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The preclinical years ruin med students

March 4, 2011

NY Times: 18 Stethoscopes, 1 Heart Murmur and Many Missed Connections

I read this article a few days ago and it has been eating away at my soul. The piece describes the author’s experience allowing second year med students to listen to her heart as part of their cardiology education. She discusses the varying degrees of the students’ engagement with her as they auscultate her chest. Some are cold and treat her almost as a prop, while others are warm and engage her, making her feel more like a person than an inanimate object.

This article has been eating away at my soul because I have not be able to stop thinking about what leads some students to be warm and engaging while others are cold and distant. Certainly personality traits play an important role. But part of the reason why medical schools interview candidates is to judge interpersonal skills–they want students who are naturally warm and engaging. Almost every single med student I know is, in fact, an affable person. Yet it doesn’t always come through in the exam room.

As part of my preclinical training (the first 2 years of med school) I have participated in numerous standardized patient encounters. In these scenarios, med students go into an exam room and interview a “patient” (really an actor simulating a scripted condition), performing any pertinent physical exams or tests, just like a real exam. Afterwards, the med student goes back into room with the “patient” and receives feedback on how they did. A few times, my “patients” have told me that I could be more warm and engaging. I’ve always thought long and hard about this after these exercises. What was I focused on in the exam room that led me to not engage the patient better?

Invariably, the answer is I was focused too much on the medical problem I was trying to discern or explain to the patient. This largely stems from hours upon hours in the library studying complex conditions and their varying presentations. 99.9% of what med students are tested on in the first two years is knowledge of basic science and pathophysiology. Rarely are med students graded on the quality of their interactions with patients. This is mirrored in the curriculum. I would estimate that less than 5% of my time during my first two years has been spent on learning to interact with patients. As the NY Times article points out, many med schools have no patient interaction until their second or even third year.

This relentless pursuit of inculcating young medical minds with basic science knowledge early in their training impacts their interactions with patients down the road. This isn’t to say medical schools are beating the humanity out of their students. The warmth and compassion that brought us into the medical field are very much still there. But sometimes, since we all have a finite attention capacity, expressing such warmth may take a back seat to running through hundreds of newly learned medical conditions, trying to find one that fits.

Great doctors are not made in just two years. Undoubtedly, med students become better with patient interactions as they progress through their medical training and become more familiar with both the science and art of medicine. However, if we want to form good habits from the outset, the preclinical years should not just incorporate earlier patient interactions, but more patient interactions. The preclinical curriculum is packed and expanding with each new medical discovery; finding room for such training is not simple. But, if we expect med students to walk onto the wards in their third year with perfect bedside manner, we need to express that expectation by improving and expanding their clinical training in the preclinical years.

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