medical education


Opinion: In Simulation Era, Your Doc’s First Try At A Procedure Should Not Be On You

A mannequin for practicing open heart surgery at the Boston Children’s Hospital’s recently unveiled simulation center. Called “Surgical Sam,” it has a life-sized “heart” that accurately mimics the beating motions of a healthy or abnormal human heart. (Jesse Costa/WBUR)

A mannequin for practicing open-heart surgery at the Boston Children’s Hospital’s recently unveiled simulation center. Called “Surgical Sam,” it has a life-sized “heart” that accurately mimics the beating motions of a healthy or abnormal human heart. (Jesse Costa/WBUR)

Most doctors never forget the paralyzing terror of their first invasive procedure.

Dr. Charles Pozner, of Boston’s Brigham and Women’s Hospital, recalls the first time he placed a central line, which involves sticking an eight-inch-long needle into a patient’s jugular vein to place an intravenous line. He had never even seen it done before, but a chief resident offered him the opportunity after a long day working together.

“When I was a medical student, the last thing you wanted to say when someone offered a procedure to you was ‘no.’ You wanted to learn, to be part of the team,” Pozner told me. The chief resident walked him through it without mishap, but “it was an unsafe thing for the patient, and an unsafe thing for me, because I was potentially harming the patient,” he said.

Twenty years later, in 2013, I went through a similar process. I watched a colleague place a central line during my first week as an intern. A couple of days later, I placed my first one, as my senior resident supervised. Thankfully, everything went fine. But that doesn’t mean I’m comfortable with the idea of wielding eight-inch-long needles after only watching someone do a procedure once.

“See one, do one, teach one” is the ancient medical adage for this: that after doctors in training have seen one procedure or operation, they’re qualified to do the next one. It has been the model for teaching physicians for generations.

But in the age of robotic surgery and simulation medicine, is this concept really acceptable anymore?

The short answer is no. Clearly, doctors in training should practice on computers and simulated patients, not real ones. Particularly when, according to a study out this week, medical errors are the No. 3 cause of death nationwide.

The longer answer is more complicated. No one openly defends the concept in medical journals — in fact, experts talk about “see one, practice many, do one.” But the “see one, do one, teach one” culture still persists in hospitals around the country, and it remains routine for physicians in training to practice their first procedure on real patients. (As a patient, what can you do about it? See the tips below.)

“Would you fly on an airplane if they say, ‘We’ll drop the price of our tickets but our pilots will opt out of flight simulation?'”

– Dr. Antonio Gargiulo

But that is changing, as more hospitals and medical schools invest in high-tech simulation centers like the $12 million center unveiled by Boston Children’s Hospital this week.

Dr. Pozner, who is medical director of the Brigham’s STRATUS Center for Medical Simulation, says that in time, medical simulation will mean the death of “see one, do one, teach one.”

The Pilot Analogy

Consider pilots. Chesley “Sully” Sullenberger, the pilot who remarkably landed his plane on the Hudson River, is often mentioned in the medical literature on simulation, as are his hundreds of hours practicing simulated emergencies. If Dr. Atul Gawande famously brought the pilot’s checklist to surgery, simulation proponents think more pilot-style simulation should be brought to medicine.

“It’s called procedural memory,” Dr. Pozner said.

And studies show that simulation works in medicine. One small study trained doctors in robotic surgery, showing that they could reach expert level proficiency by the time they operated on their first real patient.

“The main advantage of this tool is you can get technically perfect before you even touch a patient,” said Dr. Antonio Gargiulo, medical director of the Center for Robotic Surgery at Brigham and Women’s Hospital. Continue reading

Opinion: Do You Really Want Your Trainee Doctor ‘Pimped,’ Hazed And Exhausted?

By Dr. David Scales

“What kind of gas do we use for laparoscopic surgery?”the surgeon asked me. It was my first laparoscopic surgery ever, during my gynecology rotation in medical school. We were inflating a woman’s abdomen for a tubal ligation, “tying her tubes” to prevent future pregnancies.

“Carbon dioxide,” I answered, having brushed up on this the night before.

“What color is the gas tank?” he asked.

Hmmm. Different gases have different color tanks? Clearly important, but it had been in none of my preparatory reading. I stared at him blankly, my own color draining from my face. I tried unsuccessfully to peek at the tank.

“Grey,” he said, deadpan. “What color is the oxygen tank?”

Blank stare again.


I was being “pimped” — asked to instantly recall medical facts (“pimp” is said to derive from the acronym for “put in my place”). My supervisor was proving his point: Not knowing the different tank colors, I might not notice if someone inflated an abdomen with oxygen, potentially causing a horrible explosion when a bleeding vessel was cauterized.

It clearly left its imprint — this happened in 2005. To this day, I remember that green is oxygen and gray is carbon dioxide. But it was also humiliating: How could I possibly have anticipated his line of questioning?

