ken explains the hidden curriculum: how OSCE's turn us into robots

At the end of every block, we have a test of our clinical skills - talking to patients, taking vitals, doing a physical exam. It's called an OSCE, which stands for objective structured clinical examination. In theory, the OSCE is a great idea. There are definitely a baseline set of clinical skills we should have - off the top of my head: washing your hands, properly introducing yourself to the patient, knowing the components of the cranial nerve exam. But the list is a lot longer than a few things, and as always, the hidden curriculum is at work.

The hidden curriculum is trying to turn us all into the same robot interviewer. It's brutal watching interviews in small group sometimes - as long as everyone does their job, you literally watch the same interview three times in a row. Here's a sample: 

--

Hi my name is __ and I'm a first year med student working with your doctor today, if it's ok with you I'm going to ask you a few questions.

Shake hands. 

tell me more about that

So what you brought you in today?

Tell me more about that.

OLDCARTS

PMH

FHx

I'm sorry to hear that. 

SHx

Any other questions you have for me today?

Shake hands.

Leave.

--

tell me more about that

The grasp of the hidden curriculum goes further than turning us all into robotic patient interviewers. It permeates our everyday interactions. I swear I've never asked, "tell me more about that," as much as I do now. It's even ruining my relationship with Katie. 

Katie's been complaining to me recently because I had been talking weird. Whenever she says something - I'll respond in a weird monotone "pretty cool." My best pretend empathetic tone. And I'll follow up af her comments with, "Tell me more about that." Until Sudeep saw me in action, and commented on my empathetic comments to Katie, it never even occurred to me that this was happening. I was genuinely trying to be compassionate and empathetic, but my compassion and empathy neuronal pathways had been rewired. 

That's fucked up. 


One of my favorite authors is Abraham Verghese (Cutting for Stone, Tennis Partner). Both great, great reads. He doubles as an internist at Stanford, where he's a huge advocate for the physical exam. He believes a good physical exam can establish a strong patient-doctor relationship, and also provide higher quality care. He's developed his skills to the point that he gives patients a physical exam, but while he's giving the exam he goes through the patient interview. This way he can still fit in a thorough physical exam within the short patient visit time limits. Impressive. I imagine in an efficiency oriented world, he's not the only doctor that's mastered this skill. 

I hope I can get to that level of patient interviewing. In the meantime, guess I should stick to my checklists. Thanks Step 2. 

see you on the other side,

from ken

enjoy sidenote in 140 characters or less @kensidenotelife.

ken explains the hidden curriculum: MUSC match list breakdown

This table speaks for itself, but I'll throw out two thoughts I had: 

1- MUSC students match in sweet residencies. How many derm spots can there be? sidenote - quick google search says 270. Also, there seemed to be a high proportion of students matching into optho (avg salary - $300,000), but I couldn't find the national stats so I didn't put those in there. Storm Eye (the optho institute here) is highly reputed, so that probably has something to do with it. 

So this is good for us MUSC students (count it). We have a good chance of matching into a competitive residency, and this reinforces what we all know - that everyone is going into specialties looking to get money, get paid. ENT and Derm docs get paid an average of $300,000. Radiation Oncologists get an average of $500,000. Wow, no wonder rad onc is so popular lately - especially among research oriented med students.. 


2- Medicine has a problem. Too many people go into specialties, and not enough people are becoming generalists. The evidence is right here. At MUSC, an average to above average medical school - less than the average number of students go into primary care-type residencies and far more than the average match into competitive specialties. 

This puts a huge problem in medicine front and center - the lack of generalists. A problem that starts in med school because it mostly has to do with the match. Internal med/peds people can go on to specialize, but I imagine those people already have their mind made up to go into a subspecialty before they start. If we look at med students - how can we re-incentivize the system so that more students will go into primary care-type fields?

