March 14th, 2016

The Era of the Ill-Prepared Medical Student

Ahmad Yousaf, MD

Ahmad Yousaf, MD, is the 2015-16 Ambulatory Chief Resident in Internal Medicine at Rutgers New Jersey Medical School.

What is wrong with medical students nowadays? This question has been circulating in the academic medical world for years. As an intern and resident, I would hear complaints about how ‘unready’ they seemed. The grievances often include adjectives like ill-prepared, lazy,  or uninterested.  The complaints have burgeoned over time, and the examples are numerous in my institution: Students show up late to rounds with coffee in their hands; one med student had the gall to go directly to the attending and request early dismissal because he ‘had nothing to do.’ The problem seems to permeate all schools.  Beyond the effects of this behavior on student culture, it results in underprepared interns and residents.alg-school-test-jpg

As a chief resident, I have set aside weekly teaching conferences with the students, and I think I have begun to better understand the issues. Just 5 to 10 years ago, medical school expectations were high. You were expected to show up early to rounds, leave late, be at the beck and call of your resident, and have absolute respect for an attending physician.  Respect for the process of education was standard.  You dressed appropriately. You studied to impress, and you came to rounds prepared to try your best. So why have these standards changed recently? Because none of these qualities are rewarded appropriately in a student’s medical school ‘report card.’

reportcard

Medical student grades, and therefore class ranks, theoretically are based upon two major components: clinical evaluations and test scores (i.e., shelf exams). But the truth is, in medical education today, evaluations completed by residents and attendings of students on their medical teams are essentially useless. Most evals result in clinical grades that are essentially the same, no matter how hard-working or lazy a student was on the floors.  Many reasons are put forward to explain why this occurs, but I think the most important is ‘evaluation burnout.’  Academic medicine is riddled with so many unneeded and redundant evaluations that most physicians do not put the time or mindshare into making them useful.  This results in clinical scores that do not help discern who put forth the work to excel and who just showed up because they needed proof of attendance. It is for this reason that the test scores are weighted so much more heavily than clinical evaluations in the eyes of the average medical student.

“Why get to work early and learn about my patient when my test score and a review of ‘high yield’ facts from a review book will further my career more effectively than learning how to do a good physical exam?” “What is the point of having a well-prepared presentation for rounds when I will get the same score as my colleague who spent the morning going through review questions?” “What is the point of impressing my attendings when all that really matters is my grade and class rank?”

studying

These questions guide the behavior of students, and I cannot blame them. Medical school is competitive. Long-term career plans depend on more than whether a resident team thinks a student is not putting quality time in on the wards.  The finger must be pointed at our medical education system, which values test taking over clinical knowledge and skill. How can we expect to produce a generation of quality practitioners without ensuring that we instill the value of actually practicing that theoretical medicine they learn in textbooks and are quizzed on in exams?  We somehow have to shift the tide of education toward, or perhaps back toward, an environment in which becoming a physician means more than a number or letter grade or a class rank.

Do you agree that students are ill-prepared? Do you see a solution to the problem of students being less interested in the work on the wards?

~Yousaf

43 Responses to “The Era of the Ill-Prepared Medical Student”

  1. Fede says:

    Hi
    Great point. I think another important issue is the future expected compensation. We see everyday. Empowering students is key I guess.

    • Ahmad Yousaf, MD says:

      Empowerment is everything and compensation is a great carrot!

      Thanks for the comment, Dr. Fede.

  2. Shadi Mayasy says:

    Highly agree with you part of that is many of the new faculty and undertrained in giving effective feedback on the other hand the culture of medical education that is less tolerant to medical student negative response to feedback that is reported by them as lack of support by faculty staff and fellow resdients

  3. fernando says:

    Interesting article. The point is the same as in a country like Colombia or Spain. For example: in Colombia to get into residency you need to know someone in the faculty staff who will bring you into the program even without a good evaluation score. In many hospitals of Colombia recent graduates have to know someone inside the department where they apply to have a chance to get in. Then, they also say: what is the point to make a lot of effort in the wards if what I have to do is to spend energy into networking. I know many not so well prepared medical graduates who did not score high in the university exams while in medical school, who got into residencies just because they knew someone, or somebody else made the phone call. I even have dismissed the idea to do residency in Colombia since there is a lot of obscure management in the selection process.
    In Spain, there is a quite more fair system since you basically don´t need to know anyone to get into residency. Your medical board at the end of your career will be 90% of your admission into residency and 10% will be assigned to your total class rank. Then people don’t have to spend time trying to get a LoR from a faculty member, or trying to see they are liked by the staff so they can have a chance into residency. But once again, therefore, students don´t put to much attention into working hard in the ward (actually they are not allowed to see patients by their own), so they dedicate more time to study for the medical board.
    I think every system has its pros and cons, but perhaps the ideal one will be a system in which people are fairly evaluated with very objetive items; but in my own experience and from what I have seen, in medicine is almost impossible to have such objetive view to evaluate medical students and even residents.

