The dismal state of surgical education

[KinasePro]

You ask that I do not paint millennials in a broad stroke, but that's sort of my whole point. The stereotype of current learners is that they demand that I appreciate just how unique they are, and how uniquely talented they are, so obviously if you ask a bunch of snowflakes how they feel about themselves, they will confidently say that they are nothing like the unfair labels that have been forced upon them.

This isn't a generational thing though. I don't think anyone likes to be labelled with a derogative term based on the year they were born. Also, studies show that painting such large groups of people with broad strokes reflects a prejudice more than experience with said group. It's similar to discussing races or nationalities. Data show, that the more you actually interact with the people you're stereotyping, the less strongly your hold onto your stereotypes.

Also, this is a classic example of circular reasoning. "Millenials don't like being called snowflakes because they're snowflakes."

I think the big fallacy that must be addressed upfront is that somehow the process is much harder now for snowflakes than it was for students in the past. It's always been hard. Conversations 10 years ago were extremely similar to those had today....just do some thread searches on SDN if you need some proof.

Still, I think it's equally important that current teachers admit that things aren't any easier, either, as the uphill-in-the-snow-both-ways approach to education is not too effective.

Sorry, but we won't see eye to eye here. The denial of the increasingly competitive nature of "the game" of medical school and the match process is purely an SDN artifact. In real life, attendings and program directors readily admit that the process has become more cutthroat and petty than ever before. As the poster above points out, just compare charting outcomes from the last decade if you need more convincing. This is nothing new though, IMO-- I wholeheartedly agree that med school admissions has become more competitive in the last 4 years. Our MS-1 class is out of my league for sure.

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[balaguru]

When I was a resident, which wasn't that long ago, students were to stay no longer than 6pm while on the elective services and noncall days on the emergent services. Everyone understood that they needed time to study for the shelf and that what we taught in the OR and on rounds added very little to that. I'm not going to go through all the points brought up in this thread but many appear fixable by your clerkship director perhaps with some diplomatic prodding by the students.

Many of student anecdotes mentioned here, if true, are valid complaints and if the clerkship director is unwilling to do anything about them I'd bump them up to the next level. After all you're paying good money to be there.

 

[dyeguy21]

When I was a resident, which wasn't that long ago, students were to stay no longer than 6pm while on the elective services and noncall days on the emergent services. Everyone understood that they needed time to study for the shelf and that what we taught in the OR and on rounds added very little to that. I'm not going to go through all the points brought up in this thread but many appear fixable by your clerkship director perhaps with some diplomatic prodding by the students.

Many of student anecdotes mentioned here, if true, are valid complaints and if the clerkship director is unwilling to do anything about them I'd bump them up to the next level. After all you're paying good money to be there.

I wrote absolutely scathing reviews of my experiences on surgery and can only hope change will be made. However, the fact that I took surgery during one of the last rotations of the year (and many students had already gone through similar experiences) I expect that either the program did not care to change or simply had no other options for the rotation.

I agree with students of the now, I did a five year track and dear lord the ms-1s are far out of my league. Competitiveness is increasing and for some reason schools and residency programs are trying to rely on objective, standardized data more and more. Thus, even though patients and attendings may love you because you work hard and stay late, it means nothing if you do just average on the shelf.

I think a lot of this stems from the belief that med students should operate at a junior sub-intern level. Which doesn't make any sense in the current teaching structure. Students are there to learn and to interact with patients on a daily basis. They need time to study for their shelves as well as read up for cases the next day. Sure interns have in service exams and step 3 to study for, but they get a whole year and it's all they do. Students are constantly shifting frame from medicine to psych to fam med to surgery to peds every 4-12 weeks. And within those rotations they are switching in sub categories even more frequently possibly at different institutions with different systems, emrs, ancillary staff, and schedules. All of which require their own study time to impress your clinical graders. In addition, most people go oh it's your first day, but then day 2-3 they expect you to functioning at a level as if you've been doing it right alongside them the whole year. Whenever someone has asked for feedback I tell them this concept because they seem like they forgot what it felt like. They need to remember that every new block of rotation you need to assume the students know none of it (including where supplies is, what keycodes are, who the attendings are, how the schedule runs, how the list is setup) and to not hold it against them. It's a pain to do I'm sure, but I will say that the residents that have won our teaching awards last year were the ones that took the time to go over that sort of stuff.