Here's one half-baked idea: guarantee a certain subset of students admission into med school but legally bind them to commit to family med/internal/peds from the beginning. This would guarantee med schools to have a minimum percentage of their classes to go into these specialties. Perhaps you could recruit a different subset of students into these spots, ones more interested in longitudinal patient care, with good people skills rather than focusing on finding the highest IQ's. Quick google search reveals that this idea already exists at Texas Tech and Mercer. Pretty sweet. 

I wonder if there are hidden curriculum factors driving students towards some of these more competitive residencies. I'll have to think about that. 

see you on the other side,

from ken

enjoy sidenote in 140 characters or less @kensidenotelife.

ken explains the hidden curriculum: what goes in to US News & World Report rankings?

If you applied to med school, you surely took a look at this website.

The 2014 rankings just came out. The short summary if you're interested: MUSC is #59. There were two public schools in the top 10 (UCSF and Univ. of Michigan). UNC is #1 for primary care. Whether or not you think these rankings are important, everyone else does, so you might as well know how they work. If you've ever wondered why med schools do certain things, it's either to satisfy  LCME demands or to move up in US News & World Report rankings. These are the incentives that drive med schools. 

Lets start with the biggest chunks:

20% of the ranking is the opinion of other deans.

20% of the ranking is the opinion of residency directors. 

So 40% of the rankings are determined by the opinion of extremely busy people. These are individuals who might be keeping up on the latest activity of Stanford med, but they certainly aren't keeping up with the newest moves made by a school like the University of Vermont. At a recent panel of med school Deans, one dean admitted to ranking schools purely based on previous reputation because she did not know how good they were recently. Do you think a top 5 school could get by based on reputation? I'd guess yes. This is a rich-stays-rich scheme. 

30% of the ranking is faculty research activity. 

First off - how many med students are interested in research? Not many. So, why does this even matter? Second of all - do you really think med students work in these high-powered labs? Unlikely. Maybe the rare gunner MD/PhD student, but otherwise these labs aren't wasting their time training you to hang out for a summer. They're probably busy recruiting Chinese post-doc machines. 

So we've already established that 70% of the pie is worthless. Moving on. 

13% of the ranking is MCAT scores. 

Another 6% is undergrad GPA. 

And 10% is faculty:student ratio. 

Arguably, these last 29% are the best current measure of the best med schools. It's at least telling you which schools have lots of potential teachers, and which schools are bringing in the best performing undergrads. I'd be interested to see the rankings solely based on this last 29%. The first 70% basically provides the current big ponds with a huge amount of buffer to keep doing what they do, while all the small ponds are left to fight for scraps. It's a system designed to keep lower and mid-tier schools where they're at. Essentially, the only way those mid-tier schools can move up is by improving the undergrad GPA/MCAT scores, or recruiting big grant-getters. Neither of which actually improves the quality of med school education.

Overall - this is terribly disappointing. When motivated and talented 20 year olds get on the internet to decide where they want to do their medical education, these are the rankings they're looking up. I'm sure you've been told these rankings are meaningless, but you sure as hell still looked at these rankings and it meant something to see which schools were high on the list. Really the only thing these rankings tell you is that Harvard will continue to be Harvard until we start coming up with better metrics. 

see you on the other side,

from ken

enjoy sidenote in 140 characters or less @kensidenotelife.

ken explains the hidden curriculum - we don't believe you. you need more people.

I had a friend that once asked me, "What's the biggest problem facing humanity?" His answer was overpopulation. My answer was that we are becoming less and less awesome. Think about it. How many truly awesome people do you know? We're drifting farther and farther away from awesome as we lose what makes us human - believing, loving, caring. Our society acknowledges this, yet it continues to pump out boring adults that don't believe, love, or care. 

closer than you think

If I had to label our generation I'd go with overly-sensitive. Being sensitive to other humans is certainly a sign of maturity, but did we go too far? Now we're so hyper-sensitive that we won't ever talk about what we believe because god forbid we come across as self-righteous. Which, in a counterintuitive way makes us look better, so we're actually being selfish by not talking about ourselves. Confusing, but here's my take-away: the less we talk about what makes us awesome, the less awesome we become.

