It’s time to flip the medical school classroom [PODCAST]

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“As a nearly graduated medical student, I have come to the conclusion that the focus of medical school is split between training and distinguishing medical students. Modern pedagogy has not found its way into the modern medical school classroom. Preclinical students spend mounds of time on impossible tasks, like memorizing First Aid for the USMLE Step 1, without learning concrete skills that can be applied to clerkships. As for clerkships, the quality of teaching is highly dependent on the attending’s or resident’s level of commitment to education. Oftentimes, we feel like flies on the wall rather than active participants in patient care.”

David Chen is a medical student.

He shares his story and discusses his KevinMD article, “Why are medical students non-essential?”

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hello, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho. I’m the founder and editor of KevinMD, and today we have David Chen, who is a medical student who is graduating tomorrow, incidentally, and he’ll be going into primary care internal medicine, near and dear to my own heart. So David, welcome to the show.

David Chen: Thanks for having me.

Kevin Pho: So tell me a little bit about your story and your journey to this point.

David Chen: Yeah, so during my first year in med school, I kind of grew disenchanted with the whole Step 1 climate, or Step 1 mania, and how we were so focused on Step 1 to the exclusion of all the other things that matter in medicine. We joked that once you take Step 1, you can forget pretty much everything that you had to learn for it, and I felt like that was a really sad approach to take to medical education when there’s so much stuff that is really important.

And so I did some work with Step 1 and wrote a commentary piece that was published in Academic Medicine in the last couple years, and I think that kind of helped shift the conversation. That was kind of one of the many things that brought about this change to make Step 1 pass/fail. And then the piece that I wrote on your website, “Why are medical students non-essential?”, is just kind of the next further reflection on how our training is kind of almost focused, I would say, too much on the evaluation and distinguishing-medical-students aspect of things, rather than actually training us and preparing us.

Kevin Pho: So did you see a lot of that during your first couple years in medical school?

David Chen: Yeah, I mean, with Step 1, the biggest takeaway is three numbers, right, a three-digit score, and we are all so very understandably focused on it. And so I would say that I definitely saw this emphasis on distinguishing us rather than training us in the first two years, and in the last two years of med school.

Kevin Pho: So first of all, I think that Step 1 being pass/fail is definitely a step in the right direction. We talk a lot about physician burnout on my site, and medical student burnout is certainly no exception. Going to that pass/fail system, do you feel that it’s going to alleviate some of that burnout going forward?

David Chen: I absolutely do. I think Step 1 is just unbelievably stressful. I have always been a really good student, and when I was studying for Step 1, when I would take practice exams, I would just be baffled, feeling like the content that I was expected to know was totally out of left field. There are so many questions on the exam itself, and certainly in the practice exams, that just weren’t anywhere to be found in First Aid. And so it just struck me as a really unfair exam to be testing people and kind of defining their careers on things that they weren’t explicitly taught. So I think that not having that hang over our heads in the first two years will definitely help with medical student burnout.

Kevin Pho: So there have been a lot of articles on my site written on Step 1 being pass/fail. Most of them are supportive of that, but there’s been some pushback saying, “There has to be some objective measure for residencies. This is going to put more emphasis on Step 2, the clinical skills portion.” So what do you say to people who say that even if Step 1 is pass/fail, it’s just going to put more pressure on Step 2?

David Chen: Yeah, I think that it definitely could put more pressure on Step 2, and I kind of talked about this in the article. Even if all the emphasis gets shifted to Step 2, that still kind of de-heightens the first two years and enables us to focus on other things rather than Step 1. So even if that’s the case, I believe personally that that’s still a very positive step for medical education.

And then the second part, about objectivity. In America, our education system is built on standardized testing. For college, we have the MCAT, and then Step 1, Step 2; those are all standardized tests. And I think that while they are objective, they still do cater to people who have had the privilege of being in the better schools throughout their upbringing, and who have been essentially trained to take standardized tests from the get-go because of how important they are. So that’s why we see these massive disparities, almost a standard deviation, in comparing white males to Black males on Step 1 scores. And so to me, I don’t believe that it’s a good objective measure.

