Becoming a Physician_ a Differentiation Diagnosis - Specialization and the Medical Student

8/3/2019 Becoming a Physician_ a Differentiation Diagnosis - Specialization and the Medical Student

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n engl j med 365;5 nejm.org august 4, 2011

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A Differentiation Diagnosis

BECOMING A PHYSICIAN

A Differentiation Diagnosis — Specializationand the Medical StudentRena Xu, A.B.

If you walk through my medicalschool building in the evening

and follow the aroma of pizza, you’ll probably find your way to adinner talk organized by a student specialty interest group. Runningthe gamut from surgery to psy-chiatry, these groups are madeup of first- and second-year med-ical students, many of whom joined just weeks after they first donned their white coats.

Although the pizza toppings vary, the discussion topics rarely do: What are the most or least rewarding aspects of the special-ty? How is the field changing?What does a typical day comprise?And the unspoken question driv-ing students to these dinners: Isthis the specialty for me?

I arrived at medical school opento many possible paths, loath torule options in or out until I’dhad clinical exposure. Medicalschool, I reasoned, would be theappropriate forum in which toshape a preference based on evi-dence and experience, rather thanhearsay.

Soon, however, I began to ques-tion the wisdom of staying “un-differentiated.” Many first-yearsalready seemed to be singling out subspecialty interests. Classmates

began skipping lectures to shadow physicians, finding mentors tostart clinical research projects.The aspiring surgeons took turnscarrying a pager that notifiedthem of opportunities to scrubinto surgeries at nearby hospitals.

There was apparently a senseof urgency to begin the differen-tiation process, to start investingmeaningfully in a particular area.Suspecting that this was the self-imposed pressure of high achiev-ers, I asked a physician at ateaching hospital whether sheconsidered the rush rational. Sur-prisingly, she said yes — and en-couraged me to seek out researchopportunities relevant to residen-

cies that might interest me. “When you’re a first-year, you think youhave time to wait,” she said. “Youreally don’t.”

Practically speaking, she hada point. Many residency programsnow expect applicants to show evidence of substantive explora-tion in their field through re-search or clinical work. Accord-ing to the National Resident Matching Program, recommen-dation letters from physicians within the specialty are consid-

ered more frequently than any other selection criterion except scores on the U.S. Medical Licens-ing Examination. And with theapplicant pool growing fasterthan the number of residency spots, the pressure to gain a

competitive edge may be drivingstudents to differentiate earlier.1

Part of me recoiled at the no-tion of investing in a field simply because it was the competitivething to do. Yet I understood thelogic of residency programs’ rewarding depth of effort. Focusingone’s endeavors on a specific areaaffords the benefits of continu-ity. Over time, one can accumu-late relevant skills and knowledge,

tackle increasingly challenging is-sues, assume greater responsibil-ity, and develop meaningful pro-fessional relationships. It pays,then, to invest early and stay thecourse.

But this strategy presents adilemma. Although we’re encour-aged to form preferences early, we’re not equipped early to in-form those preferences. At most U.S. medical schools, third-yearclinical rotations represent thefirst opportunity to systematical-

ly explore various specialties. Inthe preclinical years, any careerexploration is done outside thecurriculum. We shadow willingphysicians on our own time, at-tempting to minimize conflicts with our class schedules.

The vast range of specialties and subspecialties

makes it easy to feel like a kid at an ice cream

shop trying to choose from among too many

unknown flavors.

The New England Journal of Medicine

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If the plethora of career inter-est groups is any indication, thistrend toward early differentiationspans U.S. medical schools. At the University of Pennsylvania, astudent-run surgical society hasestablished a program in which

preclinical students shadow fac-ulty surgeons. At Baylor College of Medicine, first- and second-yearstudents interested in obstetricscan attend weekend training ses-sions on delivering babies. At Stanford, an anesthesia interest group pairs students with physi-cian mentors and provides fund-ing for them to meet over lunchor coffee. The list goes on.

Even when the logistics work

out, however, the ad hoc natureof self-directed exploration makesit a poor substitute for institu-tional guidance: students priori-tize specialties for exploration onthe basis of incomplete informa-tion, often relying on preexistingbiases. The vast range of special-ties and subspecialties makes it easy to feel like a kid at an icecream shop trying to choosefrom among too many unknownflavors. If limited to samplingonly a few before deciding, onemay end up making an arbitrary choice.

This disconnect between deci-sion making and informationgathering has implications beyondindividual careers. In debates overfixing primary care, a key prob-lem cited has been the talent drain: the number of medical

students choosing general medi-cine has dropped steadily for years.2 Less prestige than in oth-er medical fields, a less accom-modating lifestyle, and poorer fi-nancial compensation are thought to contribute to this trend.