What does this have to do with medicine? More and more doctors enter their practicing years burned out with little energy left to care for patients, and we're left with hospitals staffed by robots. As Dr. Kern would say, this is not the fault of individual doctors. It's the fault of the medical system at large, breaking down the humanity of doctors. 

Our transformation into robots starts in med school, where the hidden curriculum is at work. Per wikipedia - the hidden curriculum is a side effect of the education system that teaches lessons that were not intended. Example - med students are encouraged to ask for help, yet anatomy lab professors chastise us every week by pimping us on the origin of obscure nerves. If they make us look like fools for not knowing every small detail, why would we dare to ask any stupid questions? And if we can't ask questions, we're left on an island to fend for ourselves. Coupled with having zero free time, the hidden curriculum leaves us too burned out to believe, love, care. Here's a diagram for you visual learners. 

If you don't believe me, hit up pubmed. There are studies that document a decrease in empathy during med school. sidenote - before I go on, I'd like to make one thing clear. This is not me vs MUSC administration. I love MUSC. I really do. I sincerely respect the work the higher ups have done to keep MUSC on the upward trajectory. MUSC is the #5 most popular medical school, 75% of students offered an invitation to attend decide to accept. That is really great. Working in academia is thankless, and I am in deep admiration. What I hate is the hidden curriculum. This is a curriculum that reaches every med school from Harvard to the Caribbean.

You might be thinking, "So what? That's the system. It's too big to change." 

Please don't believe that. 

I wish I could tell you to look up to the role models in the older generation, but Ben Carsons and Paul Farmers are few and far between. And frankly, I've heard enough about Farmer and Carson. I get it - they're great - but they're past their prime. I want to hear about how we are changing medicine. 

Throughout history, old people have dominated what young people think. They hold leadership positions, their faces run on television, they write newspaper columns. But not today. The media that modern med students consume are twitter, the blogosphere, and youtube. Conveniently, anyone can publish on those platforms. This is a time when young people can broadcast their beliefs loud and clear to anyone who will listen. This is a revolution. For the first time in history - naive, idealistic, young people have control over the propaganda. 

We are the young generation. We leave high paying jobs to pursue a life with meaning because Christopher Wallace taught us that mo money mo problems. We spend our free mornings building relationships with poor kids at local high schools. We care about 'us' instead of obsess over how to get 'mine' because we know getting 'mine' is empty. If we band together, no one can beat us. 

we don't believe you
you need more people

And that's exactly how the hidden curriculum is taking us down - the hardest part about med school is being so isolated. They want us to believe that it's 'normal' to bottle up our emotions and power through every struggle. They teach that 'humble' is doing good deeds without talking about it. They want us to prioritize our own grades over relationships. And the more we stay quiet, the more they win. Well, fuck they. 

We need med students coming together and talking about life. I'm not saying don't study. I'm just saying, don't let them take over. We need to get together and talk, respectfully disagree, and figure out how we're going to fix this mess that they left us. If we stop talking about it, we'll forget it ever mattered. And then, shit. We'll just be they.

Fellow med students. If you are still resisting the robot transformation, get at me. Keep talking. I know you are out there. Maybe we could broadcast what you believe to the world. We need you on our side. 

You know where to find me. 

see you on the other side,

from ken

enjoy sidenote in less than 140 characters @kensidenotelife

ken explains the hidden curriculum: lone wolf studying in an age of specialists

I asked a nurse his greatest complaint about doctors:

"I wish doctors would communicate better with each other."

--

Nothing we learn in med school is that complicated. Take this anatomy slide we have to learn:

There's nothing to understand about the seven nerves that go through the greater sciatic foramen, it's a list. The best way to gain this sort of low level knowledge is to solo studying. Make up a mnemonic, repeat it to yourself fifty times, write on a white board, whatever.  