Kevin Pho: So we’re certainly seeing a de-emphasis on standardized test scores. Just yesterday, the University of California said that they are not going to include ACT and SAT scores, and I think what you’re saying is certainly pervading throughout the educational milieu.

In terms of pass/fail, there are some programs where clinical rotations themselves are simply pass/fail. So I guess my question is, what do you think about pass/fail extending to clinical rotations?

David Chen: Yeah, so I personally think that it’s a fantastic thing, especially if there are problems with objectivity in terms of standardized testing. There is pretty much no objectivity in clerkship grading, and no matter how rigorous the rubric that you use, I don’t see how it could possibly get away from just having your grade be, in part, by how well your attending, how much your attending, likes you, essentially.

So personally, in clinical training, it’s always been really hard for me to kind of straddle the balance between making sure I’m learning what I need to know and kind of performing. And I was kind of a little bit late to the game, I would say, in kind of thinking that, “I’m here in med school, I just need to focus on learning.” At a certain point, I realized, “No, it really is kind of a performance, and I need to kind of pretend that I know more than I actually do,” and stuff. So I think that by having the clinical environment be pass/fail, you can really just focus on learning.

Kevin Pho: And that imposter syndrome that you’re discussing extends to internship and residency, when you’re a first- or second-year attending. It’s a continuous learning journey. So I understand you’re graduating tomorrow, so congratulations on your journey. Let’s take a step back, and let me ask you: What could you have known back then, that you know now, that would be helpful?

David Chen: Yeah, so this is something that I tell people, my friends and colleagues who are going into clinicals. I tell them that at the end of the day, it is a performance. And I think that when I kind of saw that it wasn’t always just about my learning, I was kind of disenchanted for a little bit. And so I wish I had had that expectation be a little bit more clear to me: that at the end of the day, it’s impossible to make subjective grading totally fair, and to just go into it as though it’s a performance, and that you need to just make sure that you’re learning what you need to know, but also that you’re putting your best face forward, and things like that.

Kevin Pho: And you did mention you’re going into primary care internal medicine, which is fantastic. There’s a lot of pushback on primary care, as I’m sure that you’re aware of. There are declining reimbursements, there’s the fact that advanced practice practitioners can now practice primary care, and there’s a devaluation of the physician primary care clinician. So what are the reasons that you are planning to go into primary care?

David Chen: Well, so I’m really lucky to have incredible primary care mentors at my school, such as Dr. Doug Powell and Dr. Alex Molnar, and those are both close mentors of mine. Starting med school, I wanted to go into family medicine, and I kind of see internal medicine primary care as being very much of a similar spirit. And that spirit is kind of public health, longitudinal relationships, and just really getting to know patients and providing them with high-quality care in one place, and not just referring to a different specialist for a complex patient. So I think that’s the way that we can deliver the highest-quality, most convenient, and affordable care for patients.

Kevin Pho: Fantastic. Well, best of luck to you on your next year as an intern and in residency. So tell me, what have you been curious about? What are you passionate about?

David Chen: So as we’ve talked about, medical education. I really feel strongly that medical education, our system, stands to be seriously revamped, and that there’s just so much opportunity for it. Something that I reflected on is the kind of excitement and joy that I got from my undergraduate studies in biology and chemistry and physics. I just love those so much, and I felt like they were so well put together; they were really well structured. And I just see the things that made those so gratifying as being kind of more or less altogether absent from the preclinical medical education curriculum. So I’ve been thinking a lot about how medical education could be just way more fun and fulfilling than it is.

Kevin Pho: All right. Well, I always say that physicians can always learn from the next generation, and that’s clearly you. So if you had a take-home message for my audience, what would that be?

David Chen: I think at the end of the day, it would be that we shouldn’t be afraid of big changes in medical education. Step 1 moving to pass/fail will be really inconvenient for a lot of people, but ultimately, I think we’re making the right decision, because Step 1 was never designed for the scores to be meaningful aside from being pass or fail. And so I think that we absolutely made the right decision there, and I think that there’s just so much more room we have to grow in medical education.

Kevin Pho: Perfect. Well, again, congratulations on your medical school journey, and good luck to you as you embark on your residency journey. Thank you so much for being on the show.

David Chen: Thank you so much for having me.

Kevin Pho: All right, take care. Bye-bye.

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