PERSPECTIVE BECOMING A PHYSICIAN

A Differentiation Diagnosis

A Differentiation Diagnosis Specialization and the Medical Student

Rena Xu, A.B.

f you walk through my medical school building in the evening and follow the aroma of pizza, youll probably find your way to a dinner talk organized by a student specialty interest group. Running the gamut from surgery to psychiatry, these groups are made up of first- and second-year medical students, many of whom joined just weeks after they first donned their white coats. Although the pizza toppings vary, the discussion topics rarely do: What are the most or least rewarding aspects of the specialty? How is the field changing? What does a typical day comprise? And the unspoken question driving students to these dinners: Is this the specialty for me? I arrived at medical school open to many possible paths, loath to rule options in or out until Id had clinical exposure. Medical school, I reasoned, would be the appropriate forum in which to shape a preference based on evidence and experience, rather than hearsay. Soon, however, I began to question the wisdom of staying undifferentiated. Many first-years already seemed to be singling out subspecialty interests. Classmates began skipping lectures to shadow physicians, finding mentors to start clinical research projects. The aspiring surgeons took turns carrying a pager that notified them of opportunities to scrub into surgeries at nearby hospitals.

There was apparently a sense of urgency to begin the differentiation process, to start investing meaningfully in a particular area. Suspecting that this was the selfimposed pressure of high achievers, I asked a physician at a teaching hospital whether she considered the rush rational. Surprisingly, she said yes and encouraged me to seek out research opportunities relevant to residen-

competitive edge may be driving students to differentiate earlier.1 Part of me recoiled at the notion of investing in a field simply because it was the competitive thing to do. Yet I understood the logic of residency programs rewarding depth of effort. Focusing ones endeavors on a specific area affords the benefits of continuity. Over time, one can accumulate relevant skills and knowledge,

The vast range of specialties and subspecialties makes it easy to feel like a kid at an ice cream shop trying to choose from among too many unknown flavors.
cies that might interest me. When youre a first-year, you think you have time to wait, she said. You really dont. Practically speaking, she had a point. Many residency programs now expect applicants to show evidence of substantive exploration in their field through research or clinical work. According to the National Resident Matching Program, recommendation letters from physicians within the specialty are considered more frequently than any other selection criterion except scores on the U.S. Medical Licensing Examination. And with the applicant pool growing faster than the number of residency spots, the pressure to gain a tackle increasingly challenging issues, assume greater responsibility, and develop meaningful professional relationships. It pays, then, to invest early and stay the course. But this strategy presents a dilemma. Although were encouraged to form preferences early, were not equipped early to inform those preferences. At most U.S. medical schools, third-year clinical rotations represent the first opportunity to systematically explore various specialties. In the preclinical years, any career exploration is done outside the curriculum. We shadow willing physicians on our own time, attempting to minimize conflicts with our class schedules.

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PERSPE C T I V E

A Differentiation Diagnosis

If the plethora of career interest groups is any indication, this trend toward early differentiation spans U.S. medical schools. At the University of Pennsylvania, a student-run surgical society has established a program in which preclinical students shadow faculty surgeons. At Baylor College of Medicine, first- and second-year students interested in obstetrics can attend weekend training sessions on delivering babies. At Stanford, an anesthesia interest group pairs students with physician mentors and provides funding for them to meet over lunch or coffee. The list goes on. Even when the logistics work out, however, the ad hoc nature of self-directed exploration makes it a poor substitute for institutional guidance: students prioritize specialties for exploration on the basis of incomplete information, often relying on preexisting biases. The vast range of specialties and subspecialties makes it easy to feel like a kid at an ice cream shop trying to choose from among too many unknown flavors. If limited to sampling only a few before deciding, one may end up making an arbitrary choice. This disconnect between decision making and information gathering has implications beyond individual careers. In debates over fixing primary care, a key problem cited has been the talent drain: the number of medical students choosing general medicine has dropped steadily for years.2 Less prestige than in other medical fields, a less accommodating lifestyle, and poorer financial compensation are thought to contribute to this trend. An alternative explanation

