What Do They Teach in Medical School Nowadays? -- Ruminations of a Curmudgeon by Michael Heller, MD
Sunday, April 25, 2010 
Michael Heller, MDCall me old-fashioned but I think any intern-meaning any medical school graduate- should know a few basic things.
Thing One: Basic x-ray reading.
Plain films have 4 basic densities( air, water, fat, calcium). When I point this out to my first (or second or third) years’ they look at me with a blank stare and profess that they have never heard of this concept. When we look at a chest x-ray where the heart border is obscured, the smart ones will offer the suggestion that maybe it’s a left middle lobe pneumonia. When reminded that there is no left middle lobe, the very best will remember the word “lingual.” I ask them about the silhouette sign (that’s the thing that says 2 structures of the same density will obscure the border if adjacent to each other) they make clear that they have never heard of this exotic theorem. They do not know what “KUB” stands for (kidneys, ureter, bladder), which is OK and they do not know how this is different from a “flat plate and upright” which is not OK.
Forget about “PA” versus “AP”. The word “lordotic” may as well be Greek (it refers to a chest x-ray taken on an upward angle so that the clavicles are moved out of the lung apices) and though they have heard of the phrase “oblique” (rhymes with meek), they do not know that it is the same view as “oblique” (rhymes with Mike). “Waters view?” They think it’s about the bladder and “Scotty dog” only brings forth allusions to a pet they had in childhood. Eighty –six percent of them will accept the validity of “Throckmorton’s sign” if I define it slowly and with a straight face (“the penis points to the side of the pathology”) but after all, it is correct 50% of the time -- but invalid in a patient with Peyronie’s disease.
Thing Two: Antibiotic illiteracy.
The second most common apologetic phrase I hear is, “ I’m not good at antibiotics.”*. This is like calling a plumber for a clogged toilet who then says, “I’m not good at bathrooms.” There are basically 4 types of antibiotics for anaerobes ( Flagyl, Clinda, penicillin-type drugs and Cefoxitin) and only one antibiotic (Vancomycin) we use for serious infections likely due to MRSA (which is to say, every skin and soft tissue infection and most bad non-urinary infections of any kind. ). Augmentin is never a sagacious choice, ever. The combination of Keflex and amoxicillin is always just as good, much cheaper and much, much less toxic. Neither gets MRSA, which is always a consideration. So stop using that drug. And start learning something about why you should be using gentamicin a lot more and also how to spell it. (There is no “y”.)
* The most common apologetic phrase is, “I’m not too good with EKGs”.
Reader Comments (36)
where did you learn that it was ok to make fun of med students like this?
very sad. poor poor residents at beth isreal. won't be applying there...
Medicine has changed in leaps and bounds since the time you attended medical school Dr. Heller. It is much easier to stay up to date with the specifics of your specialty (ie specific drugs, tests,etc). While medical school education has remained relatively the same at 4 years in length, there is much more information to be taught to the new doctors in this time frame. If your students and residents don't know something, I would think an educator would want to educate and not criticize them. After all, it is better to command respect then to demand it (ex. teach your art of antibiotic prescribing without the ranting of how you had it harder in residency and med students don't know even less these days). You just might find interns and residents lining up for rotations with you if your personality were less abrasive.
Gang,
In defense of the above blog (and with 17 years of faculty experience mirroring those noted above).
While I appreciate the two comments above regarding the sanctity of medical students and what is now viewed as a kinder and gentler approach to education, I think both F/U bloggers missed the point of Dr. Heller's blog.
Firstly, the title, with insight, announces that the blog is "ruminations of a curmudgeon", and second, the title directs the criticism at medical school education and its content (especially with regard to pragmatic information), not at medical students. Finally, the first line indicates that the critique involves interns NOT medical students. This is a key difference. Medical students are not yet responsible directly for patient care and are still paying tuition, residents (GY-1s who are "interns" if the term intern still applies) are paid employees responsible with attendings for patient care, and that responsibility should mean that pragmatic information be part of what an intern brings to the table.
Curmudgeons are abrasive, but their criticisms can be valuable. The intended audience is those who make med school curriculums that are devoid of pragmatic information needed by their students to do very basic bedside care as residents.
Billy
I agree with Billy and I do think the remarks were misinterpreted. It is perfectly ok to expect a resident in a busy ED to know how to read a basic xray -- although I do know which ones can actually do it and which ones to stay away from.
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