This week’s Journal of the American Medical Association has a panoply of articles on quirks of medical education like pimping. The studies raise serious questions and concerns about the health and well-being of medical students and doctors in training. Taken together, they raise one of the loudest challenges yet to the age-old medical culture of “no pain, no gain.” Continue reading

A Prescription For Better Teaching, Stronger Doctors

The author's stethoscope from medical school stethoscope. (Courtesy)

The author’s stethoscope from medical school. (Courtesy)

By James Morris
Guest Contributor

Medicine, in many ways, is changing. Patient-centered care is all the rage and the old, iconic image of the all-knowing doctor is fading away.

In one concrete example of this shift, a new Medical College Admission Test (MCAT) is just around the corner. Starting in spring 2015 for the class that will enter medical school in the fall of 2016, the new MCAT promises a “better test for tomorrow’s doctors.”

Among other changes, it will have a new section focusing on the social determinants of health — essentially asking students to consider how income and social status, education, home and work environments and other factors shape health outcomes.

Premedical education takes place at the undergraduate level. I went to medical school, but now spend most of my time working with undergraduates in the classroom.  I often think about what I learned in medical school and how it translates — or doesn’t translate — to teaching, and why it matters.

Of course, there are the obvious connections. One of the classes I teach is comparative vertebrate anatomy, and I use what I learned about anatomy in medical school directly in this class.

But there are other lessons that don’t apply. Doctors often use three-letter abbreviations in their notes. HPI is the history of the present illness, the patient’s narrative of what brought them to the doctor’s office or hospital, as heard and interpreted by the physician.

CAD is coronary artery disease. TIA is a transient ischemic attack, a “mini-stroke.”

There is a saying I remember from medical school: Physicians are especially fond of TLA’s … three letter abbreviations.

I don’t use many acronyms in my teaching. But sometimes, it’s helpful: For problem sets, I sometimes use “PS.” However, when I do this, I am inundated with emails and questions asking what they mean.

In medical school, mnemonics are also widely used to help aspiring physicians learn and remember all kinds of information. The 12 cranial nerves can be recalled using the mnemonic “On Old Olympus’ Towering Top, A Finn And German Viewed Some Hops,” where the first letter of each word of the saying is the first letter of each of the cranial nerves: olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, auditory, glossopharyngeal, vagus, spinal accessory, and hypoglossal.

Or, for Harry Potter aficionados, there is “Only Owls Observe Them Traveling And Finding Voldemort Guarding Very Ambiguous Horcruxes.”

These are handy, but I learned so many mnemonics in medical school that I often had trouble remembering which mnemonic was used for what kind of information. Is that the mnemonic for the cranial nerves, or the bones in the wrist, or the femoral triangle, or the major branches of the aorta? Continue reading

Pre-Med Stress Hits New Heights As MCAT Exam Changes Loom

By Alvin Tran
Guest Contributor

Becoming a doctor was never easy. There’s stress, there’s no sleep, there’s life and death. But now, that already tough career path will get even more complicated with the introduction of a new, far longer version of the Medical College Admission Test, aka, the MCAT.

Just ask pre-med Charles Denby, who panicked when he recently went online to sign up for the test and found all the sites in the U.S. were booked into January 2015. Why is that a problem? Well, that’s when the old, familiar four-hour MCAT takes a short hiatus and then morphs into a newfangled, nearly seven-hour version of the test that most students must take in order to get into medical school.

(Marquette University/Flickr)

(Marquette University/Flickr)

Denby, a 36-year-old consultant who is now pursuing a medical career, was not amused by the prospect of facing the new test. It’s “a curveball I wasn’t expecting,” he said in an interview from his home in Providence. Denby is hoping someone local will opt out of taking the test at the last minute so he can get a spot, though he briefly considered getting on a plane to avoid the new exam. “Germany and Israel are available for January right now,” he said.

Germany? Israel? Isn’t the MCAT stressful enough without getting on a plane and switching time zones?

Barbara Moran, a pre-med student in Brookline, who recently completed Kaplan’s MCAT prep class, was stunned to hear that her classmates were planning to travel to Indiana and South Dakota to take the exam. Moran, who took the exam Oct. 21, had reserved her seat in Boston months ago. “I suddenly realized I was sitting on the hottest ticket in town,” said Moran. “It was like having a seat to a Red Sox World Series game.”

The soon-to-be-extinct four-hour exam now tests students’ knowledge of chemistry, physics, biology, organic chemistry and verbal reasoning; and also their nerves, as they watch the clock tick down while struggling to recall obscure equations. Now they’ll have to endure that anxiety even longer: the new test is nearly seven grueling hours long.

The Association of American Medical Colleges (AAMC), which administers the MCAT, approved changes to the test in 2012.

One of the most significant changes is the inclusion of the new section that tests students’ understanding of the socio-contextual determinants of health — essentially asking students to think beyond the specifics of the patient’s body, and consider how income and social status, education, home and work environments and other factors shape health outcomes. Continue reading

Even At Mass. General, Medical Training On Addiction Deemed Lousy

Massachusetts General Hospital is one of the highest paid in the state. (Steven Senne/AP)

Massachusetts General Hospital. (Steven Senne/AP)

Even at the lofty institution that bears the nickname Man’s Greatest Hospital, most medical residents think they’re not taught well enough about addiction and substance abuse, a 2012 survey found.

