This article is the third of a six-part series, written in the hope that it will be useful to those who are considering or preparing for a career in medicine, and at least entertaining and uplifting for the rest of you:
- First Decisions: Deciding to become a doctor
- Apply Yourself: Undergraduate studies
- The Academic Eating Contest: Medical school preclinical years
- Academic Vertigo and the Identity Crisis: Clinical rotations and specialty choice
- Keep Your Nose Above Water: Surviving residency
- Living the Dream: The transition from training to practice
The first few weeks of medical school were the most remarkable time in all of my 26 years of formal education. There were about 200 students in my entering class, from diverse backgrounds, religions, and races, and a general feeling of openness and goodwill prevailed. I turned over a new leaf by going out of my way to talk to people and make new friends, and I felt a strong sense of camaraderie with all of my classmates. We had all worked hard to get there and we were all in this together.
Gradually over the following weeks and months a mostly friendly competition emerged. This was more similar to an eating contest than a footrace, combat, or other type of competition. The objective was to consume and retain vast volumes of information about the biomedical sciences. Medical school course material is not necessarily harder than undergraduate courses, but the material comes at you faster. You don’t have the luxury of messing around and wasting time. During my undergrad years I read 20-30 extracurricular books per year, the majority of which were nonfiction (Louis L’Amour’s excellent autobiographical memoir, Education of a Wandering Man, was my inspiration for this habit), but my recreational reading ground to a halt during medical school because the course work was so demanding.
The year started with a three month comprehensive gross anatomy course, including hours and hours spent each week in the cadaver lab dissecting a real human body. Each body was shared by a group of about six students, and we all took turns doing the work.
I remember spending the morning in the cadaver lab trying to find a checklist of structures on our body, and then eating my lunch while reading about the dissection we would do the next day. My undergraduate anatomy and comparative vertebrate morphology courses had exposed me to dead bodies, so I had already learned to intellectualize the experience and turn off my revulsion reflex. But some of my classmates had a hard time in the cadaver lab, and left the room to recover in the hallway or to throw up in the nearest garbage can. By the end of the course everyone had developed a level of comfort with the experience, which may be the first step in the personal metamorphosis of medical training.
Studying anatomy was an amazing experience, and one which I will treasure for all of my life. Holding a heart in your hands and tracing the route of the blood as it flows from chamber to chamber through the valves will teach you about heart function in a way that no image in a textbook can approach. The same is true all over the body, from complex joint structures to abdominal organs and peripheral nerve networks. The human body is a wonderful machine!
The cadaver I worked on was an older woman, morbidly obese. One day we dissected her feet, and found that all of her ankle and foot joints were terribly arthritic. I remember being struck by the thought that this woman must have suffered joint pain, and she probably didn’t enjoy walking. This thought suddenly made me conscious of her humanity; this was a real human being who used to breathe, and think, and love people. On the day we removed and examined her spinal cord my classmate seemed to be struck by a similar thought. She had a sober look on her face, and said, “Wow! She’s really not going to get up and walk after this!” Of course we all knew that the first time we opened up the dissecting table and pulled back the plastic, but something about removing a critical part of the body really drives that point home.
My favorite day in the cadaver lab was when we examined the brain. That was the first time I had held a human brain in my hands, and it filled me with a sense of wonder. So much of what made this woman who she was depended on that brain. Her memories, her motor skills, her ability to communicate — all of these things were somehow encoded within that beautiful squishy blob of tissue.
Later in the year we had a memorial service attended by the families of our body donors. We were able to thank them, as a group, for allowing us to learn so much from the bodies of their loved ones. I arranged some music and played in a small ensemble for the memorial service.
A traditional medical school curriculum lasts four years, with the first two years in the classroom and the second two years in the hospital. It is trendy for medical schools to mix this order up, but it’s hard to do too much clinical work before you have a solid handle on the basic biomedical sciences. The medical school I attended had two separate options for the preclinical education, a traditional lecture-based pathway and an Independent Study Pathway (ISP), which has since been discontinued. I chose ISP, informally known as “home school med school.” Rather than attend lectures, ISP students were given a textbook and a study guide with learning objectives, and a time window in which they could take each examination. The curriculum was organized into body system modules, and covered normal physiology during the first year and pathophysiology during the second year.
Choosing ISP gave me a lot more scheduling freedom than I would have had in the traditional lecture pathway, but this freedom came at the price of constant vigilance to stay on task. Everything I learned those two years was because I had forced myself to look at the book and read the next paragraph. There was no passive learning in ISP. But the scheduling freedom was priceless! I remember a day when my wife was terribly sick, and I stayed home to watch the kids while she threw up every few minutes. She was so sorry that I didn’t get any studying done that day, but I said to her, “It’s okay. This is why I chose ISP.”
ISP students had a study library with a ghostly quiet cubicle farm and a common area with lunch tables and a microwave. One of the students referred to the cubicle farm as “the nerdery.” I spent so much time in the ISP library that I could have walked through it blindfolded and identified everyone by their voice.