An alternative explanation

points to the decision-making sys-tem itself: the pressure we feel todifferentiate may skew our choicestoward specialization. Many stu-dents perceive primary care as adefault path, characterized by theabsence of differentiation into

anything else. Perhaps as a re-sult, general medicine doesn’t in-spire the same urgency to “invest early”; it’s rare, for example, tosee a classmate skip lecture toshadow an internist.

This situation seems unfortu-nate. Evidence suggests that gen-eral medicine would gain fromearly exposure: one study showedthat medical students who com-pleted general medicine precep-

torships in their first year weremore likely to choose internalmedicine residencies.3 Conversely,internal medicine subinternshipscompleted in the third or fourth year often don’t significantly af-fect career choice4 — so timingcan be critical.

Recognizing the need for early career guidance, some schools aretrying to improve their advisingcapacities. Their proposed solu-tions, however, are classroom- orconversation-based rather thanclinical. A career-development pro-gram at the University of Michi-gan, structured after a modeloutlined by the Association of American Medical Colleges, offerspreclinical students peer mentor-ing and extracurricular luncheonsessions.5 Students are not as-signed faculty advisors until their

third year; even then, the advis-ing focuses on residency applica-tions rather than familiarization with different specialties. Otherproposed models include career-development courses and profes-sional faculty advising teams.1

But students can learn much

more by experiencing variousfields for themselves. A more ef-fective approach might be to intro-duce into the first- and second- year curriculum a standardizedshadowing schedule, whereby stu-dents rotate through myriad clin-

ical settings. This would allow students to begin formulating in-formed preferences about thebroad categories of career paths.

Some might question the use-fulness of shadowing, since shad-owing students generally don’t participate in the action. But muchof what is gained from being in aclinical environment comes fromobservation. By following physi-cians through their daily activi-

ties, students experience the paceof the work, see how teams func-tion, and develop a sense of thedifferent medical challenges facedby different specialties.

As a supplementary approach,classroom-based instruction onreal clinical cases could help in-troduce various subspecialties. At many schools, courses such asgross anatomy and pathophysiol-ogy are already taught partly by acase-based method. Yet teachingcases often bear limited resem-blance to real life. One possibility for bridging this gap is weekly “specialty rounds,” modeled aftergrand rounds and taught by prac-ticing physicians. These would ex-pose students to common patient presentations in various fieldsand to practitioners’ approachesto treatment.

Shadowing and clinical casestudies are neither novel conceptsnor solutions in themselves. They are, however, potentially power-ful vehicles for implementing thesolution: a breadth of clinical ex-posure early in medical school.Students’ self-guided, sporadic ex-







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plorations aren’t always conduciveto formulating sound judgments.Curricular changes could help ad-dress this problem.

In the first week of medicalschool, a professor gave my class this advice: don’t pretend

to know more than you do. She was reminding us to be honest with patients that we were not yet doctors. But I remember her words whenever I smell the piz-za luring me to another dinnertalk. In choosing a career path,I don’t want to pretend to know more than I do. Dinner talks

can reveal only so much. I be-lieve we need broad, systematicclinical exposure early in ourtraining — when we are most eager, most ignorant, and there-fore most in need of guidance.

Disclosure forms provided by the author

are available with the full text of this arti-

cle at NEJM.org.

From Harvard Medical School, Boston.

1. Navarro AM, Taylor AD, Pokorny AP.

Three innovative curricula for addressing

medical students’ career development.

Acad Med 2011;86:72-6.

2. Pugno PA, McGaha AL, Schmittling GT,

DeVilbiss Bieck AD, Crosley PW, Oster-

gaard DJ. Results of the 2010 national resi-

dent matching program: family medicine.

Fam Med 2010;42:552-61.

3. Elnicki DM, Halbritter KA, Antonelli MA,

Linger B. Educational and career outcomes

of an internal medicine preceptorship for

first-year medical students. J Gen Intern

Med 1999;14:341-6.

4. Kogan JR, Shea JA, O’Grady E, Bellini LM,

Ciminiello F. The impact of the internal med-

icine sub-internship on medical student ca-

reer choice. J Gen Intern Med 2010;25:403-7.

5. Zink BJ, Hammoud MM, Middleton E,

Moroney D, Schigelone A. A comprehensive

medical student career development pro-

gram improves medical student satisfaction

with career planning. Teach Learn Med

2007;19:55-60.Copyright © 2011 Massachusetts Medical Society.

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Becoming a Physician_ a Differentiation Diagnosis - Specialization and the Medical Student