Tl;dr don't just say go do this; say can you do this? Do you know where everything is?

 

[SLUser11]

This isn't a generational thing though. I don't think anyone likes to be labelled with a derogative term based on the year they were born.

I should have started by admitting that I'm a snowflake, having been born in the first year of those considered "Gen y" or "millenials." I speak from some experience, as I was absolutely crushed the first time I discovered that there were things I wasn't capable of accomplishing, and I did not adjust well when things became difficult, as I'd never really been told "no" before.

Anyway, the argument about increased competitiveness is flawed. The mean has gone up dramatically on Step 1, so it's not as hard to get a 230 as it used to be for many reasons, including better resources for studying, more protected time for studying, and a general understanding that these are high stakes tests.

Along those same lines, I'm always told by people around me that general surgery is so much more competitive because there's so many more applications now.....but this is artificially increased because a fear of increased competitiveness has led to medical students casting a wider net/applying to many more places than before. If you really want to gauge competitiveness, you should look at # spots filled by US allopathic students, match rate for US allopathic students, and % AOA in a specialty.

My point, which I still believe to be valid, is that things have always been hard, and students have always been forced to balance competing interests. Comparing our time as students, which for most of current physicians on SDN is within the last 10 years, to current times is just simply not that different. If anything, student time is more protected than ever, so any complaint about increased difficulty of standardized tests is hard to accept.

But, don't take my word for it. Look at the stats:

http://www.nrmp.org/wp-content/uploads/2014/04/Main-Match-Results-and-Data-2014.pdf This year's data


http://www.nrmp.org/match-data/nrmp-historical-reports/ A link to previous reports (including pre-snowflake)

 

[SplenoMegastar]

That's just flat out incorrect. Take one look at the rise in average Step 1 scores and shelf exams over the last few decades. The average for Ortho was 245 last year, 248 for ENT, probably just as high for Uro. Since you've been through this process I'm sure you understand that's a very difficult score to get, and that's just the average!

Ehhh...doesn't a lot of the rise in step 1 scores have to do with the quality of test prep that is now available? When I took Step 1 before my long-ass PhD, UWorld was still sort of a sloppy looking website compared to the polish it has today, and I had only heard about it on SDN - it was not considered the gold standard and many in my class didn't trust it because it was so new. I think some of the new tools make it easier to study efficiently (covering more material in a similar amount of time with appropriate topic focusing done for you rather than having to treat everything in Lippincott's as if it's equally tested).

 

[balaguru]

A personal meeting wound be far more effective than an anonymous student review which if truly scathing will likely just be dismissed as a student venting over poor personal interactions on their rotation.

I wrote absolutely scathing reviews of my experiences on surgery and can only hope change will be made. However, the fact that I took surgery during one of the last rotations of the year (and many students had already gone through similar experiences) I expect that either the program did not care to change or simply had no other options for the rotation.

I agree with students of the now, I did a five year track and dear lord the ms-1s are far out of my league. Competitiveness is increasing and for some reason schools and residency programs are trying to rely on objective, standardized data more and more. Thus, even though patients and attendings may love you because you work hard and stay late, it means nothing if you do just average on the shelf.

I think a lot of this stems from the belief that med students should operate at a junior sub-intern level. Which doesn't make any sense in the current teaching structure. Students are there to learn and to interact with patients on a daily basis. They need time to study for their shelves as well as read up for cases the next day. Sure interns have in service exams and step 3 to study for, but they get a whole year and it's all they do. Students are constantly shifting frame from medicine to psych to fam med to surgery to peds every 4-12 weeks. And within those rotations they are switching in sub categories even more frequently possibly at different institutions with different systems, emrs, ancillary staff, and schedules. All of which require their own study time to impress your clinical graders. In addition, most people go oh it's your first day, but then day 2-3 they expect you to functioning at a level as if you've been doing it right alongside them the whole year. Whenever someone has asked for feedback I tell them this concept because they seem like they forgot what it felt like. They need to remember that every new block of rotation you need to assume the students know none of it (including where supplies is, what keycodes are, who the attendings are, how the schedule runs, how the list is setup) and to not hold it against them. It's a pain to do I'm sure, but I will say that the residents that have won our teaching awards last year were the ones that took the time to go over that sort of stuff.

