Posted by: oldmedicine | January 18, 2010

Thoughts on what constitutes a “good” medical school

I frequently see this on SDN, and talked about over coffee or beer by pre-med’s contemplating life:

US MD > DO >>>>>>>>>>>>>>>>>>>>>> US FMG (Caribbean).

Hmm, I like the use of math, but at the same time I must ask, what is the basis of this assertion?  Is there any data to back up the 23 greater-than operators between DO school and Caribbean, or at the same time, only one between US MD and DO?  Not really, because it is just an assumption, based on the group mind of SDN.  There are better sources of information out there if you do a little research.

At the same time, many will say that the best med school is “one you get into.”  I would tend to agree with this, if I hadn’t spent some time seeing various med schools and talking to people who have attended them (real life people – not anonymous online avatars).

The fact is, people who ascribe to these views are looking long term – in the pre med world this means looking at match lists. Match lists are recruiting tools that some med schools choose to use to get people to come to their school.  The match, as you may know, is when 4th year medical students are chosen, or more importantly, choose, to attend a certain residency.  The interesting thing about the med school match is that the program also chooses, and a computer then matches what the students want with what the programs want, and voila! students fill our nations federally funded post graduate medical education positions.

The problem with looking at match lists is that they are just that – a list.  The is no other information included, just a list of specialties and locations where people are going – no names, no numbers, nothing.  If the grade point average and board scores (USMLE or COMLEX) were listed, along with some information about the competitiveness of the program, then they would be helpful – but without they are just a way for a school to brag that they sent a certain number of people into specialties that the pre med world considers “competitive” – like orthopedics, Neurosurgery, ophthalmology, Radiology, Dermatology, and maybe Anesthesia.

Because we have no information about what the individual student actually wanted to do, and what his or her grades were, this list means nothing.  For example, a student could have been a top performer in medical school, and chosen to do a fairly non-competitive specialty like family medicine or pathology… just because they like it.  Also, because residency programs are so widely divergent, it is impossible to know if  these programs are actually any good – because JUST LIKE CHOSING A MED SCHOOL – it is hard to judge the quality of a residency program without meeting the people who run it and attend it, what kind of patient population they have, and what kind of practices the graduates of these programs go into.  So, to further my earlier example, we could see a student who has poor grades go into a neurosurgery program at a weak community (non-academic) program that doesn’t see a lot of crazy pathology, has a reputation for malignancy in the ranks, and doesn’t have a good record of job placement after graduation.  This line on the match sheet would, however, impress the young (or old) pre med, even though it isn’t actually that impressive and at the worst, might be purposefully misleading.

If anyone ever starts to read this blog, you will hear me say this again and again: visit the schools you plan on attending, and talk with the administration, students, and professors. Buy the Medical School Admissions Requirements (MSAR – linked on the right side of this page) and glory in its wealth of non-subjective data. Using faux-data like match lists and even board passing rates to judge schools, both positively and negatively, is a mistake.  At the same time, using sources like US News and World report to judge a school is also a mistake.  The major contributory factor to US News rankings is the amount of NIH dollars that the school receives to conduct bio medical research.  Yes, they now include a “primary care” ranking – but this is a relatively subjective survey ranking that is multiplied or divided or squared by how many graduates they have going into primary care.  Another problem with US News – an increasing amount of schools don’t participate, so the rankings really don’t mean shit.  I will make a bet with you – Harvard, Washington U of St. Louis, UC San Francisco, Johns Hopkins, and Duke will be in the top 5 to 10 schools every year. This never changes, to the point where no one even cares anymore.  Let the MBA schools and Law schools compete for rankings – no one cares about med school rankings.

But what is the reason that no one cares about med school rankings?  And why shouldn’t you care about med school rankings?  Because to a large measure, in the end, everyone gets the same job and all get to suffer as an intern and a resident. A top ranked law school will get you a substantially better job than a lowly ranked one, but both a top ranked and lower ranked med school will both get you a low paying, horrible job being an intern.  Your grades and board scores are going to decide both what specialty and where this shitty job is located, with the rank of your medical school meaning little, if anything.  This or course, concludes my proof on match lists – they are a display of the hard work of individual students, and while this may reflect well on the med school tangentially, in the end there are too many variables to even begin to calculate if a prospective med school had anything to do with the shininess of its match list.

That was a long rant, so what does constitute a good medical school?

Medicine is a profession of reason.  In order to reason, you must be able to observe, then analyze using background knowledge, come to a conclusion or decision, and finally act to resolve.  Integrate this into medical education and a few things become obvious.

First, you must attend a school which gives you a great deal of scientific and medical information – both historical and current, so that when you observe and analyze a problem, you are able to correctly identify what you are seeing.  Second, the medical school must give you enough experience and practice so that when you act, you do so properly with respect to both science and the amalgamation of all medical knowledge collected by doctors and researchers up to this, or any future, point.

All medical schools do a reasonably good job of giving you scientific and medical information. The LCME ensures this by both controlling accreditation and the board exams that students must pass to continue the education.  However, I do not believe that all medical school are equal when it comes to giving students experience – the key to integrating that information into actual practice.

Honestly, this was one of the major issues I had with the DO schools that I visited, and is assuredly an issue with foreign schools in the Caribbean.  Since most DO schools (basically all, with the exception of PCOM) are not integrated into a hospital system, the student can end up in settings where there is no actual teaching environment.  Caribbean schools send their students, almost exclusively, to overcrowded clinical sites in New York City and metro New Jersey.  I would take a very long look at the clinical training that a school gives you before deciding to attend, especially the accountability of the clinical sites and their program directors to the schools to deliver a good education.

This is also an issue with some MD schools – especially newer schools and those not established with a major medical center.  Tread carefully and ask hard questions.

Another issue – people often act like getting into any school is fine because all that you need to become a doctor is to pass the USMLE medical board exams.  Well, if this is true, why don’t we just say screw it and offer an online course that concludes with the boards, followed by setting up shadowing with a few local doctors? I’m sure someone is thinking about doing this… probably for profit and in an island south of Florida.

You need to be in an academic environment, on the cutting edge of science.  Being involved in some sort of research, or at least being exposed to it, is an important part of becoming a physician.  Remember my point about knowing the current and past of medicine? Well, you should also be cognizant of where the future can lead.  This doesn’t mean you have to do research, but being exposed to instructors who have the resources to be on the cutting edge of science is, in my opinion, very important.  Doctors need to be active in pushing the profession forward, and having relationships with people who are doing this is very important.  If you aren’t going to be active in research, then you must at least have a respect for it and have enough understanding of it to integrate it into your practice.  Again, this is where a couple of MD schools, probably a majority of  DO schools,  and all of the Caribbean schools fall short.

The final issue I want to talk about is cost.  As an older person, hopefully you have respect for what debt can do to your life.  Just saying, “Oh well, I have $250,000 dollars of debt” gets exponentially more irresponsible the older you are and the more people you have to support.  I think that people understand this, and this is why oftentimes people will select a state supported medical school over a private one that they might think is better.  I will talk about financial matters more in a later post.

This whole issue is just a bunch of personal choices.  If you just want to expediently get yourself towards a medical degree, without regards to cost, then there are many options – all of which are decent, including Caribbean schools.  Medical education is a balance of course work, clinical experience, and research – and all schools have their own formula for achievement.  I hope my personal belief is somewhat well detailed above, but I encourage you to make your own.

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