    • Ahmad Yousaf, MD says:

      There is definitely delicate balance between grades and effort we have yet to achieve. Thanks for sharing.

  4. Christopher says:

    I recently finished residency in Internal Medicine at Boston Medical Center, and can say with confidence that the BU medical students were a professional and hardworking bunch. This may be due to how we are instructed to evaluate them. Rather than give simple numeric scores, we are given categories: Professionalism, Reporter (how well they presented), Interpreter (how they formulate an assessment and plan), and Educator (how they bring useful information to the team), and then asked to describe short anecdotes of something they did in that category. This way, if someone truly went the extra mile, it is easy to show it, and if someone didn’t they get a generic description that shows that. Most of my students went the extra mile, and they were a pleasure to work with.

    • Student says:

      Hi Christopher,

      It’s truly a small world. I am a medical student at BU, though I don’t believe I had the pleasure of working with you. The system you are describing is unique to the Medicine clerkship. Other clerkships use a series of objectives with numerical values from 0-4 (1=25%, 4=100%). In order to achieve a 4, students are stated on the evaluation to do tasks such as “regularly cite current literature” in notes and presentations. I have rarely seen even the attendings, residents, or interns do this.

      The most frustrating thing for me about being a medical student on the wards is the sense that what you do does not matter. Our notes are labelled with that big disclaimer “ATTENTION: This note was created by a medical student…Do not refer to this note or the associated feedback for patient care, billing, or medicolegal purposes”. No one actually needs us for anything. We are actually been told by chiefs and attendings that the hospital runs with or without us–as if I need to be told this. If I had a dollar for every time I’ve asked a question and been scolded for it, been “corrected” by a superior with incorrect information on their part and felt powerless to say anything about it, or was told I was over stepping my boundaries by trying to take on more responsibility, I could pay off my student loans.

      The third year was a beacon of hope to me during the first two. I kept thinking “If I can just make it to the third year, I can finally start doing something for other people”. It’s amazing how naive I was.

      • Ahmad Yousaf, MD says:

        It seems my post is coming off a bit anti-student, which was not my intended goal. Instead, my goal was to point the finger at the academic system that assesses student worth on grades over clinical acumen. The resultant student culture is but a response to the system they have been dumped in. I am happy to hear your clerkship is unique in delievering appropriate feedback and I think we all have a lot to learn.

        Thanks for commenting.

  5. Eden Girma says:

    I agree with Dr. Yousaf! As medical students, (regardless of where you went to school) achieving high board scores has been drilled into our heads as if that is the only thing that would make us a great physician. I have also been told by many residents that “LORs and evaluations don’t even matter”, but that has never stopped me. I am not a perfectionist either.
    Medicine is a second career for me; i was an ER scribe for 3 years before I applied to medical school and prior to that i worked for a brokerage firm. One of the most valuable lessons I have learned in life is that you are never done learning and there is an opportunity to learn to always be first in line. Like the majority of people, I am a kinetic learner– I learned far more from being in clinic than those books could have ever taught me. Medical school shouldn’t stop at those 3 digit board scores. I am sure if there was more weight given to evaluations by programs, we would have more well rounded physicians that are there for all the right reasons.

    • Ahmad Yousaf, MD says:

      “Medical school shouldn’t stop at those 3 digit board scores.”

      Most definitely! Thanks for the comment

  6. I’ve seen this as a nurse for the past 30 years. Don’t stop what you’re doing and what you know is right. It will pay off throughout your career. Those kind of dead beats seem to filter through somehow, but when the chips are down they don’t succeed. They may end up with a similar position and even similar salary, but what you will contribute to your patients, their families, and ultimately to yourself is something they will never achieve. Work ethics and integrity is just as valuable as Medical School, and you can never go back. I’m a firm believer in developing solid foundations from an early age. Otherwise, there’s nothing to build upon.

  7. Steve says:

    This is a common complaint I’ve heard as well. Though I’m not sure that attendings weren’t complaining about medical students the same way twenty years ago. One question is, what changed?