Whenever people ask me questions about the material I usually want to tell them: "Dude you're over-thinking this, just memorize the words, and you'll be fine." I'd love to understand the concepts underlying cell signaling, that's why I signed up for a PhD. But during M1.. ain't nobody got time for that. The list of things we need to memorize is endless, and we aren't even at second year yet. Do you really think you're going to be spending the time to understand the mechanism of every single antibiotic? I sure as hell won't be. 

Group learning is useful for solving complex problems like say, understanding basic science research papers. That's the kind of problem it'd be nice to tackle as a group. Science is supposed to be about the discovery of new ideas, and this sort of higher level knowledge demands collaboration between peers. Yet, everyone has to tackle the ME paper assignment by themselves. 

In med school - there's really zero incentive to work together. The lone wolf studying strategy is the most efficient way to do med school. And a lot of times, it's the only way to do med school. It's not like they let you take exams together. And frankly, that's what they want you to do. 

Who is they? It's abstract, but they is everyone that is cynical. Everyone that says, "Yeah, healthcare is messed up, but it's so big you can't do anything to fix it. You'll learn eventually." Everyone that wants you to leave med school dead to the world.

They want you to study by yourself and become obsessed with how well you understanding the material. ergo - stop caring about whether anyone else understands it. It sounds like a great system to develop overconfident get-mine solo practice doctors, but everyone knows there's too much paperwork to run a solo practice these days. We're also coming upon the age of specialists when collaboration will be at a premium. Think about a disease like diabetes - it's complex. You might need primary care physicians being the point guard for vascular surgeons, endocrinologists, physiatrists, opthalmologists, I could literally list every speciality. Not to mention nutritionists, personal trainers, policy makers...

Doctors are notorious for not playing well with others. Well, the root of the problem starts here in med school. Instead of talking with my classmates about complex medical problems like environmental exposure and diabetes, I'm spending every waking hour with my headphones on, noise-canceling the world, and sorting out meiosis. So I can get mine. 

That's your education at work. 

See you on the other side,

from ken

taking requests for future blog posts. please comment or email.

ken explains the hidden curriculum: I should be a gunner

A new segment on sidenote where I explain the hidden curriculum because, well, I know everything. You're welcome. 

I just wrote a running diary about the stress of med school peaking on the day before the exam. And it raised a lot of internal frustrations. I feel like I'm having an identity crisis. 

sidenote - shoutout to DWill, who inspired this post:

I hate caring about med school tests. I hate grades with a passion. I know they're complete bullshit. I've already spent 4 yrs in undergrad proving to myself that I'm smart, I shouldn't need any med school grades to tell me I'm smart. 

But I want that honors carrot. And I hate myself for it. I wish to God I didn't care about it. The day before the exam, all I could do was get stressed out about cramming more knowledge in, and wondering how I would score, not compared with myself, but compared with all of you. 

The hidden curriculum wants you to care about getting honors so they can control you. They want to mold you into the kind of med student they want you to become. They want you to spend all your time studying, following orders, ditching anything resembling creativity. They want you to become their bitch. 

Who is they? They is everyone that wants you to be boring. They is everyone that wants you to live in a white picket home instead of a hut in rural Haiti. They is everyone that wants you to become rich instead of great. 

My biggest question: Am I being stupid for not giving into They? Is my life an idealistic fantasy trying to fight the power? 

Why shouldn't I just leave sidenote behind? Some days I love it, but other days.. is it worth it? 

I know I'm smart. I can look at my MCAT and undergrad grades for three seconds and know that. If I took all the time that I invest in relationships with friends, relationship with wife, writing sidenote, following basketball, working out, and funnel all those hours into studying I know I would crush med school. 

On one side, my pride is yelling at me to leave everything else behind, get on that adderall and gun for AOA and 260 on Step 1. And some days, the other side just doesn't feel as loud. 

See you on the other side,

from ken

taking requests for future blog posts. please comment or email.