In the 2004 film, Dodgeball: A True Underdog Story, a group of social and athletic misfits commit themselves to the near-impossible task of winning an international dodgeball tournament whose prize money might save their beloved gym. From the outset, they are faced with a comical menagerie of obstacles including a maniacal rival gym owner, far more talented opponents and their own ineptitude. Their improbable journey is a surprisingly direct big-screen allegory for the pathway to becoming a doctor. The challenges aspiring doctors face are well documented and even celebrated in the media: tired residents face long hours in the hospital, tired attending physicians are annoyed by their tired residents and tired medical students contemplate the long road ahead. What the media and the medical education establishments fail to portray, however, is that not all these obstacles are created equal. They exist along a spectrum from “balls” to “wrenches.”
Early in the film, our ragtag heroes meet their coach, Patches O’Houlihan, a former dodgeball star fallen precipitously from his glory days. As Patches addresses the team, Justin, an aspiring high school cheerleader who hopes dodgeball will improve his romantic life, questions their unconventional training:
Justin: “Shouldn’t we, like, learn by dodging balls that are thrown at us?”
Patches O’Houlihan: “That’s what this sack of wrenches is for.”
(Patches theatrically empties a sack of wrenches onto a table.)
Patches O’Houlihan: “If you can dodge a wrench, you can dodge a ball.”
(Patches proceeds to throw a steel wrench, hitting Justin squarely in the face. Justin falls to the ground, writhing in agony.)
Patches O’Houlihan: “Any other questions?”
Peter La Fleur: “Yeah, uh, Patches… are you sure that this is completely necessary?”
Medical education whips students through an endless obstacle course that includes much more than late nights at the hospital. Some of these obstacles, such as learning the physical exam or the pathophysiology of heart failure, are useful and often rewarding. It is impossible to achieve mastery or even competence in medicine without a tremendous amount of dedicated practice. Let us call these vital educational tasks “Balls.”
On the other end of the spectrum are the artificial barriers erected to winnow the weak or unworthy. There are the two semesters of calculus, physics and organic chemistry required by many medical schools and the questions on Step 1 of the USMLE about which bacteria grow on cystine tellurite agar (C. diphtheriae, for those currently studying). These onerous, often useless requirements are the “wrenches.”
The argument for wrenches on the path to doctorhood is as follows: if you can dodge a wrench, you can dodge a ball. Students able to memorize the various bacterial growth media will likely remember the drugs to prescribe in an acute myocardial infarction. Likewise, students who can work through a challenging physics or calculus problem might also think critically about a complex patient in the intensive care unit. Medical schools and residency programs searching for ways to differentiate increasingly qualified groups of applicants turn to wrenches like USMLE or MCAT scores as indirect indicators of future performance. This is partially true; MCAT scores correlate with performance on other multiple-choice tests, such as the USMLE Step 1, but fail to predict clinical performance in residency. Similarly, USMLE scores correlate with some pre-clinical grades but demonstrate no relationship to measures of empathy or other clinical evaluation in medical school.
Medical education must be completed within a fixed amount of time; curriculum planning is a zero-sum game. As medical schools have increased the time allotted for test preparation (my school provides two months to prepare for the USMLE Step 1 exam), scores have risen steadily. Yet it is hard to imagine that additional multiple-choice questions are the ideal way to build empathic and clinically capable caregivers. More time dodging wrenches leaves less time to dodge balls — to practice the game itself.
There is no one solution to the perfect curriculum. Many activities that seem to be wrenches have positive consequences not directly related to medical practice. Volunteer experience, narrative medicine or research electives may produce more compassionate, thoughtful practitioners while not directly preparing students for the next stage in their education. Some of these ancillary activities have been shown to increase empathy or reduce emotional distress. Our goal should not be to pare medical education to the skeletal essentials. Instead, we should treat education like a complicated ICU patient, constantly re-evaluating every intervention and test.
In the end, Patches leads the Average Joes to victory but the concussions and potential tetanus exposure from the wrenches add nothing to their quest. Despite a seemingly endless barrage of wrenches many students do, in fact, navigate medical training with poise to become fine physicians and surgeons. Even as we celebrate their success, we should ask ourselves: if mandatory hurdles in physician training don’t build better doctors, why not replace them with ones that do?