    I’m not sure that the importance of the written test has changed. Has the percent of its worth toward the grade changed over the years? Or has the content of the exam changed to being less clinical? I’m not sure it has. Or is it simply that the attitudes of the medical students have someone changed?

    Certainly there are more evaluations and higher likelihood of evaluation burnout.

    One thing that has changed, not mentioned in the article, is loss of medical student autonomy over the years. I went to medical school and trained at different institutions and noticed some trends:

    With the increasing efficiency of hospitals and lower emphasis on education, and higher emphasis on avoiding malpractice lawsuits, the medical student’s work is becoming less and less valued.

    Medical students used to be able to write notes in the paper chart, and the resident would cosign. Now med students write notes in an EMR. The note cannot be cosigned. In our EMR the note was marked with big red letters: MED STUDENT NOTE. TO BE DELETED. NOT PART OF MEDICAL RECORD. The attendings rarely if ever read the note. The residents uncommonly read the note. Where I interned, it was viewed as lazy for the resident to copy the med student note if it was good and edit it as their own. The work the med students put in is not valued.

    The same goes for orders. Medical students used to be able to write orders in the paper chart and practice, and the resident could cosign. Now EMRs rarely even have the ability for a med student to practice writing orders. Med students have no feeling of control of what happens to the patient.

    Where I went to medical school, I saw on the AI rotation that the medical student had a high degree of independence. Where I interned, the med student AI rotation was exactly the same as the third year rotation, just repeated. No additional responsibilities were granted.

    As academic physicians are inclined to be more efficient in hospital based systems where they are asked to take on more patients, there is less time to teach medical students, and this is not encouraged by administration. Admits, admit, discharge discharge with short length of stays is what is being passed down by administration (and above them, Medicare and insurance, admittedly) as of top importance, not taking time for education.

    Medical students are performing less and less procedures. With the expanding efficiency structures of hospitals, and the education system, now with increasing fellows and specialties, nursing students, PA students, specialized nurses, etc, there is less for the medical student to do. Central lines are rare because these are all instead now done by the nurse PICC line team. Or residents or fellows do the central lines if there are any. A medical student can’t intubate anymore due to rules or anesthesia teams. They just have to do it on a dummy one or two days of the rotation. Medical students don’t place NG tubes anymore because there is an NG tube nurse team. An mildly invasive procedure is a no no these days for a medical student to perform in some institutions.

    Certainly this will be different in different institutions. But I believe the trends are there all over the country.

    My hypothesis is the reason why medical students no longer work as hard is because they have less autonomy. Their work is simply not valued by educators as it was in the past.

    My solution is this: Pay mind to the medical students. Remember, they are paying money to be there. Read their notes and comment on ways to improve. Allow them to practice placing orders somehow. Give up some of your procedures and let the medical student do them. Ask the nurse PICC line/NG/central line/art line team if the med student can do a procedure with them. Get back to the old days of education.

    -Steve, an attending physician

    • Michael Y. says:

      Well said.

      I thought it was cool in the paper medical record that one could easily see the note written by the medical student, the intern, the resident, the fellow, and the attending. It was easy to see as a medical student what one was moving towards. I cannot imagine that is the case now with the EHR.

      By the way, I do not believe that the grading system has changed in the 25 years since I finished medical school. The test grade has always counted for far more than the clinical component in clinical rotations. I thought it was silly then, when I figured out the sham. I think it is silly now.

      • Ahmad Yousaf, MD says:

        I definitely agree that EHR/EMR systems make it even easier to avoid appropriate evaluation and feedback of the medical student notes and thought process. This, along with the restrictions put on them in terms of note writing and order entering has to be at the center of the conversation on what needs to change to make things better.

  8. John Cronin says:

    Thanks for this. I agree with what you are saying regarding reforming med school education and the limitations of the current system.
    I take issue though with one thing. That is the underlying thought that med students are not as good/respectful/hard-working as they were “in my day”. I see this attitude in many of my contemporaries who have recently completed their postgrad specialist training. The reality is that it was always thus. There were always slightly lazier students. I knew some people in med school who hardly ever turned up at all, let alone with a coffee in their hands. There were also always brighter students. I’m quite taken aback with how committed and knowledgeable many students are today. Perhaps I’m comparing them to what I was like myself.
    i agree that assessments need a different focus rather than just a relaying of facts. This is something I found frustrating in my med school days (a good few years ago now) and I don’t think it’s changed.

