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Excerpt from Chapter 1 A Med Student's First Year Let's say you make it through your premed coursework, do well on the MCATs, and actually get into medical school. What happens next? Rachel Sobel was a young medical writer when she decided that the world she'd been covering as a journalist was something she wanted to experience firsthand. She'd majored in the history of science at Harvard and finished her premed coursework shortly after college. In 2002 she enrolled at the University of California, San Francisco School of Medicine (UCSF). "The process of becoming a physician is exhilarating," she said. "You will learn more about yourself and the world around you than you ever have." When she started school, Sobel also chronicled her experiences as a new med student. Here's her report from the front lines.
Meet Mr. Danovic Sirens were blaring when the paramedics wheeled in John Danovic. The twenty-nine-year-old motorcyclist, who had just been laid off from his trucking job, had been drinking. He got hit by a car and thrown from his bike. Blood oozed from wounds in his scalp and chest, and a broken bone was jutting out of one arm.
The scene could have come straight out of any ER, but the case of John Danovic unfolded before my eyes in a lecture hall, not a hospital. The "blood"was actually a viscous burgundy concoction, and the team of doctors and nurses attending to the actor playing Mr. Danovic were my professors. Welcome to my first lecture at medical school.
Med school isn't famous for its drama, nor is it known for its openness to change. Yet as the Mr. Danovic lecture reveals, change is afoot. Indeed, there is something of a revolution underway, transformingthe first years of medical education. Many schools are dramatically revamping their curricula to prepare future physicians for an increasingly fragmented health care system in which any body of biomedical knowledge is bound to be quickly outdated.
Medical education has been virtually unchanged since the early twentieth century, when educators first standardized training. The "2+2" curriculum devoted the first two years to basic science lectures and the last two years to hospital training. Most med schools still use that general framework, but at UCSF and several other places, the first two years would be unrecognizable to a physician who graduated even five years ago. Forget lectures from 8 a.m. until 5 p.m.
Professors here have trimmed away esoteric hard science, keeping only what's essential to patient care. The reasoning is that you don't have to be a biochemist to be a skillful internist. In place of all that lab time, new disciplines are now considered essential to medical training, such as psychology, ethics, and even anthropology. For example, a patient assaulted by a gang (a real victim, unlike Mr. Danovic) talked to us about the psychological dimensions of healing.
David Irby, vice dean of education at UCSF, told me that the school's overhaul was driven in part by studies saying that newly minted M.D.s were unprepared to navigate today's health care system.
There was also a widespread sense that medical school, rather than being an inspiring experience, had become a deadening one. Why did education have to be a boring exercise in memorization?
Mr. Danovic's case teaches that it can be otherwise. From him we learned the proper way to insert a chest tube (over the rib so you don't hit the nerves or vessels) and to recognize the signs of shock. Making the material more clinically relevant is not only more compelling but also more practical: According to Irby, study after study suggests that human memory is better wired for narrative than for rote learning.
Another major change taking place in medical training is an increased emphasis on cooperation, which grew out of the frequent observation that new doctors had great difficulty working in teams. You can imagine twenty- and thirty-somethings scoffing at the nursery school notion of cooperative learning, but in fact it's instilled so subtly that it's the way we're learning to think about how medicine works. Grades are pass/fail, which discourages competition. Half our classes take place in small groups, where the only way to learn is from one another. Picture a class where everyone doffs their shirts (women wear sports bras) and students draw on each other with Mr. Sketch markers to learn the complex intertwining of nerves, arteries, and veins of the arm. Being halfnaked with classmates in "surface anatomy" isn't exactly a breeding ground for cutthroat rivalry.
Speaking of anatomy, I know my Uncle Peter will ask me over winter break how it went. Before I left for California, he regaled me with tales from his own medical school days-and reminded me to get there early for anatomy to get the best cadaver. I'm bracing for the next "In my day..." speech. But at UCSF, we learn from already dissected cadavers, and there is no competition to get the best one. Instead of spending hours trying to dig out, say, the renal artery, the idea is to save time and learn first from an intact specimen. To be sure, students still do a lot of memorizing. (For the eight wrist bones, remember: Some Lovers Try Positions That They Can't Handle: scaphoid, lunate, triquetrum, pisiform....You get the idea.) And budding surgeons can take a dissection elective, on, say, the abdomen or the pelvis. No one knows if this new approach will prove better than the old one. Other schools that have made similar switches admit to growing pains.
The ultimate measure is whether this generation of M.D.s will be better doctors in the modern health care system. On that, we'll have to wait to hear from the real Mr. Danovic.