Tl;dr don't just say go do this; say can you do this? Do you know where everything is?

 

[SplenoMegastar]

I also actively participate in my program's residency application and interview process. I see a ton of applications/CVs every year. Many posters here do the same. So telling us we are oblivious to the competitiveness of the process is just wrong. If anything we likely have a better sense of it than the students here, by virtue of the sheer volume of applications we've reviewed.

Does this mean you will reply to my impending WAMC thread before it gets closed?!

 

[KinasePro]

I should have started by admitting that I'm a snowflake, having been born in the first year of those considered "Gen y" or "millenials." I speak from some experience, as I was absolutely crushed the first time I discovered that there were things I wasn't capable of accomplishing, and I did not adjust well when things became difficult, as I'd never really been told "no" before.

I guess we come from different families or social strata, then. I never had delusions that anything was possible and I deserved the world on a silver platter. My family qualifies as "working poor," so maybe I had less privileges to persuade me into believing I was a snowflake. Who knows? But I'm just calling it as I see it, and your discussion on this topic reveals some pretty strong prejudices against those coming behind you in medical training.

Anyway, the argument about increased competitiveness is flawed. The mean has gone up dramatically on Step 1, so it's not as hard to get a 230 as it used to be for many reasons, including better resources for studying, more protected time for studying, and a general understanding that these are high stakes tests.

Hmm, seems convenient to dismiss increasing step scores and MCAT admission scores with such hand waving. It is as hard to get a 230 now as it was then, because the test hasn't been graded any differently. I agree that students are working harder now (studying more, realizing stakes are higher, using more resources), but you're proving my point. Many schools have not provided additional protected study time, btw.

Along those same lines, I'm always told by people around me that general surgery is so much more competitive because there's so many more applications now.....but this is artificially increased because a fear of increased competitiveness has led to medical students casting a wider net/applying to many more places than before. If you really want to gauge competitiveness, you should look at # spots filled by US allopathic students, match rate for US allopathic students, and % AOA in a specialty.

But, don't take my word for it. Look at the stats:

Match rate and % AOA are flawed indicators of competitiveness. Match rate fails to take self selection into account. The derm and ortho applicant pools are far more competitive than the PM&R pool, for example, yet they have similar unmatched rates. Students are actively advised away from competitive fields if their numbers are not up to par. Despite increasing self-selection and enrichment of competitive applicant pools, the unmatched rate remains high.

% AOA doesn't change for the national student cohort, ever. There is a set number of AOA students in the applicant pool and there will never be more or less, regardless of quality, unless new medical schools are opened (...which is happening actually, btw). If you can imagine a terrible national cohort of medical students, who averaged 202 on step 1, they will have the same %AOA as an elite national class averaging 270, because it is awarded based on performance relative to peers. Therefore, it would be wrong to predict national %AOA to change as competitiveness changes. Rather, the fixed number of AOA applicants will shift between specialties and the competitive fields will always have the lionshare (derm, ortho, ent, uro). The %AOA in each specialty depends on whats popular at the time, not the quality of the entire student cohort.

Our only objective data is the standardized test scores, which are sky rocketing, along with admissions GPAs, # publications, years experience post-undergrad, and MCAT scores. Occam's razor would dictate that students are getting better, but I suppose we are free to interpret the data however it fits into our prejudices.

My issue with the students who say something to the extent of "you don't understand how hard we have it" is that...we do. It's silly to argue otherwise. We went through the exact same rotations. And we stay in constant contact with med students going through it today. We just also have a bit of a different perspective after watching a few hundred or so med students go through their rotations as well, and seeing the full spectrum of excellent to terrible students.

I also actively participate in my program's residency application and interview process. I see a ton of applications/CVs every year. Many posters here do the same. So telling us we are oblivious to the competitiveness of the process is just wrong. If anything we likely have a better sense of it than the students here, by virtue of the sheer volume of applications we've reviewed.

The shelf exam has always been important. It has always been a struggle to balance studying for your actual rotation and the cases you'd be seeing and studying for the exam. I couldn't get honors on my clerkship unless I got honors on the shelf exam either.

