Training wheels

So tonight's blog is the first of a two part series dedicated to how I got here and what doctors, in 2009, go through to get trained. I find this an opportune time to write about the subject as our president is currently considering the ever expanding topic of "Healthcare Reform" which most people do not know how to define. In Obama's efforts to reform, much has been speculated about who is to blame and who should pay. Someone, after all, is going to have to give up something or nothing will change. In light of this, Atul Gawanda's recent piece in the New Yorker caught my wife's attention, and then mine:

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

My patient wife has now been with me for seven years, that's seven out of the eight I've been in medical training. My average salary, including the negative $34,000/year in loan debt I was in during medical school and then the $48,000-$54000 salaries I've had in internship, residency and now fellowship comes to an astonishing $8000/year average net in those 8 years. We have squeaked by with moonlighting, and very good money management (by her, thank god!) But needless to say, articles about blaming doctors scare both of us- sitting where we sit- having put in everything to make virtually nothing yet. Especially given how much money insurance companies made last year.

So I'll start at the beginning which is how to get into medical school. Basically, medical school is a daunting task from the moment a young high school student or college student begins to read on what getting in requires. There is the traditional pre-med track which, as of 2009, still includes very unnecessary coursework (physics, organic chemistry, calculus) and a few vital topics including biology, chemistry. At most schools these are the more popular classes and majors. At most schools these are also the toughest to get As in. And you need As. The average GPA for enrollment in a US medical school in 2008 was a 3.76 on a 4 point scale. You also need superb extracurricular activities, letters from multiple professors, and more and more, hands on experience in the form of volunteer work or real work. An increasing number of applicants are graduating and becoming EMTs or paramedics or nurses prior to applying to medical school. They are well ahead of the traditional track college grads in terms of real life experience (something I think vital to becoming a well-rounded young doctor).

As for the odds: According to the American Association of Medical Colleges, in 2008, there were 558,053 applications from 42,231 applicants, (an average of 13 applications per applicant) to US medical schools. Of these 42,231, there are 18,036 spots to fill. So approximately 1 out of 3 applicants lands a coveted spot. An approximately 2 out of 3 do not. That's 2/3 of people going through all of the same training, coursework, letters, applications (13!) and interviews as their more fortunate peers who are told "maybe next year." That's right, interviews. One needs to travel at his or hr expense to the medical schools for rigorous interviews where everything is asked from, "How much money do you expect to pay on your own and how much are your parents going to pay?" (which one of my friends whose parents were dead was asked at a certain southern state school) to "Who is your favorite American Idol?" Most of the questions are geared towards seeing how you do under pressure. And many of these quizzes have no right answer. One famous admissions director was known for theatrics, often leaving the room during his interviews for an uncomfortable amount of time. I interviewed at 9 medical schools in 2000-2001, and I left 9 interviews feeling odd, and somehow wronged.

So if you are in the lucky third, you're in! And then comes the biggest reality check of your life: Medical school is hard. It's really, really hard. For two years you memorize the equivalent of the New York City phone book. I counted tests one semester in my second year: 37. I was tested 37 times in 21 weeks. Almost two tests a week. After a while the multiple choice bubbles all look the same, and the books all sound the same. And then comes the first of 4 huge national tests, the United States Medical Licensing Examination (USMLE) step one. This is notoriously the worst experience of everyone's life. It's a testament to minutia, a dedication to memory and unimportant tidbits. The stuff written at the side margin of page 238: That's tested. The stuff mumbled once by a professor who barely spoke English: On the test. And it's 8 hours long, at a computer testing center, usually somewhere you've never been before. Most students set aside approximately one month in order to prepare for Step 1. Most medical schools build this study period into their curriculum as a "vacation" period between the second and third years. While text books from classes and review books are a large part of preparation, commercial test-prep services and software are extensively used. This represents an additional $500-$1500 out of pocket expense.

If all goes well, you pass. by report, 7 out of 100 in my medical school class did not and repeated the test. Once complete, you move on to the third year of medical school and things really heat up. Third year is sort of like playing pro-football with no pads and no experience. You are rounding daily with medical teams, always judged by your smile and apparent willingness to learn, a tough thing to keep up as the days grow longer and the tasks grow more mundane. For instance, on my surgery rotation, I stood for 11 hours once holding a retractor in place. I did not ask to go to the bathroom (that is unheard of). I did not eat. I just stood, in place, holding for 11 hours. On my medicine rotation, I was once asked to "support" a patient's testicles while someone scraped the skin beneath them into a vial. And on and on the stories go. The good news is that, luckily, you're learning the whole time, and hopefully you have not decided yet that this profession is for fools but rather it is a privilege to be there (which was a tough sell on testicle night!) In truth, in the first two years you learn the words and alphabet of medicine. In the third year you get dropped off in the foreign country for immersion. The experiences are unforgettable, and often difficult. I had never actually witnessed someone breathe their last breath. I had never seen an ulcer so deep that the bones and muscles were exposed all the way down. I had never seen a husband lose a wife, or an old person dying alone, or someone on the brink of dying walk out of the hospital a week later.

Meanwhile, the grades pour in. I was evaluated for my six rotations an average of 14 times per rotation. Most of these evaluations are subjective. The surgery resident who cheated on his girlfriend in front of me at a bar one night evaluated me poorly. There was nothing I could say. By and large, having now been on the flip side as the evaluator, I think it entirely (with a few exceptions) the fault of the residents and attending physicians if a student under their tutelage does not excel. Everyone has passed the brightness test, some just needs constructive feedback early on to help shape behavior and learning. One of the more detested med students I encountered got a much needed sit down by an attending 2 weeks into his medicine rotation on my service and ended up a superstar. It turned out that she was terrified, and overcompensated by coming across arrogant. And that emotional roller coaster, mixed with terrifying immersion is the third year of medical school.

And the truth is, med school could and probably should end there. By the end of third year, students have rotated through Medicine, Surgery, OBGYN, Psychiatry, Family Medicine (in some places), Pediatrics and occasionally Neurology and are prepared to chose their paths. So then you wait another year, taking electives and as much time as you can to your family and friends before Internship. First, of course, two more step exams for the USMLE. One (Step 2 CS) requires travel to one of six US cities where fake patients are arranged with fake ailments and grade you according to your diagnostic skill, physical exam prowess, and generally, how not creepy you are. This costs $1000 plus travel. The other is Step 2 CK. For most people, this is easier than Step 1. And most do better (as did I) on this exam. But for me, I found it a more terrifying task. Partly, perhaps, because it is 9 hours long. But mostly because I felt a strong sense of responsibility to pass- a voice inside me begging: "You can't screw this up, or you're a shitty doctor." I've never felt pressure like that. And that was only the first of so many times that I felt that way.

My next entry will focus on Internships and Residency. But before I part I will say this for medical school, and pre-med as well: Only fools go so far as to get into medical school these days without a clue of what is to come. There is a reason, in times of economic prosperity, that the number applications for enrollment to US medical schools plummet and then peak in times of trouble: Other jobs represent easier earned money. But the day I graduated from medical school, not yet knowing that I knew nothing still, I felt a sense of joy that I had chosen a path that asked everything of me. It was a humbling experience, really, to take the diploma from the Dean of Students' hand. I knew now that there was no turning back, and that I was truly a step closer to my dream. I just didn't know yet what that dream really encompassed.