Graduate Medical Education: Another Perspective

By Anne Vinsel, MS

Comments on "We Need an Attitude Adjustment" by Benson Wilcox, M.D.

Dear Dr. Wilcox,

I share office space with an area used by medical students to look through notebooks of physicians they can shadow and use as mentors, and I coach some medical students for their boards, so I hear (or overhear) a lot of raw discussion around choosing specialties. My comments are based mostly on overheard discussion between third and fourth year medical students, along with some direct questioning of students I know. I gather from your prose that the surveys to which you referred questioned residents who were already in cardiothoracic or surgery programs. The group I hear from are those who could conceivably make good surgeons but never apply to surgical programs. I would imagine this is your target group.

They are indeed hesitant about surgery in general and cardiothoracic surgery in particular, even if they are clearly attracted to surgery and show signs of surgical temperament.

The major difficulty by far is lifestyle, particularly long and unpredictable work hours. Since the residents in surveys you cited had already accepted long work hours by applying to a surgical residency, I would not expect to see much dissatisfaction from them on this issue. However, the students I hear from express a great deal of concern.

I think you were correct in identifying a gender component, but I believe you may not have clearly made the connection that the additional two years pushes female students further away from prime childbearing time. They make that connection, though, and despair of having one or two children during their residency. Something you didn't mention that crops up quite a bit is that male students do not want to be as absent from their (prospective) children's lives as their own fathers were, or they don't feel it's fair to dump all the child-rearing burden on their wives, who are often medical students themselves. I suppose the tradeoff used to be that although the CT surgical resident's wife never saw him and had to have and raise children solo, the prospect of her not having to work and the eventual promise of a very good income sufficed. Talk about shrinking applicant pools! Now the resident's spouse works, either for career reasons or due to economic necessity, and naturally resents a spouse's attempt to be completely excused from domestic responsibility. Or the resident's spouse is another resident, making it pretty hard to justify dumping all the household management on the female of the pair.

You're also facing competition from more areas where the excitement is similar but the work hours are better controlled (one example is emergency medicine, which has a 60-72 hour work week by decree).

In contrast to the surgical residents you mention, the medical students I hear from who are interested in surgery but don't apply to surgical programs are worried about finances, particularly loan repayment. They are ok with the length of the cardiothoracic residency; they seem to understand how long it takes to develop those skills. However, a seven year residency puts severe financial pressure on them because they may have to start making large loan payments while they are still on a resident's salary. I realize the general impression may be that loans can be deferred throughout the length of a residency, but that's no longer true. The old-style deferments are not available for loans taken after 1993, and there is a three-year limit on economic hardship deferments (which most residents with substantial debt do qualify for). After three years of residency, the resident must choose between making heavy payments while still a resident or going into forbearance and having interest compound. Extra interest could be as high as $30,000, depending on type of loan, interest rate, amount of forebearance, amount borrowed and consolidation status. They hate that. If you could get the federal government to extend the economic hardship period to cover an entire residency, regardless of length, I believe it would help your applicant pool.

The other interesting (and paradoxical) financial aspect is that medical students don't seem to care as much as they used to about ultimate income, making CT surgery relatively less attractive than it used to be. With respect to money, many of our medical students don't necessarily want to make as much as possible, they want to make "enough," which includes minimizing the interest they pay on their loans.

Oddly, the next most common objection is something I haven't seen discussed among surgeons until you hinted at it. The students I hear have been raised on digital special effects and video games. They view what used to be exciting (bypass MACHINES) as strange and vaguely distasteful (it has moving parts? you can't run diagnostics?). They are much more interested in something like TEE, and tend to look at the screen rather than looking at the actual site of the surgery. They don't say this as bluntly as I'm putting it, but I sense they feel that cutting open a chest is crude and shouldn't be necessary. They are more excited about endoscopic procedures, but ultimately feel that some kind of robotics should be available that doesn't require so much cutting. A related aspect is that they have far more experience with computers and joysticks than with mechanical tools, and don't have much comfort level with sawing, cutting, burning or stitching implements. Machines without chips seem old-thinking. Also, they are used to learning hands-on, and I can see that the equivalent of hacking could be a problem for medical students in surgery. Watch-and-learn or (even more) read-and-learn are boring concepts to them; they want watch and do it, preferably at the same time. Anything you could do without hurting patients to get them more hands on exposure while in medical school should help. There's a lot of talk about how boring surgical experiences are, all you get to do is stand there and maybe hold a retractor, no interactivity.

After they've had a surgical rotation, they often do report disgustedly on disrespectful behavior of surgical faculty toward residents. That style is dead everywhere else (even the military is dumping on it); it should leave surgery permanently. These students have had warm and caring teachers all their lives, Mr. Rogers and Sesame Street on TV, and they think the suck-it-up hierarchical style is either deranged or sadistic. They don't trust people who act like this. Although I can see a certain functional utility to it, they sure don't.

A related issue is pimping, which they also consider old-fashioned. Students see the pimping style as valuing short-term detail memory, which seems stupid to them because you can now put that stuff into a small digital device, freeing up your brain for the increasing complexity of information they now have to juggle. This time, faculty are seen as crazy, sadistic or clueless. There was a similar generational shift years ago in mathematics, when rapid mental calculation (math team tricks) suddenly became useless as computers got more handy. (Can you take the cube root of a number greater than 300 in your head? Why not?)

There's also competition from other areas where things seem to be moving very quickly. Oncology, genetics, immunology and informatics are popular with our students, I suspect because they seem so much more hopeful than they did previously.

My ideal survey would get medical students together outside of school, administer a nice dinner and hopefully get at least some of them drunk, then have someone with no power who's a good observer (definitely not an MD) take good mental notes. Our students seem quite conservative about sharing their thoughts with anyone above them in the food chain.

Good luck with the problem; I don't see the need for CT surgery to decline, although I'm very able to believe the field may change radically.