Julia knows exactly the kind of doctor she will become

"Sorry, can't educate you about this Fragile X Syndrome your baby boy has, but I CAN talk to you about German health care reforms from 2003-2007."

Ladies and gentlemen, since you were aghast at the long silence on this blog, let me tell you what has been keeping our two class-clowns from their ranting: our med school’s obligatory course on health care structure, policy, and reform*.

Yes, this is a good idea at its core… after all, if we didn’t know anything about the organizations that will be paying us some day that would be pretty lame. However, this class is decidedly a scheduling bully—perhaps a little insecure about itself, and therefore going to make your life miserable to puff up it’s own sense of self-importance. Weekly quizzes requiring recall of minute details from the readings and lecture slides? Awesome. In-class “debate” group presentations, where the professor may-or-may-not call you a liar? Hmm… alright, I guess... Arbitrarily restrictive, two-page, double-spaced paper proposing 1-3 major health care reforms, while giving background and then providing objections to it? Ugh, just leave me alone already!

This class single-handedly managed to eat up more time weekly than musculoskeletal, genetics, and hematology combined!

So, while that pain in your shoulder causing you to be unable to raise your arm to shoulder-level may be very concerning… Can I interest you in a discussion on the pros-and-cons of a physician’s duty to follow public health mandates during a disaster?

David fails to understand honors (/pass/fail grading)

In the long months since Kevin's illuminating "year 2 is just year 1's uglier, more high-maintenance sister" entry, we have received countless e-mails with pressing questions and comments about the absence of irreverent med school insider-y wit filling the empty spaces in the lives of our devoted public. Here's a sampling of our fan mail:

Whyyyyyyyyyyyyyy???!!!!!
- Julia

I miss you guys so much it hurts sometimes.
- Jess

My one goal in life is to live long enough to see just one more post.
- John (the old one, not the stalker-y one)

Well, the posting drought ends now. RIP, John. (Oh, and Kevin has promised to write several more posts in the near future, though the quality may not rival 'year 2/year 1' brilliance.)

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Second year, in all of its we-survived-first-year-and-now-we’re-almost-to-third-year glory, has added a new wrinkle to our academic lives: the ‘H.’ Whereas our med school employed a strictly Pass-Fail system during year one, we now face the world-altering prospect of a 50% increase in the number of possible grades. And though popular wisdom places these grades well down the totem pole of importance in one’s residency application, most students are nonetheless interested in filling their transcripts with as many pre-clinical H’s as they can muster.

The logic behind second year grades seems pretty clear: after a transitional first year where mastery of basic concepts is most important, an H/P/F system gives students a chance to distinguish themselves as the material becomes more advanced/clinically relevant. It rewards those who make the extra effort to excel, and such sustained motivation can only have a positive influence on one’s ultimate clinical competence.

Grading systems are designed to both motivate students and, by definition, stratify them based on performance. Grades provide valuable feedback to students and also give administrators at the next step in the academic ladder an essential signal about student achievement. There’s a reason med schools don’t let pre-meds take their pre-reqs P/F; a P only indicates the student demonstrated the minimum competence required to complete the course. Student X may have excelled or almost failed, but no one can know for sure within a purely P/F system.

The major downside of the H/P system is that, though it provides more information than the P/F system, it falls short of a third choice with a full range of grades (akin to the GPA system in college or HS) for no real reason. If adding the H makes sense, why not just take the plunge to a 4.0 scale with the traditional complement of +/-‘s? The purpose of grading is to provide valuable information to all interested parties: to students about their performance, to teachers about how well the material is being learned, to residency administrators about the academic prowess of prospective applicants, etc. If information is the goal, what benefits are there to purposefully providing less information in an H/P/F-only system*? Here are a few I’ve heard, but for the most part, they don’t stack up to deeper review:

1) The H/P/F system is less stressful.

In our system, a final grade of 90% or above usually qualifies one for honors. There may be extra essays involved to reach the holy honors land, but there’s always a numerical cut-off that separates the two strata. Thus, grading is essentially an all-or-none exercise. There is really no major difference in mastery between someone who scores 90% and someone with an 89.1%, yet there’s a reasonable chasm in their ultimate grades. The person with the 90% is in rarified air. The sub-90 % kid is left with a grade that is indistinguishable from a 70% effort. Compare this to a system in which 89% is a B+ and the resultant grade-point differential of a question or two is far less consequential. Which one is more stressful?

2) The H/P/F system motivates students to excel.

Though this is true, it fails to acknowledge that a more traditional grading system incorporates the same educational incentives without dragging along a few major downsides. In a typical 4.0 system, a student who gets an 85% in every class collects a series of B’s that ends up numerically equivalent to a colleague who gets half A’s and half C’s. In the H/P/F system, the former is left with a dreaded P-fest (teehee) while the latter gets rewarded with 50% H’s. Yet who is really the better student? The person who does consistently well but never aces anything or the one who completely ignores half of his classes in order to honor the other half? There may be no clear answer, but it is intuitively obvious that the H/P/F system incentivizes just this sort of all-or-none effort. Grades can both motivate students toward better performance and lead them to utilize practical ways to game the system.