As SLU said, if anything students have more protected time today than they did a few years ago. The students at my school aren't supposed to pre-round (so they come in right around 6) and we are supposed to let them go home at 5 unless they are still scrubbed in. So yes, I find it reasonable that they somehow manage to squeeze in their studying in the evening and actually be present on the wards during the day.

Wait.. aren't you PGY3 or 4? If so, you're in the millenial snowflake group and your experience won't be much different from those applying this year.

Anyway, no one is saying attendings are "oblivious," just that its peculiar that the surgery sub forum on SDN seems to be the only place where people deny that the medical profession is becoming more desirable and more competitive. Again, program directors in many fields acknowledge this in the real world.

 

[KinasePro]

I'm a PGY5. I'm closer in age to SLUser than to today's M3s/M4s.

You're match experience wasn't much different than what ours will be today. And if you're born after 1980, i have some bad news for you...

 

[TallScrubs]

My issue with the students who say something to the extent of "you don't understand how hard we have it" is that...we do. It's silly to argue otherwise. We went through the exact same rotations.

The thing that pisses off many med students is that it seems that residents and attendings don't remember what it was like--often only a few years ago (granted, i'm talking about rotations and not about boards, etc). That being said, I think too many med students aren't based in reality and don't understand that--yes, although you're paying good money to be there--everything isn't all about them.

 

[dyeguy21]

The thing that pisses off many med students is that it seems that residents and attendings don't remember what it was like--often only a few years ago (granted, i'm talking about rotations and not about boards, etc). That being said, I think too many med students aren't based in reality and don't understand that--yes, although you're paying good money to be there--everything isn't all about them.

I really dislike med students that think it is all about them, my issue is that when you pay 55-60k per year in just tuition fees I expect to be trained not "figuring it out on my own."

 

[SLUser11]

Anyway, no one is saying attendings are "oblivious," just that its peculiar that the surgery sub forum on SDN seems to be the only place where people deny that the medical profession is becoming more desirable and more competitive. Again, program directors in many fields acknowledge this in the real world.

I can tell from your posts that you are extremely intelligent and insightful....although apparently your parents didn't tell you this as often as mine told me....but what you are lacking is experience. Anyone with real-world experience would argue against your comments that the medical profession is becoming more desirable. And, anyone who has spent years educating students and residents would argue against your statement that students are getting better.

This argument could go on all day, but we won't come to a consensus. Residents think students are lazy and entitled, and students think residents are bitter and out-of-touch.

Please, if you have time, read this thread I made back in 2011: http://forums.studentdoctor.net/thr...ctive-or-just-evolved-with-experience.795584/

It is a commentary on the differing perspectives between residents and students. If you read it, you'll see that we are not dismissive of students at all. Certainly SDN has major issues with sample bias, but many of your residents and attendings are working hard to find a way to educate you.

 

[balaguru]

I can tell from your posts that you are extremely intelligent and insightful....although apparently your parents didn't tell you this as often as mine told me....but what you are lacking is experience. Anyone with real-world experience would argue against your comments that the medical profession is becoming more desirable. And, anyone who has spent years educating students and residents would argue against your statement that students are getting better.

This argument could go on all day, but we won't come to a consensus. Residents think students are lazy and entitled, and students think residents are bitter and out-of-touch.

Please, if you have time, read this thread I made back in 2011: http://forums.studentdoctor.net/thr...ctive-or-just-evolved-with-experience.795584/

It is a commentary on the differing perspectives between residents and students. If you read it, you'll see that we are not dismissive of students at all. Certainly SDN has major issues with sample bias, but many of your residents and attendings are working hard to find a way to educate you.

While there never seems to be an end to the belly aching from older physicians about the decay of the medical profession, I wonder how much influence the great recession had on undergrads who grew up shortly after it. If you can clear the hurdles, medicine does provide a fairly recession resistant and structured pathway to a good living. The same cannot be said about the more technical and entrepreneurial professions.

 

[TallScrubs]

While there never seems to be an end to the belly aching from older physicians about the decay of the medical profession, I wonder how much influence the great recession had on undergrads who grew up shortly after it. If you can clear the hurdles, medicine does provide a fairly recession resistant and structured pathway to a good living. The same cannot be said about the more technical and entrepreneurial professions.

