Leave a comment

Reflections on M1, Part 1: A Curriculum Like No Other

On July 27, 2020, I began the first day of orientation week at the Medical College of Georgia (MCG). After over four years of living in Atlanta, the initial 25-minute drive from home to school threw me back to my high school days of having to wake up at six o’clock in the morning. The entire first week was a bit of a blur, and I do not remember much aside from getting my stethoscope and helping draft a class oath. By the second week, the enormity of the curriculum hit me like a truck, and all the tropes I had ever heard about the difficulty of medical school immediately took effect — drinking from a fire hydrant, finals week of undergrad every week and unlimited, but undesired, pancakes.

The sheer amount of information for which we were responsible each week spanned hundreds of PowerPoint slides, several pages of handouts and any supplemental resources I needed to skim for background knowledge. Having been out of school for a year, I often found myself re-reading the same sentences or replaying the same audio clip from lecture, still not comprehending and letting this gap in my knowledge cloud my brain and prevent me from focusing on the rest of the lecture. One of the most frustrating feelings was thoroughly studying a topic and staring at a chart or pathway for several minutes, thinking I “mastered” it, and then forgetting it minutes after reading something else that would displace its spot in my hippocampus. By week three, I began using the spaced repetition flashcard software Anki. Every Thursday night to Friday morning, I would go through hundreds of cards, taking advantage of the spaced repetition algorithm that would never seem to let me off the hook. I ultimately owe my ability to pass the Foundations module to this invaluable tool.

Moving forward, each week largely involved the same rinse and repeat motions leading up to taking and hopefully passing the quizzes. However, my experience as an M1 likely departs significantly from students at most other schools due to a new preclinical curriculum change that added a multitude of activities outside of traditional science lectures. Sprinkled throughout the week were  six hours of small-group Case-Based Learning (CBL), four hours of Patient-Centered Learning (PCL), one hour of Health Systems and Holistic Patient Care and a one hour CBL case wrap-up. I shared my weekly schedule with my M2 friends, who were unfamiliar with this new curriculum and required to be on campus for a very minimal amount of time, and they expressed their sympathy.

In CBL, we would work through real patient cases in groups of eight students, tasked with suggesting additional questions to ask the patient, deciding labs and imaging to order, then finally arriving at a diagnosis using inductive reasoning. It was basically training for the cerebral part of becoming a physician in a low-stress setting, but it incorporated interpersonal aspects too. Sometimes, my preceptor would ask, “Can you explain what this all means, doc?” prompting us to temporarily pause from using medical jargon to clearly summarize the high points.

Once, I was in the hot seat while role-playing explaining the difference between a bone marrow transplant and blood transfusion in lay terms to a father of an infant with Severe Combined Immunodeficiency (SCID): “basically, a bone marrow transplant would get to the root cause because blood stem cells from a healthy donor would give rise to an entire lineage of immune cells.” It was a difficult balance between using direct, accessible language while also being thorough. In that moment, I appreciated that just knowing the material was not enough; effective communication is paramount, especially in situations when the patient or their family are anxious or hurting.

The formal “doctoring” part was taught in PCL. So far, I have learned how to take a medical history, perform a partial physical exam and educate a patient on a common complaint. Thankfully, we first would practice on each other in a group of four so that I would hopefully not draw a blank when interviewing my first Standardized Patient (SP) or fail at taking a blood pressure three times consecutively when it really mattered.

I thoroughly enjoyed the 30-minute Wednesday and Thursday lectures on Health Systems and Holistic Patient Care, whose topics were geared toward the assigned CBL case. Our professor in the Department of Population Health Science, Dr. Dan Rahn, delivered the Wednesday morning lectures, where he urged us to consider each case on a structural level: social determinants of health as they related to the patient’s situation, “value-based” care, drivers of cost among other topics.

One of my biggest takeaways was that the system is not broken or failing; it is working as intended to generate profit for those that have a vested interest in making sure nothing fundamentally changes. There is a contradiction between health-providing bodies (doctors, nurses, therapists, social workers) and health-denying bodies (insurance companies and the like). As future physicians, we will interact with commercial insurers daily, often when seeking prior authorization for a procedure, or otherwise justifying to someone who has never laid eyes on our patients why treatment is indicated. Until we question the value proposition of certain stakeholders in our healthcare system, we cannot in good faith envision a better way forward for healthcare reform.