points to the decision-making system itself: the pressure we feel to differentiate may skew our choices toward specialization. Many students perceive primary care as a default path, characterized by the absence of differentiation into anything else. Perhaps as a result, general medicine doesnt inspire the same urgency to invest early; its rare, for example, to see a classmate skip lecture to shadow an internist. This situation seems unfortunate. Evidence suggests that general medicine would gain from early exposure: one study showed that medical students who completed general medicine preceptorships in their first year were more likely to choose internal medicine residencies.3 Conversely, internal medicine subinternships completed in the third or fourth year often dont significantly affect career choice4 so timing can be critical. Recognizing the need for early career guidance, some schools are trying to improve their advising capacities. Their proposed solutions, however, are classroom- or conversation-based rather than clinical. A career-development program at the University of Michigan, structured after a model outlined by the Association of American Medical Colleges, offers preclinical students peer mentoring and extracurricular luncheon sessions.5 Students are not assigned faculty advisors until their third year; even then, the advising focuses on residency applications rather than familiarization with different specialties. Other proposed models include careerdevelopment courses and professional faculty advising teams.1 But students can learn much

more by experiencing various fields for themselves. A more effective approach might be to introduce into the first- and secondyear curriculum a standardized shadowing schedule, whereby students rotate through myriad clinical settings. This would allow students to begin formulating informed preferences about the broad categories of career paths. Some might question the usefulness of shadowing, since shadowing students generally dont participate in the action. But much of what is gained from being in a clinical environment comes from observation. By following physicians through their daily activities, students experience the pace of the work, see how teams function, and develop a sense of the different medical challenges faced by different specialties. As a supplementary approach, classroom-based instruction on real clinical cases could help introduce various subspecialties. At many schools, courses such as gross anatomy and pathophysiology are already taught partly by a case-based method. Yet teaching cases often bear limited resemblance to real life. One possibility for bridging this gap is weekly specialty rounds, modeled after grand rounds and taught by practicing physicians. These would expose students to common patient presentations in various fields and to practitioners approaches to treatment. Shadowing and clinical case studies are neither novel concepts nor solutions in themselves. They are, however, potentially powerful vehicles for implementing the solution: a breadth of clinical exposure early in medical school. Students self-guided, sporadic ex-

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PERSPECTIVE

A Differentiation Diagnosis

plorations arent always conducive to formulating sound judgments. Curricular changes could help address this problem. In the first week of medical school, a professor gave my class this advice: dont pretend to know more than you do. She was reminding us to be honest with patients that we were not yet doctors. But I remember her words whenever I smell the pizza luring me to another dinner talk. In choosing a career path, I dont want to pretend to know more than I do. Dinner talks

can reveal only so much. I believe we need broad, systematic clinical exposure early in our training when we are most eager, most ignorant, and therefore most in need of guidance.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org. From Harvard Medical School, Boston. 1. Navarro AM, Taylor AD, Pokorny AP. Three innovative curricula for addressing medical students career development. Acad Med 2011;86:72-6. 2. Pugno PA, McGaha AL, Schmittling GT,

DeVilbiss Bieck AD, Crosley PW, Ostergaard DJ. Results of the 2010 national resident matching program: family medicine. Fam Med 2010;42:552-61. 3. Elnicki DM, Halbritter KA, Antonelli MA, Linger B. Educational and career outcomes of an internal medicine preceptorship for first-year medical students. J Gen Intern Med 1999;14:341-6. 4. Kogan JR, Shea JA, OGrady E, Bellini LM, Ciminiello F. The impact of the internal medicine sub-internship on medical student career choice. J Gen Intern Med 2010;25:403-7. 5. Zink BJ, Hammoud MM, Middleton E, Moroney D, Schigelone A. A comprehensive medical student career development program improves medical student satisfaction with career planning. Teach Learn Med 2007;19:55-60.
Copyright 2011 Massachusetts Medical Society.

Graphic Warnings for Cigarette Labels

A slide show of the nine graphic warnings is available at NEJM.org

Beginning in September 2012, the Food and Drug Administration will require larger, more prominent health warnings on all cigarette packaging and advertisements in the United States. The move to these labels marks the first change in cigarette warnings in more than 25 years and is considered an important advance in communicating the dangers of smoking. There will be nine different text warnings with accompanying color graphics designed to increase awareness of the specific health risks associated with smoking.

n engl j med 365;5

nejm.org

august 4, 2011

393

The New England Journal of Medicine Downloaded from nejm.org on September 27, 2011. For personal use only. No other uses without permission. Copyright 2011 Massachusetts Medical Society. All rights reserved.