3) It doesn’t really matter; preclinical grades are of little importance and it’s what you learn that determines how you perform when it really counts (during Step 1 and on the wards).

Sure, those other things are more important predictors of matching success than the preclinical transcript, but that doesn’t mean the latter is insignificant. At our school, preclinical grades factor into the behind-closed-doors ranking system that determines whether or not we’re eligible for AOA, which almost everyone agrees is a meaningful distinction. And regardless of how much they ‘matter,’ we should still try to find the best way to dole ‘em out.

4) Stop ranting and go do something useful like studying.

OK fine, you win. But instead of studying, I’m going to figure out if there’s some sort of 15-15-1 equivalent to residency applications…

*It’s not even so much, or at all, about how high the ‘H’ threshold is – it’s actually a lot easier to honor any given class at our school relative to the stories I’ve heard from friends at other institutions – but rather about the utility of the H/P/F system itself.

Kevin realizes year 2 is just year 1's uglier, more high-maintenance sister

Finals are finally over and that's the conclusion I've reached.

Kevin may have accidentally ruined someone's future

For everyday our school has applicant interviews, they invite 3 current medical students to come speak during the lunch session and answer any questions the applicants might have. This is a mutually beneficial setup: the applicants get to ask questions they might not otherwise ask, and medical students get some free food. Robby and I were coming out of one of these sessions when we noticed one of the applicants had apparently left his personalized packet of information (necessary for his interview) on the table. I argued that he would likely remember and come back for his stuff, Robby – citing a popular Abe Lincoln tale - insisted we return the materials to the admissions office lest it be stolen by less than scrupulous villains. Since I’m always ready to random conduct acts of charity, I acquiesced. When we finally made our way to the admissions office, we happened to run into the same gaggle of applicants and as well as the admissions tour guide. I immediately handed the packet to the guide only to hear “Oh this applicant should be interviewing right next door to where we ate lunch.” Oops.

So this then dawns on me: this applicant probably stepped out to use the restroom, prepping for a hour of good ol' ethical grillin, only to come back to find his stuff gone. I conjecture this is what most likely happened afterwards...

Finding his prized information stolen could have very well ruined his mental focus and mojo, causing him to give terrible answers at the interview. This would inevitably lead to his rejection at our school, undoubtedly his first choice institution. Distraught at this recent failure, he becomes so dejected he withdraws his other applications, sells his belongings and moves into the mountains to rough it as a grizzly man. Either that or he ends up in dental school, not sure which one is worse.

Clearly no good deed goes on unpunished.

Julia presents a landmark case of PMS

We here at IDDx are always looking for ways to improve the quality of our content (see: Beef Stew). A few months ago we experimented with guest authors by publishing an article written by the now infamous Jess. However, the reviews were less than favorable, featuring comments such as “Oh god my eyes,” “I think I just threw up a little in my mouth” and the much feared: “You’ll be hearing from my lawyer.” One drawn out mental anguish lawsuit later, we have decided to venture into the realm of guest authorship once again, this time with a new, less Jess-y, author. Enjoy

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Okay, so PMS in the general population may not be that remarkable, but when a landmark case - such as I am about to relate to you - is encountered… well, is there not an intellectual duty to report it?

I was in the hospital cafeteria trying to grab some lunch in the small window of time between my visit to the gym and class. I grab some veggie burrito and head over to the cashier. I get into a line behind a woman who is already checking out and thank my lucky stars that I managed to avoid what is normally a long line and crush of people at lunchtime. Things are working out today. Huzzah!

Wrong.

While this woman is seemingly gathering up her plate and soda, the cashier has already rung me up. As I am handing over my cash, this woman turns and tries to walk through me, presumably to get a napkin or utensil or something. Instead of then going AROUND me the way a normal person might, suddenly I hear her bark at me “Uh, could you not put your dirty hand over my food?!” I am so shocked by this I simply say sorry, take my change and go.

Come to think of it, I don’t even think my hand WAS over her food. Perhaps it was in the airspace adjacent to the plate in question. But, to be fair, there is no way to prove that the microbes on my hand WEREN’T propelling themselves into the air and free diving into her mashed potatoes, so we can probably overlook this. Aren’t we always hearing about what a problem iatrogenic infections are around hospitals?

So I walk out of the cafeteria, prized burrito in hand, and begin to head back to class. However, I quickly realized that someone was on my heels, tailgating me. I turn my head to look over my shoulder et voila! It is the nasty lady herself. Is she done with me yet? Oh no, dear reader, she still has a little something snotty left.

“Oh great and why don’t you get your hair everywhere too?”

Excuse me? Now, what we had here was a definite pot-and-kettle situation. I have long curly hair that I was wearing down at that moment. However, she ALSO had long, dark curly hair that was down.

