A defining moment
As I struggle to dig my car out from another New Hampshire snowstorm, I dream of skiing—my solution to surviving winters at Dartmouth. Through skiing I have become well acquainted with the many forms snow can take: from winter powder to spring corn, from corduroy to boilerplate. Most people might have no need to distinguish between the varieties of snow. They need only to refer to a homogeneous, inconvenient, and hopefully infrequent collection of ice crystals falling from the sky. But to skiers, snow is too imprecise a term to be useful.
A new name or definition can allow us to see nuances that had before gone unnoticed, and as part of Geisel's curriculum reform task force, I have been thinking about another term: medical student. I've concluded that we in medicine need to consider whether this term is too broad to cover the differences in experience and knowledge between students at different points in their education.
To many physicians, a medical student is someone in the midst of a homogeneous four-year experience spent occupying the library, with occasional vacations to lectures, exams, and clinics. They might not need different words to refer to medical students, just as for most people there is no need to distinguish between types of snow. But to medical educators, medical students are as homogeneous as snow is to skiers.
I am now in the fourth year of being referred to as a medical student, a journey that began in my first year with the "On Doctoring" course. First I shadowed a primary-care physician at Dartmouth-Hitchcock Keene. Then I stuttered my way through taking a history. Next I stumbled through a physical exam. Even by the end of my second year I would not have described my interactions with patients as "smooth." Yet after my third-year clerkships I could sail through taking a history and performing a physical exam. During a sub-internship at Brigham and Women's Hospital in Boston, nurses would seek me out to sign orders, mistaking me for an intern. My progress was in large part the result of medical educators who provided me with opportunities for growth by allowing me to take on responsibility commensurate with my increasing skill and knowledge.
Still, I have been told throughout my time in medical school that I can't do this or that—that I'm "just" a medical student. I could have protested. Instead, I kept working, striving to be more than a passive learner and refusing to wait for real responsibility to be granted when I graduate in June and, along with my classmates, suddenly switch from medical student to medical doctor.
A new name or definition can allow us to see nuances that had before gone unnoticed.
As we reimagine medical education, we must redefine what it means to be a medical student to allow for graduated responsibility based on learning new skills and increasing knowledge. Curriculum reform is sweeping through many medical schools, and some are seizing the opportunity to redefine what it means to be a medical student. One school's redefinition caught my eye. At orientation, incoming students are trained as certified medical assistants. First-year medical students are now defined as medical assistants. This redefinition does provide responsibility based on certified knowledge and skill. But medical students are as similar to medical assistants as they are to nursing students or to social work students—or as winter powder is to spring corn. Each member of the health-care team has an important and unique role to play in patient care. Training medical students to perform each role on the health-care team is neither an efficient use of resources nor an effective way to produce doctors. We in medicine must take on the responsibility of defining first-year medical student within the larger definition of medical doctor, rather than borrowing definitions from other members of the health-care team.
Redefining what it means to be a medical student can benefit the medical centers where students are trained. In any health-care system, value is derived from delivering high-quality patient care at a low cost. If we sideline caregivers with the knowledge and skills to contribute to patient care, we reduce our quality and increase our costs.
Currently, our educational system is structured to value all medical students the same. But naming and defining the different roles that medical students play will allow us to value their contributions and allow the students to value themselves. Giving students a chance to feel valuable is an essential component of medical student wellness, an issue that many medical schools are now trying to address. Some programs are trying to make students happier and healthier by providing more padding to the medical school experience: more padding on the comfortable chairs in the library, more padding to final exam grades, more padding on either side of a hospital shift. All this padding can make a difference. But at best, it can only keep students from hating medical school. It cannot entice students to love their work.
Naming and defining the roles that medical students play can help change students from passive learners to active participants in the kind of work that will make students love the experience of medical school. Our health-care systems and our educational systems will become stronger when students become partners in the meaningful work we all share, the work that drew us all to medicine: caring for patients.
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