The Thursday session honed in on a psychosocial aspect of the CBL case, and it felt nice to just listen to the lecturer without having to take busy notes as they spoke. I was particularly fascinated by the lectures on alternative therapies to treat pain, suicide screening & risk assessment, eating disorders, and intimate partner violence (IPV). These topics at least partially fall under the wheelhouse of most specialties, yet interestingly, they often get put on the back-burner, even in primary care settings. I learned that some of the reasons why include not just lack of time, but lack of comfort with breaching sensitive subjects with patients and fear of harming the doctor-patient relationship (even though screening for suicidal ideation or IPV would likely strengthen it). It is not enough, then, for me to just be aware of these topics or view them as extra resources, but it is critical to deliberately apply their lessons. With the same energy with which we methodically practice the “OLD CARTS” checklist for taking a history, it would serve us well to also zoom out, look at the big picture, and also prioritize the more humanistic elements of our patient encounters.

On that note, my favorite part of the first module was the Friday morning CBL case wrap-ups that often featured real patients. These lectures felt superior to others in medical school because they humanized the person we spent the past week discussing on paper. I felt immensely grateful to the patients for sharing their stories—stories that could not be captured by a meager few lines in the HPI or social history. They spoke to their experience of pain beyond single-adjective descriptors, detailing the side effects of their medications, relationships with their doctors that were complex and not always rosy, and the support networks that kept them resilient.

Behind each chief concern was a human being with thoughts, feelings and beliefs — yet in our CBL cases, everything is compact, and time is hard to appreciate. As I try to imagine the patients’ ER visits and hospital admissions, I think of each blood test as a instant in which they were sticked, each CT scan a trip to a dark room, each radiology or pathology reading as potentially a life-changing piece of news, and of course, and the hours between those ordeals as palpably stressful. It was hard to overstate how much we valued them for inviting us to a glimpse of their most trying moments.

Still, there is no denying that our guinea pig curriculum has flaws. Our preclinical curriculum is single-pass, meaning we learn both normal physiology and pathophysiology together. In principle, I agree with it but, because my fundamentals were weak (my doing, to be fair), I struggled with being presented treatments for diseases I barely understood. Also, CBL for two full hours three times a week may be overkill for some cases. There was the occasional PCL session in which I nearly fell asleep from sitting for four continuous hours and was wishing I could have been at the simulation center instead. Lastly, our tight schedules leave less-than-ideal time for extracurricular interests and wellness activities. I hope that the kinks will be worked out for next year’s M1s to provide as perfect the mix of all components: sufficient background info but not too many minutiae, emphasis on learning by doing but not going overboard and a spaced-out logical pace instead of 900 slides of dermatology crammed into the last instructional week of Tissue-Musculoskeletal.

Regardless, my school’s comprehensive and integrative curriculum has changed my mind about and better prepared me for our weekly assessments as the months progressed. Early last Fall during a student-guided quiz review session, I recall when someone asked why a certain piece of information in a clinical vignette was necessary for correctly answering the question. I nodded along — there was a symptom listed that distracted me and did not really add much to the question. In response, another student stated that it was indeed not relevant and possibly served as a distractor. I felt slightly annoyed but did not think much of it. Then, later throughout the semester, I came across multiple instances in CBL and PCL in which the patient’s story provided details that not only were not crucial for making a diagnosis but were actually examples of atypical presentations. I realized that if the practice of medicine was filled with ambiguities (patients do not present as multiple-choice questions), then it is not wrong for our quizzes to reflect that reality and evaluate our conceptual competence.

A few months ago, I came across a Reddit post in which a distressed M1 pointed out that there were too many mandatory events that detract from studying for USMLE Step 1. Though I definitely share the sentiment if it comes to any required session on “wellness,” my view is that Step 1 becoming pass/fail is an opportunity to actually view structured supplemental learning as enrichment, not chores. In years past, it would make perfect sense to act as a rational actor in an irrational system, to cast aside anything that unnecessarily eats up valuable time to study for the most important exam we would take in our life. But under the new incentive structure that no longer privileges the knowledge of inconsequential basic science trivia, what was previously extraneous now actively guides our development as future well-rounded physicians. In that respect, the curriculum may be somewhat of a double-edged sword. We work through real patient cases, practicing real-world clinical skills including ultrasound, and even see real patients via telehealth on a monthly basis. But it admittedly comes at the price of precious schedule availability and time to pursue our outside passions.

It is still too early to know how fruitful my school’s new experiment will be in my journey as a future physician. As I reflect on the utility of the curriculum, despite its non-ideal design and implementation, I remain hopeful that I can leverage its strengths before I set foot on the wards.

Rishab Chawla Rishab Chawla (2 Posts)

Contributing Writer

Medical College of Georgia

Rishab Chawla is a first year medical student at Medical College of Georgia in Augusta, GA class of 2024. In 2019, he graduated from Georgia Tech with a Bachelor of Science in chemistry. He enjoys reading, going outdoors, and learning new languages on Duolingo in his free time. After graduating medical school, Rishab would like to pursue a career in psychiatry.