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.

Concentration of Effort, Academics, and Managed Care

I follow the Nephron Power blog because I have maintained a life long interest in Nephrology or at least since I found out what it was in Medical School.  The conventional wisdom at the time was "Oh you're going into psychiatry - take as many medicine electives as possible because you will never have the chance to do medicine again."  If there are any medical students reading this - I ended up doing another 22 years of following renal function, treating people who were delirious and in renal failure, treating manic patients who were in renal failure waiting for a kidney transplant, and consulting with Nephrologists.  I  can say without a doubt that the Nephrologists who I worked with are some of the brightest, most thoughtful and hardest working people I have ever known.

I still  consider the Renal Service where I worked in medical school to be the model for academic medicine and how to teach medical students and residents.  It was located in two adjacent hospitals and headed up by a cranky old guy.  I say "old" realizing that he was probably about the same age that I am right now and he had the appearance of being cranky like a lot of old guys can get.  You could tell he was very bright, very interested and not above giving the medical students a hard time.  He made sure that on all of the consults we had conducted the appropriate "liquid biopsy" by performing our own urinalyses on patients we were seeing.

We rounded three times a day seeing all of the hospitalized patients in the morning, clinic patients in the afternoon, and hospital consults in the evening and at night.  My last action as a medical student was staffing two Renal Medicine consults at about 8PM the night before I graduated.  The other team members included another two attendings, two fellows, three Internal Medicine residents, and another medical student.  The physical layout of the service was two hospital wings and a very busy clinic with a separate day for a Hypertension clinic.  The hospital service was in the same hospital as the transplant team and we would also care for patients with transplant complications.

The  atmosphere on this service was electric.  Everyone was on time, interested, bright, academic and effective.  To this day - I consider this team from the 1980s to be the prototype for what a teaching service in a Medical School should be and in many ways how serious medicine should be provided.  When I left the hospital that night after the last two consults staffings of my medical student career I can remember thinking - should I have gone into medicine and become a nephrologist?  My fantasy in psychiatry became to recreate this model or at least parts of it in psychiatry.

Flash forward 26 years.  Most people would be fairly surprised to find out that you can come close to my fantasy in very few psychiatric units.  The patient flow into and out of many psychiatric units generally does not depend on academic considerations like providing the best medical and psychiatric care to patients.  In most cases patient flow does not depend on the judgment of psychiatrists.  My ability to care for patients with the most severe illnesses did not come about because there is an elite cadre of psychiatrists who are academically interested and have the necessary resources to provide that level of care.  It came about because the system where I worked needed a place to put these folks and I happened to be a psychiatrist who was interested in all of their problems.

I got very close to recreating at least the inpatient side of my old Renal Medicine service, but these days there are just too many administrative problems along the way.  It is impossible to take a learned approach to medicine and psychiatry with administrators breathing down your neck about an absurdly short length of stay.  It is a clash of paradigms and as far as I can tell the administrators have won.  You cannot possibly address complex problems when someone is telling you that the only reason a patients should be in the hospital is that they are "suicidal" or "homicidal" - both very loosely defined business terms for getting the patient out in time to capture about a 20% profit on the DRG payment.  Let's suspend the reality that this person is just  too ill to function or that their illness has created an impossible situation at home or they are not able to care for their new medical diagnoses until they have recovered their cognition to some extent.

If you are really interested in a rigorous approach to tough problems these days you will run afoul of a huge managed care infrastructure that is there to process patients in and out of hospitals based almost entirely on business decisions.  That makes life a lot less interesting for physicians and a lot more frustrating for patients.  Patients coming out of the managed care environment have an almost universal experience that they were hardly seen in the hospital and when they were, there was not a lot of interest in solving their problems.  They end up saying what they think people want to hear in order to be released and after they have been discharged realize that nothing has changed.

In the final analysis these are contrasting models but nobody pays much attention to the contrast.  An academic full spectrum of care model versus a severely rationed model where care is based on an administrators notion of "dangerousness".  Clinicians aware of the full spectrum of illness, grappling with all of the nuances and offering the necessary care versus a doctor sitting in an office prescribing pills as fast as they can.

That is what we are talking about and in that context - I will take the Renal Service any day.

George Dawson, MD, DFAPA