  9. Amy says:

    The technology age has also affected affected medicine. Slowly gone are the days of making mega bucks. Florida is a good example of how awful the medical world us. Slowly the medical world is realizing that male dominance is past.

  10. Amy says:

    One only has to look at the medical profession by coming to Florida. The problems you see brewing are nothing new. The field of medicine as with every industry has transformed due to technology. I think the whole male dominance situation is finally occuring. So much that doctors did in the past is thrown to other medical groups. Your issues are known in the “outside world”.

  11. Franz Buergler says:

    More weight should be given to the clinician’s assessment of the performance of the med student in question. Performance in Multiple Choice questions imho is a weak indicator as to how the colleague will perform later in his career. KG Franz Burgler

  12. sara says:

    I couldn’t agree more. Portugal. Same here!

  13. EMT-P says:

    I am not a medical student, but my SO is an MS3 at a very competitive medical school. I am a paramedic and I’ve been working in my current capacity for 3 years and in clinical settings for the past 7 years at various levels. Your assessment is spot on, at least from an external perspective. My SO learned early on in her third year that excelling in rounds was rarely rewarded and that her grade depended much more on her shelf exam scores. Further, when she did put in extra work in her early rotations, she was not rewarded and her grades suffered because the time she spent in clinic detracted from the time she spent doing shelf review. This is frustrating to see as a lower level provider. I realize that my knowledge level barely scratches the medical surface, but clinical skills and assessment techniques are the most important part of any sort of medical practice, and when I see my future superiors failing to receive the intensive clinical training that I long assumed they received, it not only worries me but makes me weary of working with younger physicians. I realize this is biased, but when an intern can’t intubate a patient or place an IV or accurately read a 12-lead I give them, I feel cause for concern. Those same interns can detail to the molecular level the pathology involved in so many disease processes that I will never learn, but a shift in focus to clinical skills needs to occur.

  14. Khalid Haque says:

    Having taught medical students (undergraduates and postgraduate s) for over 40 years I could not agree with you more. Practicing good medicine is both an art and a science that is best learnt at the bedside. There is so much to learn from the patient. Sadly, medical educators have all over the world are slowly forgetting this and more and more giving importance to test results. No wonder medicine is now viewed as just another profession rather than a vocation.

  15. S says:

    thank you for this worthless tirade against medical students without a shred of tangible suggestions that we can use to further our roles in patient care. i’m a clerkship student that has tried for nearly a year now to get more involved with my patients. i’ve asked for nearly a year to put in an LP, or a central line, or a chest tube, or draw an ABG, or anything. “oh, i’m not sure if you’re allowed to do that yet” says the nurse practitioner.

    no one wants us around. period. i go to see a new admit in the ER and report back to my team, but wait the intern already chart rounded and put in the orders. i write my notes every day, but wait absolutely no one reads them. i can’t really blame them, our notes can’t legally be used for billing. so what is our purpose then? how many times can we ask “is there anything else i can do for you?” before we just get fed up and leave? you come from a completely different era where the workflow of your service actually depended on the presence of medical students drawing labs, wheeling to imaging, etc. we don’t have the “luxury” of doing that anymore.

    i can think of maybe one student who had the “gall to request early dismissal”. so yes, i take offense when you call us “lazy”. the vast majority of us are dying to be more involved. i go to a so called top 10 medical school and wish every day i could be knocked down a tier or 3 just so i could work at a county hospital where me showing up mattered because patient care depended on it. i apologize to my future patients for my lack of skills, but i really tried. i really did.

  16. MS4 says:

    MS4 here. MS3/MS4 clerkships have been the most frustrating two years of my life. I WANT to be more involved in patient care. My requests to do more (write notes, place orders, do small procedures) are almost always denied and my efforts ignored. I’m at an academic hospital, designed to teach medical students and residents, and yet I find there’s very little effort to teach the medical students!

    I worked in the medical field as an MA and EMT for several years before going to medical school. My preceptors in those fields made a real effort to teach me. I do not see the same being done by attending/residents. The attendings are always “too busy” to teach (outside of scheduled didactics), thinking the residents are doing some teaching. Well, the residents are overworked and don’t want the added responsibility. So who have I learned from?! The techs, the nurses, and the PAs have taken a more active role in my education that most of the attendings/residents I’ve rotated with. It’s a shame.

    I’ll be an intern in a few short months. I’m not sure I’m ready. I sincerely hope to teach the medical students more than my residents taught me, but I’m not sure if I’ll be able to do so.