SLU said more desirable and he's correct--it's not becoming more desirable. Your argument is that it has the benefit of being relatively recession proof, which is correct. That being said, we're losing reimbursements, losing autonomy, and people hate us. What part of it is becoming more desirable?

 

[balaguru]

I think it's inevitable that standardized test scores increase the older a test gets. It just stands to reason that studying resources become more efficient over time as people share their experiences with the test and which resources/strategies work best.

Competitiveness seems to be getting confused with applicant caliber. Strictly speaking it is measured by match rate. Competition increases when you have more people competing for the same number of spots. But trying to compare the caliber between 2 populations like PMR and ortho applicants using it is obviously flawed.

You can however make inferences about the caliber of students if you study the competitiveness within a single population over time as long as underlying criteria such as MCAT, GPA and experience are stable or improving. Using the AAMC data for medical students MCAT and GPA scores at least remained stable and possibly showed a trend upwards but something did happen between 2002 and 2007 and you might be able to make a generalized statement that the students who matriculated after 2007 are "better" than the students who matriculated previously.

I guess we come from different families or social strata, then. I never had delusions that anything was possible and I deserved the world on a silver platter. My family qualifies as "working poor," so maybe I had less privileges to persuade me into believing I was a snowflake. Who knows? But I'm just calling it as I see it, and your discussion on this topic reveals some pretty strong prejudices against those coming behind you in medical training.



Hmm, seems convenient to dismiss increasing step scores and MCAT admission scores with such hand waving. It is as hard to get a 230 now as it was then, because the test hasn't been graded any differently. I agree that students are working harder now (studying more, realizing stakes are higher, using more resources), but you're proving my point. Many schools have not provided additional protected study time, btw.



Match rate and % AOA are flawed indicators of competitiveness. Match rate fails to take self selection into account. The derm and ortho applicant pools are far more competitive than the PM&R pool, for example, yet they have similar unmatched rates. Students are actively advised away from competitive fields if their numbers are not up to par. Despite increasing self-selection and enrichment of competitive applicant pools, the unmatched rate remains high.

% AOA doesn't change for the national student cohort, ever. There is a set number of AOA students in the applicant pool and there will never be more or less, regardless of quality, unless new medical schools are opened (...which is happening actually, btw). If you can imagine a terrible national cohort of medical students, who averaged 202 on step 1, they will have the same %AOA as an elite national class averaging 270, because it is awarded based on performance relative to peers. Therefore, it would be wrong to predict national %AOA to change as competitiveness changes. Rather, the fixed number of AOA applicants will shift between specialties and the competitive fields will always have the lionshare (derm, ortho, ent, uro). The %AOA in each specialty depends on whats popular at the time, not the quality of the entire student cohort.

Our only objective data is the standardized test scores, which are sky rocketing, along with admissions GPAs, # publications, years experience post-undergrad, and MCAT scores. Occam's razor would dictate that students are getting better, but I suppose we are free to interpret the data however it fits into our prejudices.



Wait.. aren't you PGY3 or 4? If so, you're in the millenial snowflake group and your experience won't be much different from those applying this year.

Anyway, no one is saying attendings are "oblivious," just that its peculiar that the surgery sub forum on SDN seems to be the only place where people deny that the medical profession is becoming more desirable and more competitive. Again, program directors in many fields acknowledge this in the real world.

 

[Frederica]

One of the issues in medical education is that healthcare professionals are expected to teach, but are not taught how to teach. Some are natural born teachers, but there are very few people who are natural born teachers.

Generations have always thought the ones that came before them don't understand, and the ones who come after have it easier than they did. In 10 years, we will have this same conversation when today's students are attendings and there will be a new generation of medical students. Educational theories and teaching styles will change and today's medical student will complain that tomorrow's medical student has it easier than they did.

