Thought this would be interesting to those who might have made it this far.
Paying off medical school debt in 2021? 4 things to consider.
From your grumpy Uncle Dave.
At sometime in your training or career, you will be in a supervisory role. There are lots and lots of books and posts about being a good supervisor. This is my take on some nuances of the subject.
Traditionally
In industry the bosses don’t fraternize with the workers.
In the military, and still today, officers are forbidden from fraternizing with enlisted and those of lower rank and can be punished under UCMJ (Uniform Code of Military Justice, the laws that military personnel have to live by).
Kings don’t mingle with the common folk.
We’ve all heard of instances where a good friend gets promoted and suddenly they change and the friendship becomes strained. The one left behind blames the promoted one of being aloof, arrogant and full of themselves.
So, why is that? Long standing customs are there for a reason. Sometimes the reason is wrong, but not often.
The company, the military or whoever wants the executive to be able to implement orders without undue influence affecting them in their duties. The executive is being paid to represent the company, and not the worker. Some will be able to fraternize and maintain their friendship with the person that is being ordered (fired, reprimanded…). Most will not. Therefore the organization, or military or whoever implements a rule that the uppers can’t fraternize with the underlings, preventing the possibility of relationships developing and preventing the possibility of undue influence in the wrong direction.
If an executive and a worker present complaints to the company or the executive presents the complaints for the workers, the company now has to decide if the executive is looking out for the company or the worker? The company hires executive level employees and expects loyalty to them, not to the workers.
Surely one can see the military’s need for separation of tier. Life vs death.
Currently
When fraternization is discouraged
See the comments above about traditional industry and military standards. But, courts have upheld the rights of workers doing whatever they want during off-work hours (in industry but not the military).1,2 So, here fraternization comes down to mean sexual harassment, public display of affection or intimate contact while on the clock. Using these definitions, it is easy for the employer to craft rules against them.
A contentious divorce/break-up/domestic dispute is not something most people want to watch, much less at work.
Appearance of impropriety can be as destructive as the actual inappropriate act. Tongues will wag and soon the appearance becomes widespread reality.
When fraternization is encouraged
At these institutions fraternization is viewed as close working relationships that improve cohesiveness, sharing of knowledge and skills. It is felt that these relationships improve the product and therefore the business.
But if there is a mix of tier levels, ingratiation of a lower level to the upper level may backfire.4
In the late 1860’s, a confederate ship roamed the high seas and was captained by Captain Waddell.3 At that time the captain was an autocrat and had supreme power over the ship and crew. Well, up to an extent. He certainly didn’t want to swim home, so his rule had to be somewhat acceptable to the rest of the crew. But, early in their voyage, he had a round table discussion with his Lieutenants and took the majority advice on what to do about a particular problem. Thereafter, for the rest of the voyage, his crew was close to mutiny. By allowing his command to be dictated by lessor members, he had shown weakness.
Leadership
Audy Murphy was a great American Hero of WWII. He is known for being the most decorated soldier of WW II, an actor and wrote an autobiography.4 One of his approaches to being a platoon leader was allowing his men to complain all they wanted, if they did their job. The take home lesson from this is that the leader should not over manage his team. If it works and a change isn’t going to improve the chore, don’t change.
Lead from the front, you can’t lead from the rear. Don’t expect one of the team to do something you won’t or can’t.
Show Respect
Should one praise a worker for doing an adequate job? Or, only if they do an exemplary job?
Should one critique a worker in the presence of his co-workers, expecting peer pressure to influence the outcome? Or, punish the group with the same expectation? Hoping the outcome is what one wants and not a unified rebellion.
Your Uncle Dave’s opinion
Inspired by Madison.
1. https://smallbusiness.chron.com/dangers-fraternization-workplace-36544.html
2. https://www.todaysworkplace.org/2007/02/06/the-underrated-importance-of-fraternizing/
3. http://www.tomchaffin.com/book/sea-of-gray/
4. https://www.goodreads.com/book/show/300674.To_Hell_and_Back
So, what is the day in the life of a medical student like?
That depends on the school and the year one is asking about. For instance, Baylor 1979-1983, was a traditional 4 year curriculum with 2 years of classroom and lab work then 2 years of supervised, clinical, hands on patient care. Right across the street was the University of Texas Medical School-Houston and the structure was different with them doing a mix of classroom and clinical starting in the first year.
