Preventing the Great Washout

Traditionally, the fourth year of medical school is often a “diastole” year: most of the required and time-intensive clerkships have been completed, students scatter to all corners of the country for away rotations, and the focus is less on grades and more on “Where am I going next?” For me, fourth year has not been much of a break. After an intense six-month marathon through Internal Medicine, Family Medicine, and Surgery, I then tackled my sub-internship on the Stroke Service in July (one of the busiest services in the hospital that ranges from the ED to the Neuro-ICU to the Med-Surg floors to the clinic), the USMLE Step 2 CK in August, three months of away rotations at Harvard hospitals, and then an epic cross-country interview season spanning four months. Last month, I returned to a “normal” 7-9 hour workday/5-6 days per week schedule collecting data from electronic and paper medical records for my research project. Finally, this month has given me a chance to breathe, reflect, and start building some tools for future learning, practice, and teaching based on the knowledge and wisdom I have collected over the past three and a half years of medical school.

Then again, this month could also mark the beginning of the great washout: this spring is the time when medical students start to rapidly lose all of the information they have crammed into their heads for three years. Most medical school teaching is structured to accommodate the same faulty principles of learning in college: it is heavily didactic and encourages students to cram and purge (after the test). Accordingly, a lot of medical students show up at the beginning of July at their hospitals with only the shadow of knowledge they had acquired in previous years. The knowledge is eventually unearthed and solidified with greater amounts of patient care experience, but this transition can be rough (in teaching hospitals with lots of supervision and redundant capacity, this is mostly rough on the learner, not the patient).

The utility of the Advanced Clinical Teaching course for me is very similar to that of the Psychology of Leadership course I took during my senior year of college: these courses provide me with the tools by which to improve my own performance and that of my team. By learning to teach more effectively and by developing “canned talks” on methods of understanding instead of pure detail, I am building a scaffold, a neural network, in my own brain within which to organize and sort the details of my past and future learning. When faced with daunting amounts of work and stress, it is easy to resort to lowest common denominators and instinctual (and often counterproductive or inefficient) methods. “Daunting amounts of work and stress” is a pretty good description for the next stage of my training: internship and residency. If nothing else, my prebuilt scaffold will facilitate better instinctive behavior: I can find the right answer, the right diagnosis, the right treatment faster and better than if I had no structure at all.

For better or worse, none of my ranked programs are “easy” programs, and I expect to work hard and work long hours in exchange for amazing learning experiences with excellent clinicians and teachers. I don’t expect to have the same sort of reading time I have had in medical school or the same amount of time to prepare presentations for my teams, so my methods of learning and teaching have to be honed to a sharp point before starting my internship.

I am very happy that I have developed what I believe is a good series of 15-minute wards/whiteboard based talks focusing on key topics in Neurology. These talks are designed both for medical students and interns who do not plan to pursue Neurology training as well as though who may be developing an interest in Neurology. The aim is to develop methods of understanding and provide an anchor for future self-directed learning, not deliver large amounts of detail. My current teaching portfolio currently includes:

• Introduction to Neurology
• Altered Mental Status (Differential Diagnosis/Initial Approach)
• Stroke (Recognizing the Signs/Stroke Mimics/Approach to Treatment and Management)
• Headaches (Differential Diagnosis)
• Increased ICP (Differential Diagnosis/Approach to Treatment and Management)
• Seizures (Differentiating Causes of Loss of Consciousness/Differentiating Causes of Transient Neurologic Deficits/Determining When to Treat)
• Spinal Cord Disorders (Differential Diagnosis)
• The Essential Neurologic Examination (for the Non-Neurologist)

Future topics in Neurology I hope to cover before intern year:
• Vertigo (Differential Diagnosis)
• Dementia
• Movement Disorders
• Multiple Sclerosis

I also hope to develop talks for major topics in Internal Medicine before intern year begins. If nothing else, I hope to have a foundation upon which I can rebuild what I have learned and rapidly incorporate new knowledge as new patients arrive at my door.

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1 comment
  1. Ben said:

    I always thought you’d make an awesome teacher, Lester. I’m really happy to hear that it’s happening and rewarding for you not just personally but also to prevent all that medical wisdom from bleeding out of your brain :).

    Also, did you seriously just call 4th year a “diastole”? We need to get you Starcraft II and fast… STAT!

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