlaiseP posted, I interpreted that the opposite is also happening, too much IT without enough user input. It’s highly likely both things are both true and false and are also iterated many times throughout the total system.

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      • Writing Effective Use Cases. An oldie but goodie. Not to be followed precisely — it’s meant to give you an idea of how to think about wrapping your head around a solution.

        Writing effective use cases allows you to put together wild-eyed spec of the Underpants Gnome Profit sort — or solid thinking. A good set of use cases is really a screenplay.

        But in answer to your question, three sorts of people have come to replace the old systems analyst.

        The Business Analyst (BA) interviews everyone, identifying their mandate, roles and responsibilities in the process. The BA produces something akin to a use case. The last person you want in this role is a coder. Coders write awful use cases.

        The Architect takes the work of the BA and turns it into use cases. They’ll usually work with a Lead Developer, taking the high level use cases and turning them into technical spec.

        The Database Analyst (DBA) works with the use cases and the Lead Developer, composing Logical Units of Work (LUW). These days, there’s often a layer of objects between the SQL database and the applications.

        The Capacity Planner works through the infrastructure requirements, usually in concert with the existing IT guys who have a good idea of what’s really going on, the DBAs will provide input on storage requirements, the Lead Developer and Architects will produce testing mechanisms, the Security Analyst will work with all of the above — it’s all gotten quite specialised any more.

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  4. For what it’s worth, IT is somewhat similar in this. Sure, you can master Windows 98 and be able to swap out Pentium II CPUs with your eyes closed… but, next thing you know, you’re hearing that Windows 2007 might be due for a tech refresh and you’re thinking “don’t they mean Windows 2003? Oh, wait… yeah…”

    The black hats are coming up with new and interesting attacks every day and you’ve got to figure out how to harden your system in such a way that will not only stop the bad guys, but let the good guys keep on keeping on.

    Now, of course, it’s not life/death the way that Medical Knowledge has the potential of being… but a guy who was Hot Stuff in 2005 ain’t gonna be Hot Stuff in 2015 unless he was running full steam ahead the entire time… and he’s still going to be 10 years older than the guys who will be Hot Stuff standing next to him.

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  5. Out here the new MD’s get a ‘GP rotation’ for 6 months at a regular Dr’s clinic as part of their studies. I had one when it came time for my annual pap smear – which regular GP’s administer here.

    So there I was, I… assumed the position… with all the paraphernalia in place and all, and was busy counting ceiling tiles and whatnot.

    Nothing’s happening.

    I can see him turning his head from side to side and peering.

    Finally I ask him, “Is something wrong?”

    He said, “I can’t find your cervix.”

    I said, “I assure you, it’s in there. It’s at the end. Try looking there.”

    He looked again, and then stood up and said, “I need to get one of the other Dr’s in here to lend a hand.”

    I’m like, why don’t you ask them all? What about the folks in the waiting room?? (I didn’t say it, but I was definitely THINKING it.)

    My regular GP came in, they both had a huddle down there as class came in session.

    I can laugh about it now, I was definitely mortified about it then – but I can’t really feel angry. I mean.. he HAS to learn how to do it – and that means someone had to be in that chair. It just sucked that it was my turn!

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