Now, Baylor is doing the same thing as UT did back when. From the Baylor web site, “The traditional model with its abrupt transition from classroom focus on basic sciences to clinical rotations is replaced by longitudinal integration. Early introduction to seeing patients provides meaning and context as you gain the foundational knowledge required to practice medicine.”1
My personal experiences would be mostly archaic, so let me approach the question as I think it would apply to today’s new students.
Time management?
There’s an oxymoron for you, if there ever was one. It is really an issue of organization of time usage. The major difference between University life and Medical School life is the pressure one feels to assimilate the large amount of information. The holidays are the same and weekends are off unless you are on a clinical rotation. After my first year in practice, I was amazed at how much time is free time in Universities and Medical school. You’ll wont see that much free time again, until you retire or die.
As soon as you get your schedule for the semester or year or whatever, start planning how you will organize your time. It is always helpful if you find somebody that has done the same rotation and query them as to how it works. How time is organized will vary depending on each individuals sleep and study habits. Regardless if you are a day person or night person, one who studies constantly or a last minute crammer, you need to plan out your use of time. If you are married or are in a relationship, share the plan. Calendars, electronic or paper, are a must. This is a good time to put your OCD to good use.
Food
Resist the urge to eat when you are tired, thinking that it will re-energize you. It won’t. It will just make you even more tired. And you will not be getting as much exercise as you might need. And you gain weight. Causing the whole process to spiral down.
One thing students and residents become expert at is finding noon conferences that serve food. Make the effort to identify these. If you are not required to be elsewhere, attend one. Larger medical centers will probably have several to choose from Monday-Friday. Usually, at the end there will be a few items left over and if you are on call that night, hey you now have scored 2 free meals.
Family, spouse, pets
Family, spouse, non-married relationships, significant other, boyfriend, girlfriend or whatever you call them, if you live with them you owe them respect. I strongly recommend a face to face discussion about expectations before you start on this journey.
There will be times when the medical student has to work late, can’t get to a phone to call, changes plans at the spur of the moment, hits the wall of sleep deprivation, stresses or feels over whelmed with duties. There will be times the other one, the non-medical-student, becomes frustrated with the seeming abandonment, the loss of attention or feels over whelmed with duties at home from financial obligations, the burden of children without the help of the medical student, or whatever. The various scenarios are infinite, but if many of them can be acknowledged ahead of time, it makes handling the unforeseen easier. There has to be give and take on both sides and both have to be willing to sacrifice something for the other while accepting the sacrifice of the other with grace. When talking to each other, use common respect. Use please, thank you and other forms of polite discourse regardless of how tired or stressed you are. Don’t raise your voice, ever. Don’t roll your eyes, grit your teeth, sigh heavily or show any subtle body language to say what you shouldn’t.
Avoid the trap of language. The medical student is going to learn another language with idioms unfamiliar to the non-medical-student and it is sometimes consciously tempting and sometimes unconsciously spontaneous to use this new language. The language should remain the same as it was before medical school. In other words, don’t use fancy, high highfalutin medical terminology in sincere conversations with your non-medical-student mate.
Arrangements to care for pets in case of unforeseen delays or in prolonged absences should be made. A cat or dog sitter that the animal is familiar with and likes will go a long way to avoid destructive behavior these companions can come up with.
Navigational skills
Especially at older and larger centers, navigation skills are important. Or recognizing that it is a personal deficiency and learning who among you has those skills and sticking close to them. Older centers started, probably, as a single building and as needs arose, were added on to. To do that, architects were hired and plans drawn up and implemented. I don’t mean to be insulting, but one of the chief requirements to becoming a medical facility architect is learning how to connect medical buildings in the most M.C. Escher fashion.2
Just get along
I guarantee that at some time in your training, you will come across someone you don’t like or that doesn’t like you. Develop the skill of not letting this interfere with your work product. Cat fights, baiting, inter-team rivals or just all out brawls are not going to help your patients get better or help your learning process. It may even be the patient that has issues with you. Be stoic. Don’t let your emotions show. Address the problem or issue in an honest but gentle manner without resorting to hyperbole, baiting, unprofessional language or demeanor or attempts at domination. After all, it is your job that’s at risk. You’ve worked hard to get here, work hard to stay.
Nerves
The best way to calm nerves is confidence. Public speaking, presentations on rounds, interviewing a patient, etc. Having the confidence that you are well prepared for the topic at hand and having experience of numerous prior contacts in this situation is a cure for the jitters. Some people use drugs, such as propanolol for example. But if this works, it doesn’t work if the encounter is spontaneous and immediate and you haven’t had the opportunity to take the drug. I prefer and recommend gaining confidence by study and repeat exposure. In other posts, I have advocated group studying. See one, do one, teach one. The best avenue to learning something new. In a study group, a given topic can be assigned to a member to research and give a presentation to the group. It’s a great complement to traditional studying techniques.
