The Best Advice I Got In Medical School

It has been a long time but when you get to be an old man you can obsess about what you currently know, what you used to know, and how you got here.  I got some life-changing advice as an undergrad but not much good advice in medical school or residency. I can say without a doubt, the best advice I got was:

“If you are sure you are going into psychiatry, take as many medical electives as you can. Don’t take any psychiatry electives because you will be doing that for the rest of your life.”

I did not have to think too much about it because I enjoyed most aspects of medical education and training. The only two negative rotations I had in my training were based primarily on the staffing patterns at the time and they were not major medical or surgical rotations. They also did not seem to be very interesting. Practically all of the medical and surgical residents I worked with were outstanding in many ways. I felt like an integral part of the team and I was happy to do the necessary work.

As a result of the advice I took endocrinology, cardiology, renal medicine, allergy and immunology, neurology, infectious disease, and neurosurgery in addition to the required general medicine rotations. I took a little flak from the Dean. There was some concern that there were not that many spaces available in medical electives. At one point it was suggested that I should limit myself to two or three medical electives. I prevailed and got what I wanted largely because the specific rotations were at a public hospital and the local VA hospital. 

One of the aspects of medical training that is not discussed enough is camaraderie. When you are a medical student, your role is often ill-defined. The role generally depends on the staff you are working with, the institution, and the general culture within the medical school. At the hospitals where I spent most of my time medical students were an integral part of the team. On day one – you are assigned patients and admissions. You were expected to report on patient progress and write progress notes. You learn communicate with everybody in the hierarchy ranging from the intern to the resident to the attending physician. You are supposed to learn how to research and study the specific problems that your patients had and in some cases do a special report. Examples would include a chart review I did on gram-negative meningitis at the VA medical center and presentation on anaphylaxis on my allergy rotation at Milwaukee County Hospital. Both of those studies went extremely well.

But camaraderie is more than knowing the chain of command, hospital systems, and how to get the work done. A key component is the educational quest that everyone is on. Doing rounds with five or six different people at all levels of training ranging from novice to world expert is experience that you don’t get in many places. Some of the results can be stunning. I did a consult on a patient with possible spontaneous bacterial peritonitis (SBP). I wrote up the consult form and prepared to present to the attending physician that afternoon. When he walked in the room from about 10 feet away, he asked everyone else on the team what the problem was with the patient’s leg. I had been focused on abdominal, systemic, and laboratory findings. Nobody could answer the question. The attending physician who happened to be an expert in streptococcal infections, pointed to a rosy rash on the patient’s left shin and suggested that it was a form of streptococcal cellulitis. He did the necessary tests to confirm that diagnosis at his lab.  One of the many processes that must be attended to in these rounds is the pattern matching aspects of diagnosis. It was vaguely implicit in my training and I realized only later when teaching a course in avoiding diagnostic errors - that these rounds are the place to ask experts: “What are you seeing that nobody else is?” All experts including psychiatrists recognize certain patterns and can make more rapid and more accurate diagnoses than people outside their specialty.

A lot of people reading this may have a hard time believing that what you learned in medical school is relevant to a specialty that you practice your entire life. After all - aren’t these specialties updated at some point and doesn’t your knowledge base become dated? It is surprising how the basic approach to the patient that is unique to each specialty does not change much. There is still relevant review of systems, specialty specific diagnoses, and laboratory testing. Working with specialists for even a month gives medical students and residents a clear idea of how to approach patient problems in a systematic manner. Even though there have been radical changes in some specialties like cardiology, most medical specialties change slowly at the mechanistic level typically with some pharmacological innovation. A clear example relevant to psychiatrists is the endocrinology of metabolic syndrome and diabetes mellitus. Over the course of my career that has resulted in increasingly complex pharmacotherapy ranging from insulin, metformin, and sulfonylureas to an additional five classes of drugs and more complicated insulin preparations.

A unifying concept that I learned on all those medicine specialty rotations is that it is important to still know about these mechanisms and medications even if your specialty involves another bodily system and you are prescribing an additional treatment. No matter what specialty service I was on there was never the idea that we could focus only on a specific bodily system and ignore the rest. On all of those rotations including neurosurgery, I was often the person focused on what was going on with the patient’s brain.

Learning medicine and neurosurgery on all of these rotations was quite exciting. I am much more likely to retain information if I am excited about it. I was excited right up until 11 PM on the last day of medical school.  I was doing renal medicine at the time and the senior resident was going to be a rheumatology fellow. We finished rounding about 6 PM and he noticed we had 4 or 5 additional consults. He was the kind of guy that you really like working with. He had a great sense of humor and was always engaging. He could even engage an introvert like me. I remember him saying: “Look I know - this is your last day but you could really help us out by doing some of these these consults. The new team is coming in tomorrow and I don’t want to leave all of these consults behind.” He threw in a couple of politically incorrect jokes for good measure and I headed off to do two consults. We came back and met with the attending physician who was considerably older than I am right now and finished them all by 11 PM. I really did not want to say goodbye to that team. But I headed off by foot across the golf course sized county hospital grounds to my apartment on 89^th St.

The knowledge gained in that fourth year of medical school was a springboard for the next 30 years. I continue to read about all those medical specialties and remember what happened in 1982. I continue to research all the medical problems and medicines that my patients are taking. I continue to wish at times that I was still on that renal medicine team back at Milwaukee County Hospital.

I didn’t get a lot of good advice in medical school but for all those reasons the advice about what to do in my fourth year was the best.

George Dawson, MD, DFAPA





Supplementary 1:

Second best piece of advice in med school was from the head of our Biochemistry class in the first year.  Our biochemistry class consisted of lectures and research seminars where we read and critiqued biochemistry research. At one of the first lectures, the department head stated:

"Subscribe to the New England Journal of Medicine and read it."

I have been reading it ever since and that was definitely a good idea.


Supplementary 2:

I did take one psychiatry elective in the last two years of med school - Infant Development and Psychotherapy.  It was taught by two psychiatrists who were very excited about the field Frank Johnson, MD and Jerry Dowling, MD - both Medical College of Wisconsin psychiatrists. We screened infants and very young children at risk especially if they had one or both parents with severe mental illness. We instructed parents on how to interact with their children in order to overcome behavioral difficulties associated with disruption of the infant or child and parental bond.  Every week we had a research seminar where we read relevant papers on the subject.  We had a very large clinic where we did evaluations and saw large groups of parents. It was a very positive experience and has implications to this day.  As far as I know there are no clinics in the US like the one we had in 1982.  It provided a valuable service to infants, young children, and their families.

1: Wesner D, Dowling J, Johnson F. What is maternal-infant intervention? The role of infant psychotherapy. Psychiatry. 1982 Nov;45(4):307-15. PubMed PMID: 7146225.