Think, Julia, think! “Um, could you try and not ruin my day as well?” Ok, not the wittiest thing I could probably have come back with, but honestly I was so shocked by this behavior coming from a total stranger… I mean REALLY.

Well at this point she just ignored my existence and stalked back towards her office. Touche, cranky-professional woman. Until we meet again... one month from now.

Kevin falls, David watches

As many of you know, the second year of medical school is traditionally far harder than the first. We’re preparing for the USMLE Step 1, whose effect on our ultimate career opportunities makes the MCAT look like a third grade math quiz, juggling more clinical responsibilities, and incorporating significantly more pathological correlates into the basic science curriculum. To top it all off, the Candyland-like existence of Pass-Fail grading from first year has been replaced by the cruel Sorry-esque wasteland of the Honors-Pass-Fail system (stay tuned for more H/P/F musings from me soon).

This added pressure forces most people to adjust their study habits. Many students work harder, longer, or find methods to increase their academic efficiency. I’ve adapted by preparing myself for the inevitable career switch to some sort of trade school. Kevin, unfortunately, has fallen prey to a far more sinister path…

Recently during lecture, one of our professors relayed a humorous anecdote about his freshman year of college. In preparation for an exam, he had taken an ill-advised number of caffeine pills to gear up for an all-night learning extravaganza. Tears, as is often the case when anyone labels anything an “extravaganza,” were around the immediate corner; he was jittery, unable to study, and couldn’t even hold a pen in his hand when he entered the test completely sleep-deprived the next morning. Most people would react to such a story by learning a valuable lesson about using caffeine in moderation. Kevin? Not so much.

I’ll let him describe his thought process:

"Hmm...the professor is saying something, maybe I should listen. I like words! Caffeine pills to study for a test? That sounds like a good idea. Let me do a cost-benefit analysis. I'm already spending quite a few dollars buying coffee day in and day out. Why not switch to the pill form? After all, it’s considerably cheaper and more convenient, with the only difference being the stigma attached to taking a pill. I'll pick up a small bottle of No Doz over the weekend and use it as necessary. And, in other news relevant to this particular internal monologue, I’ve reached the obvious conclusion that David is far superior to me in many ways. I’ve come to view him as something of a demigod amongst the mere mortals that populate this particular institution. Self, let me enumerate the ways in which he brightens the world. Number one…"

Ok, so I may have fabricated some, or all, of the preceding stream of consciousness. Yet after Kevin brain-birthed the severe preemie that was this particular idea, I bore witness to the ebbs and flows of his No Doz-fueled journey. Here’s a running timeline of my observations:

Monday

1pm: Kevin is visibly tired. He’s nodding off a bit in class and mentions that he had to wake up extremely early to prepare for a lab meeting. His week is off to a good start.

2pm: Kevin puts his plan into action, taking one No Doz and washing it down with a Coke.

3pm: Kevin is taking notes like a madman. Holy crap, he’s a learning machine. How much knowledge can one man accumulate? Maybe he’ll remember me when he’s President of Medicine…

11pm: Kevin is online, working on an abstract he needs to submit for his research project. He indicates that it’s going to be a really long night. Good thing he had that No Doz earlier.

Tuesday

1pm: Kevin was up all night working on the abstract and only got a few hours of sleep. The solution? You guessed it - No Doz II: Son of No Doz. And he’s off to that rarified air of godly productivity most people can hardly fathom…

Midnight: Kevin is online. He has to get up early tomorrow yet again, but hasn’t been able to fall asleep.

Kevin: Ohhh noooo…I think I’ve made a terrible mistake.

Wednesday

12:30pm: Kevin, apparently unaware of the causal relationship between No Doz and his deteriorating QoL, stumbles into class on the strength of sheer willpower and an early-morning No Doz.

Kevin: I think I should’ve paid attention when they talked to us about D.A.R.E. in 5th grade.
David: I’m pretty sure we saw your story on a PSA. Except your name was Johnny…and then you died.
Kevin: …
Kevin: …
Kevin: …
David: If you develop an arrhythmia, can I listen?

2pm: Kevin is struggling. His head is on the desk. Hm…what should I do? Send him my notes? Try to wake him up? Or I could just poke him. Yeah, I’ll just poke him.

Julia: Uh, is Kevin OK? Maybe you should po-

David: Already on it.

2:30pm:

David: Are you OK?
Kevin: I need to leave class to go take a nap.
David: So this is how it ends, huh?
Kevin: It’s been a good run.
David: RIP, good sir.

5:30pm:

Kevin: I'm going home to sleep. Sooo tirrred.
David: Why is your eye twitching?
Kevin: Maybe this wasn't such a good idea.

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Luckily, after a few nights of rest, Kevin was back to normal by the following week. His No Doz days are now behind him. He’s a little bit older, a little bit wiser, and ultimately not much worse for the wear. Plus, I’ve inherited some No Doz…

Comic: Ideal vs. Reality - Anesthesiology

Perhaps I have these two cases flipped.