Scut work
Scut work could include drawing blood for lab testing, starting IVs, retrieving report results, communicating with other teams, nurses or staff. Before computers, students often would be expected to find and retrieve the paper medical charts of the patients on the service. Believe me, computers have astronomically improved and eased this task. But, scut work is still learning and it’s paying your dues for the education you are getting from other team members.
Sleep deprivation
Modern training regulations limit the amount students and residents can be made to work.3 That is unfortunate. The reason I say this is because, until you have been challenged, you don’t know your limits. Many times in my career, I have had to work for many more hours than the current training guidelines define as reasonable. If I didn’t work those hours, patients would not have been able to get medical care because there wasn’t anybody else. It is part of the package that you are getting in choosing medicine as a career.
Drugs
Don’t. Various forms of speed, amphetamines including Adderall and the like, are a trap. There was a saying in the 60’s, when drugs and free love were so prevalent, “Speed Kills.” Believe it. One might get by for awhile, even some might get by completely, but for most, you will be adversely affected. Besides, it’s illegal. Even having a physician prescription can be illegal if the diagnosis was obtained nefariously.
Your Uncle Dave,
Weary
1. (https://www.bcm.edu/education/schools/medical-school/md-program/curriculum/foundational-sciences-curriculum)
2. (https://moa.byu.edu/m-c-eschers-relativity/)
3. https://en.wikipedia.org/wiki/Medical_resident_work_hours
Look at this from the top down as well as the bottom up. First, let’s get the stats out of the way.
Life expectancy in the US for females is 84y and for males is 80y, and there aren’t many octogenarians in practice. The average age of retirement for physicians is 68y. We can’t do much about choosing when we die but we do have a little choice when it comes to retirement. If things go well and we are healthy, competent and have the motivation, means and desire we could practice to the age of 70. Or we could give it up at 50 and go sailing, or whatever. So, we are looking at a career, including preparatory training, that may span 50 years. Consider that the FBI and other law enforcement and public service jobs have mandatory retirement at age 57, shortening the career span by up to 13 years.
The average medical career is 31-36 years. That leaves a 14-19 year span that could be outside the training-career. That span could be at the beginning, the end or divided in any way between them.
We don’t have much choice as to when we start elementary school, either. Grade-wise, it is pretty much at age 6y. School in the US is 12 years to graduate from High school. Ergo, we assume that most career oriented individuals will start college at 18. But that is not always the case. Take, for instance the following chart of 4 different paths to a medical career.
But life happens, right? So, what about life and commitments outside of our career? The search for romance, possibly marriage and children? What about dependent adults, or unexpected illness? Our parents don’t live forever and who knows what our genetics or fate has in store for us?
Some examples.
I was 24 when I entered college, 28 when I entered medical school, and 36 when I finished residency. During that time I got married and had 2 children. I’ve had a 31 year career, so far.
One of my students, who was married, was accepted to medical school shortly after having her first baby. Her husband was just graduating from residency and moved 300+ miles across the state. She raised the baby, breast fed and graduated to join her husband where he had established his practice.
One of my current colleagues started medical school at 22 with 2 children and had 2 more during residency.
Another of my colleagues worked as a roust-a-bout in the oil field after high school. He decided to improve things and trained and worked as a Paramedic. He liked the medical aspect of things and returned to college and ended up in medical school.
It can be and is done all the time. I’m not saying the path may or may not be easy, mine was. But, it is certainly doable.
How does the nuclear family, extended family and/or support system affect our decision in career choice? Clearly, the better the support one has the easier the process will be. But, if one knows ahead of time that there will be no support, then they can plan appropriately. It is probably wise to do so, anyway. There may need to be some introspection to see how one might measure up under less than ideal circumstances. Don’t do it alone, though. Friends, family and even less close acquaintances can often give advice on our character that we aren’t consciously aware of.
In military vs civilian career paths, the major difference I see between them is that the military is more likely to uproot you and move you overseas. Moving from one base to another is generally guaranteed in the military but occurs in civilian life as well. For instance, jobs are lost or unsatisfactory. Maybe you move up the career ladder, requiring a move. Maybe you have to move to be close to elderly parents that need help? Hierarchy, chain of command, and protocol don’t differ that much. The pay difference is primarily seen at the last half of the career, less so in the beginning. Military careers have hidden benefits the civilian side doesn’t get. By that time the military physician has accepted the financial lot in life he/she is dedicated to a career in the military, anyway.