The hospital itself, Massachusetts General Hospital, sent over word of the study today, and says it has since increased addiction training for medical residents, who estimate that one-quarter of the inpatients they see have a substance abuse problem. From its press release:

BOSTON – A 2012 survey of internal medicine residents at Massachusetts General Hospital (MGH) – one of the nation’s leading teaching hospitals – found that more than half rated the training they had received in addiction and other substance use disorders as fair or poor.

Significant numbers felt unprepared to diagnose or treat such disorders, results similar to surveys of practicing physicians. In response to the findings, published online in the journal Substance Abuse, the MGH has increased residents’ training in addiction medicine.

“Our residents estimated that one in four hospital inpatients has a substance use disorder, which matches what other studies have found and represents a disease prevalence similar to that of diabetes,” says Sarah Wakeman, MD, chief medical resident at MGH and lead author of the report. “Finding that the majority of residents feel unprepared to treat addiction and rate the quality of their education so low represents a tremendous disparity between the burden of disease and the success of our current model of training.”

The study’s authors note that residents provide most direct medical care in teaching hospitals and often find caring for patients with addictions to be troublesome – possibly due to a lack of training and faculty role models – which can lead to a lack of trust between patients and physicians. Continue reading

Latest Data: Average Med School Grad Owes Over $166K

Know a virtuous young person who wants to become a doctor for all the right reasons? Think their soaring idealism might need a bit of ballast from financial reality? Here it is: The latest figures on medical school debt, just out today from the Association of American Medical Colleges.

The mean debt load for students from all medical schools is $166,750, up 3 percent from last year, and the median is $170,000, up 5 percent from last year. And it doesn’t much help if you go to a public medical school — the mean debt is about $156,000, compared to nearly $184,000 for a private school.

Depending on your repayment schedule, the new AAMC data show, your total repayment after graduating could total as much as $476,000. And we wonder why health care is so expensive in this country? Doctors’ salaries are of course only one element of our high price tags, but it’s an element that sets us apart from Europe, where medical education tends to be lower-cost or free. reported recently here:

Meanwhile, tuition rates continue to increase dramatically. The median cost of attending a private allopathic medical school has grown at 1.8 times the rate of inflation during the last 13 years. At public schools, it has grown more than twice the rate of inflation, the AAMC said.

Public medical schools have been particularly hard hit, as states have reduced funding in a poor economy.

Readers, what is to be done? See the full AAMC data below. One interesting note: 30% of graduates plan to enter loan forgiveness or repayment programs: Continue reading

What Med Students Learn From Sticking With Their Patients

Altaf Saadi, a Harvard Medical School student doing an "integrated clerkship" at Cambridge Health Alliance

Medical school is an infamous time of maximal stress, as a student bounces quickly from specialty to specialty and patient to patient, building emotional calluses. In a fascinating interview just out in The Boston Globe about medicine’s tendency to “dehumanize” doctors, Dr. Omar Sultan Haque says, “Empathy decreases as you get more experience with patients. The nicest people you’ll ever find who are doctors are in the first two years of medical school.”

But what if it doesn’t have to be that way? At least, not all of it? A study just out in the journal Academic Medicine reports positive findings on a different model for the third year of medical school: Students follow their patients “longitudinally,” through all their treatments, even from hospital to home.

The study of third-year students in Harvard Medical School’s “integrated clerkship” at Cambridge Health Alliance found that they scored just as well as their peers on standardized tests, but they felt differently about their experience. They saw it “as more humanizing (even transformational) and less marginalizing than do their peers in more traditional clerkships. Strikingly, these strongly positive perceptions exist in the face of an experience that is described as both more hectic and more stressful than the traditional clerkship.”

Here, Altaf Saadi, a third-year Harvard medical student currently participating in the Cambridge Integrated Clerkship, describes what it’s like to have real time to spend with a patient who is going through cancer treatment and navigating the medical system.

By Altaf Saadi
Guest Contributor

This Monday, my internal medicine supervising physician and I saw Helen’s bald head for the first time. “Do you want to see it?” she asked. And, with our encouragement, she slowly removed her caramel-colored wig.

“You two are the first people to see my head like this.”

She was in her third cycle of Cytoxan and Taxol — two chemotherapy medications for treatment of her breast cancer — and she had lost her hair, among a dizzying number of other side effects she has experienced. So we sat there in the primary care clinic, weathering the initial influx of pain, bearing witness to her experience of cancer.

These are real fears patients have, fears that often do not get communicated when relationships are not established with patients.

Helen (not her real name) is one of nearly 500 patients I have seen as part of my third year at the Cambridge Health Alliance. I am one of ten students in this year’s Harvard Medical School-Cambridge Integrated Clerkship, an innovative model for third year medical education that centers learning on the experience of the patient. Traditionally, third year medical students complete discrete “block” rotations in core disciplines such as Internal Medicine, Pediatrics, Obstetrics, and Surgery. They rarely see patients more than once. As part of the Cambridge Integrated Clerkship, we instead spend time in all of the disciplines throughout the year by following “our” patients through those disciplines. Continue reading