  17. hector says:

    Could it be that medicine is not attracting the cream of the crop anymore because of changes over the past 5, 10, 20 years making medicine less attractive (decreased compensation, increasing regulatory burden, increase in average training time…). Sure, we can fill med school and most residency slots, but I think the best and brightest might be turned away.

  18. AspiringDoc says:

    Medical schools are now just accepting people who are the best of the best. If you don’t get accepted you probably are not good enough academically to make it. Medical school boards care about their pass rates on the USMLE steps. If they accept students who pass their schools yet fail the USMLE it reflects poorly on the school in general. If you are not a genius, medical school is taxing beyond belief. And academic achievement is rewarded more than interpersonal skills. In fact, there are students who will sabotage others by giving wrong information. (speaking from experience). I was denied from many, many medical schools before I was finally accepted at one. I just completed my midterms for physiology as a MS1. In response to the paramedic: an ecg and its interpretations consisted of two hour long classes with approximately 6 total questions on the midterm compared to drugs and their interactions consisting of 40+ questions. Some students will prioritize learning things that pay off instead of learning things because they are important. It is also true that many physicians future physicians may have no interest in Emergency med, or cardiology so they may find little interest in critical care. Personally, I find both fields to be fascinating and I think of myself as a bit of an anomaly. Academically, I am one of the worst students at my school. One of my redeeming qualities was that even when faced with classes that are worth less to my overall GPA; I still work my hardest. I scored in the top 10% of my class in practical examinations (worth one unit) compared to most academic courses worth 5-7units and as well as in the top 10% in Bioethics (worth 2 units) and the top 10% in Preventative medicine(worth 2 units). I’ve met some medical students who are previous lawyers that want to use their degree to make money suing doctors. I’ve met medical students who are pHD’s that are more interested in research. I’ve met medical students who are more interested in pathology and who care more about what caused an individual to die. People will spend more invested time into things that interest them, things that pay off, or things that make them feel good. If working longer hours means, they aren’t able to focus on an upcoming exam(decrease their performance), what or who they are working with do not interest them(make them feel bad), and who they work with make them enjoy work less. What reason is there to go above and beyond?

  19. Eliot says:

    I agree with this article. But, I remember when I was a medical student 10 years ago, I asked the resident and the attendings if I cna do the procedures. They laughed at me but eventually trusted me enough after I kept nagging them and watching them do it. One part of it is the persistence and the other part is the willingness to teach. But, the bottom line is this: you can whine and moan and write all you want, but what matters is if you put your money where it counts and actually go out and practice what you preach. Yes, there are restrictions and rules and limits in a hospital setting, but, that doesnt mean that rules and limits cannot be bent a little. I trained at a hospital where there was an EMR and med students wrote notes. i read my med student’s notes and gave them feedback. My attendings didnt though. I brought my students around on rounds and taught them interesting things and gave them tips, but my attendings didnt. It goes both ways… The student needs to want to learn, and the teacher needs to want to teach

  20. Ralph says:

    I graduated from a prestigious medical over 30 years ago. I was never the best medical student on the rotation, but I held my own, and had a pretty good idea what was expected of me. My daughter, now a resident in a high-level program elsewhere, would confirm most of what Dr. Yousaf has stated here.

    The current, deplorable attitude of med students as nicely outlined by the author speaks partially to the selection process of the medical schools, and partially to the evaluation process. Both are broken and in need of repair, STAT! Evaluations need to assess a number of factors, including the level of empathy these kids have (or more likely DON’T have) for their patients. I’ll leave that to the experts.

    Let’s be candid about something: Medical schools select for those whose entire high school and college experiences were tailored to making them look good on paper. Padded resume’s, all A’s, high MCAT’s (thank you Stanley Kaplan) are the ticket in. My son started off as a pre-med. He is very smart, perhaps not quite genius level, but could not compete against the (majority foreign) students who literally studied or otherwise did something academic 18-20 hours per day. Literally. Out of the almost 1,000 premeds in his entering Freshman class, not even 150 remain. I submit that we have weeded out quite a few who would have been excellent, caring, feeling physicians, for some ideal of the “brilliant scientist” who can’t begin to grasp the feelings and concerns of the average patient. Is this where we wanted to go?

    Having picked the “winners” of the numbers lottery, why are we at all surprised that they continue the same behavior that got them this far?

    I’m quite happy to be at the end of my career, but now I’m starting to worry about those who will be managing MY care in the years to come.

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