Time waits for no one. So, if you are planning on having a family, don’t put it off “just because” of pending school or training. Instead, plan inclusive for school or training. The school or training facility cannot discriminate against you because of your starting a family. Of course there will be a delay in your training, but it is a situation that can be done. We have all heard about the situation where things get put off and put off until it is too late. It isn’t a matter of being too old, it is a matter of not planning ahead.
Resilience vs naiveté. Remember that a plan is perfect up until the second it is put into place. At that second, fate stirs it with it’s wiggling little finger and changes have to be made. An unexpected pregnancy, a parent dies leaving a family mess or one encounters an unexpected illness. A change in plans is needed, but not necessarily capitulation.
What about being too young to go to medical school? The prodigy who graduates from high school, or even college, at 16 and gets into medical school. What life experiences do they have for a foundation on which to base advice for life-changing or life and death issues? What maturity do they bring to the table? Despite similar concerns, the prodigy do exist.
As well do those too old.
Your Uncle Dave
Weary
Acknowledgements
This post was inspired by BimmerGirl and Gunny Angel.
BimmerGirl provided the graphics.
Location
Most applicants assume that they will only apply to the closest/in-State schools because of residency issues. There is the option of moving to a more desirable location to establish residency before applying. Each State varies as to residency requirements and should be researched. Differing locations may have benefits that affect a particular individuals needs. Climate, proximity of family and therefore support, cost of living and a host of other factors may make one locale more desirable than another.
Look at Texas, for example, which has about 12 Medical/Osteopathic schools at which one might get favorable residency status for tuition. The cost of living is very favorable. Eventually one might appreciate the absence of state income taxes. The climate may vary across the very large state but, in general, is temperate. (Other than having been born, raised and schooled there, I have no affiliation with the State of Texas and receive no kick back if you decide to enroll there.)
Another consideration that location may have is population. Certain areas of the country have differing populations and if one is interested in a particular disease, training in an area that has a density of a population that has a propensity for that disease makes sense. For instance, if you’re interested in Tay-Sachs disease, you might move to a community with a concentration of Eastern and Central European Jewish immigrants.
Expense
Tuition and living expenses are a significant factor. If you haven’t read my post on this, please look here. Living expenses should be considered in concert with location. For instance, if funds are severely limited, consider the location in the light of where you will live, travel and train. Will you be able to afford to live close enough to the school and be in a safe area? Will you be able to afford transportation to and from school at all hours of day and night, safely?
Reputation
The reputation of the school is probably the least important criteria. Remember that the person graduating last in their class is called Doctor. The same is true of the school from which they graduate. For 99.9% of graduates, the reputation of the school will have negligible, if any, effect on their following career. After graduating from Medical School, choosing a residency is a completely different situation, but by that time, one will have had time and experience to have researched where they need/want to go for more training. Just as in undergraduate school where a student’s major may change weekly, in Medical School, one’s choice of career specialty may change several times. Therefore, I opine that the Medical School’s reputation is the least relevant factor.
Having said that, there may be an individual or 2 that knows early exactly what they are going to do and chasing the Ivory Tower is the only path they will consider. There may be an argument for training at a particular institution, in these cases.
Volume
The top factor in choosing a Medical School, residency and fellowship is the size. Here, size matters. The number of clinical sites, patient encounters, referrals, faculty, resources, other students and other staff are all very important. If one is to study and practice Medicine, then as a foundation the most experience one can get is the most beneficial factor to that foundation. For instance, the best opportunity to encounter a rare disease, illness or injury is at a facility that has the most volume. Since a smaller facility will usually refer an unusual case to a larger facility because of lack of experience treating the unusual, larger facilities will provide a better opportunity for that encounter.
Not to harp on Texas too much, but consider the following. The Texas Medical Center , in Houston, is the largest medical complex in the world.
10,000,000 patient encounters
180,000 surgeries
750,000 ER visits
9,200 patient beds
The world’s largest children’s Hospital
The world’s largest Cancer Hospital
So, if there is a rare case, one would be more likely to stumble across it and would be more able to find faculty experienced in treating it in the larger volume environment than at a smaller facility.
St. Elsewhere
If one is interested in an international practice, I suggest that training be in the US to start. Foreign medical graduates that immigrate to the US are required to complete a residency in the US before they are allowed to practice. Even if they have completed a residency in another country and been in practice elsewhere. It’s my opinion that having the training in the US first will provide a better opportunity to expand to other countries later, if desired. Others may have a different opinion.
Your Uncle Dave