I didn’t really study for examinations when I was a student; I studied to learn the material. One of my classmates referred to the process of cramming for exams as “academic bulimia.” It doesn’t help you to binge and then regurgitate the material if you can’t remember it at all a short time later. So I studied to learn, not to perform.
This strategy was not always successful in the short term, but it has paid dividends in the long term. The pharmacology module is a good example: our task as students was essentially to distill a 1,500 page textbook into a 4 x 500 table, and then memorize that table for the exam. Unfortunately at that point in our studies we had not yet learned any pathophysiology and didn’t even know the names of any diseases, so there was no conceptual framework to place this information into. It was a job for brute force memorization. I spent a couple of weeks drawing comic strips to help me remember the names of drugs, their mechanisms of action, and their side effects. My performance on the examination was not stellar, but this painstaking creative process was effective, and I can still remember today the stories and drawings I made to help me remember these drugs. I didn’t learn all of the material, but what I did learn was put into long term memory. This solid foundation made pharmacology one of my strengths during the clinical years of my education.
(A banner collage of more of these drawings can be found here. Can you find the following drugs in the pictures: clonidine, rosiglitazone, leflunomide, ondansetron, acetazolamide, colchicine, allopurinol, turbinafine, nystatin, griseofulvin, dapsone, rifampin, digoxin, triamterene, chlorpromazine, haloperidol, thioridazine, argatroban, lepirudin, trifluperazine, prilocaine, lidocaine, cocaine, fexofenadine, and loratadine?)
I enjoyed a lot of subjects during the preclinical years, but neurophysiology really stood out as being my favorite. My least favorites were renal pathology and reproductive endocrinology. I actually failed the reproductive endocrinology exam and had to remediate it, but I consoled myself by the fact that I had a reproductive success while studying that module: my third child was born!
One Step at a Time
The United States Medical Licensing Examination is a three-step exam, and the first step is taken at the end of the second year of medical school. Step 1 tests your knowledge of all of the basic biomedical sciences, including the normal physiology and pathophysiology of all the organ systems of the body, the various bacteria, viruses, fungi, and parasites that try to attack the body, and the drugs that are used to treat diseases. USMLE Step 1 is a monster of an exam, a truly worthy sequel to the MCAT. And like the MCAT, a poor performance on this exam can be a serious setback and can even derail entirely your dream of becoming a doctor.
The second year curriculum ended several weeks before the test date for Step 1, and I spent those weeks trying to consolidate everything I had learned in the previous two years, plus identify and fill in any gaps in my knowledge. Small study groups would naturally gravitate together during these weeks as we all felt the stress of what was coming, and I spent about half of my time in solo study and the other half in quiz sessions with one of my classmates.
Fortunately I did well on Step 1, but not everyone did. One of my friends failed the exam and spent the next year studying to take it again before she could move on to the hospital rotations.
The lull between the end of the second year and the start of the third year is the calm before the storm. As busy as the preclinical years feel at the time, older students sometimes look back with fondness on those years, like teenagers idly pining for their lost childhoods. Med 1 and Med 2 represent the culmination of your book learning days, a fitting finale to the classroom education which started when you were 5 years old in Kindergarten.
But your transformation has already begun, in ways that you may not be aware of yet. At this point you probably know more about human anatomy, physiology, and pathophysiology than any lay person does, and you see the world through different eyes. You can look at a living person and imagine the locations of all of their internal organs. You know how all of those organs work, and how their functions are coordinated and regulated. You also know the ways that each organ system can malfunction or fail, and something about the medications which are used to treat these conditions.
Never mind that this knowledge is almost useless in the absence of any clinical skills. That deficiency will soon be rectified, as you enter the world of clinical medicine in your third year of medical school. This change in your education will mark a change in your life that you will never be able to undo. I will warn you now that this change will be a bit rocky, and some of the darkest days of your education are in your future.
In retrospect, this point in my medical education was a lot like my last day in the Missionary Training Center. At that time I was an over-confident 19 year old kid who had a testimony that the gospel was true, and I had spent the last several months immersed in the scriptures, but I knew very little about their real-life application. I was like a seed, containing all of the potential of a tree, ready and eager to sprout when planted and watered.
Fast forward a few days and I found myself knocking on doors and stopping people on the street in north London. Struggling against my unrecognized social phobia, my mission became the hardest experience of my life up to that point. This transition from theory to practice was humbling and hard, but it changed my life for the better in ways that are difficult to undo.
The same is true of your clinical education. You have stuffed your brain full of medical knowledge for years, but you have only the smallest perception of how that knowledge is practically applied. It is time to step outside of the classroom and into the hospital room. That is what we will do in the next post.
Part 1 of a medical education memoir: Deciding to become a doctor.
Part 2 of a medical education memoir: Thoughts and memories about undergraduate studies and applying to medical school.
Part 4 of a medical education memoir: Thoughts and memories about medical school clinical rotations, specialty choice, and applying to residency.
Part 5 of a medical education memoir: Stories and memories from the dark days of internship and residency
Part 6 of a medical education memoir: Adventures and lessons from my first years in practice