To the student who complained they are paying money but are not being taught. You are an adult and your attendings are treating you like an adult. One of the hallmarks of adult learning is that the adult learner is motivated to learn and thus seeks out answers (See Malcolm Knowles). As a graduate student, I am responsible to ensure I have gained the knowledge of the concepts my profs want me to know. My profs do not stand in front of the classroom teaching me what I should know; I read up on what my profs expect me to know and I come to class prepared to discuss these concepts. The problem for younger learners is they have been told exactly what they need to know in elementary, high school, and college. In graduate/medical school, they are expected know things without being told exactly what it is they need to know. Adult learners are expected to be independent learners.

 

[dyeguy21]

To the student who complained they are paying money but are not being taught. You are an adult and your attendings are treating you like an adult. One of the hallmarks of adult learning is that the adult learner is motivated to learn and thus seeks out answers (See Malcolm Knowles). As a graduate student, I am responsible to ensure I have gained the knowledge of the concepts my profs want me to know. My profs do not stand in front of the classroom teaching me what I should know; I read up on what my profs expect me to know and I come to class prepared to discuss these concepts. The problem for younger learners is they have been told exactly what they need to know in elementary, high school, and college. In graduate/medical school, they are expected know things without being told exactly what it is they need to know. Adult learners are expected to be independent learners.

I'm fine with learning on my own as are most med students. We study up on our patients, prep for cases, and study for shelves. What we take offense to is the idea that the privilege to study on our own should cost such ridiculous amounts in the 3rd and especially 4th year. It seems great to have vacation blocks in 4th year, but we are still paying for a full year of tuition plus money on interviews and travel.

 

[SLUser11]

One of the issues in medical education is that healthcare professionals are expected to teach, but are not taught how to teach. Some are natural born teachers, but there are very few people who are natural born teachers.

I used to agree wholeheartedly with you, but my enthusiasm is diminishing. As I've read through some books on surgical education, and gone to several conferences on surgical education, it seems like an awful lot of theory without any proven results. Some of it is a little too warm fuzzy for me, but some of it also misses the forest for the trees.

We can flip classrooms, brief/debrief, etc all day....but what we really need to do is hold residents accountable, provide appropriate and graduated autonomy, and find an effective way to evolve along with evolving rules/regulations to keep our instruction high-yield.

As you know, there is a certain surgical program known for years of innovation in surgical education, and they've published widely on the topic......but have a look at their QE and CE pass rates on the ABS website, and you'll see they don't really have it all figured out.

 

[Frederica]

I used to agree wholeheartedly with you, but my enthusiasm is diminishing. As I've read through some books on surgical education, and gone to several conferences on surgical education, it seems like an awful lot of theory without any proven results. Some of it is a little too warm fuzzy for me, but some of it also misses the forest for the trees.

We can flip classrooms, brief/debrief, etc all day....but what we really need to do is hold residents accountable, provide appropriate and graduated autonomy, and find an effective way to evolve along with evolving rules/regulations to keep our instruction high-yield.

As you know, there is a certain surgical program known for years of innovation in surgical education, and they've published widely on the topic......but have a look at their QE and CE pass rates on the ABS website, and you'll see they don't really have it all figured out.

Do you think milestones will help? Residents now know what benchmarks they need to hit, and faculty have a better idea of how to judge residents based on those benchmarks, removing the subjective evaluations that weren't with their weight in gold anyway.

How should accountability be incorporated into resident training? I don't disagree, just picking your brain.

 

[vhawk]

SLU said more desirable and he's correct--it's not becoming more desirable. Your argument is that it has the benefit of being relatively recession proof, which is correct. That being said, we're losing reimbursements, losing autonomy, and people hate us. What part of it is becoming more desirable?

Because "desirability" is a relative and not absolute trait.

 

[vhawk]

I used to agree wholeheartedly with you, but my enthusiasm is diminishing. As I've read through some books on surgical education, and gone to several conferences on surgical education, it seems like an awful lot of theory without any proven results. Some of it is a little too warm fuzzy for me, but some of it also misses the forest for the trees.

We can flip classrooms, brief/debrief, etc all day....but what we really need to do is hold residents accountable, provide appropriate and graduated autonomy, and find an effective way to evolve along with evolving rules/regulations to keep our instruction high-yield.

As you know, there is a certain surgical program known for years of innovation in surgical education, and they've published widely on the topic......but have a look at their QE and CE pass rates on the ABS website, and you'll see they don't really have it all figured out.

Agree with this, more accurate than you probably think.