5 Things I Wish I Knew Before Starting Medical School
Dr. Jake Groenendyk is a native of Sioux Center, Iowa. He attended Covenant College in Lookout Mountain, Georgia, and graduated with a B.A. in Biology, followed by an M.D. from Washington University in St. Louis. He is now an internal medicine resident at Northwestern University, and in his free time enjoys reading, running, and cycling.
Imagine that you’re officially done being a pre-med.
You’ve survived all of your pre-med requisites, maintained your GPA, mastered the MCAT, polished off your personal statement (several times), submitted your AMCAS / AACOMAS, got your secondaries in on time, nailed the interview, and cried when you got the acceptance letter.
Bliss. You’re officially going to medical school.
But, how long does that feeling of security last before you realize you know very little about what medical school is actually like? Pre-med seems like the hardest thing you have ever done, but then they say it pales in comparison to the firehose of information that is your first year of med school.
What did I truly learn in college? Were my study habits effective? Will I have any free time whatsoever in medical school?
These were just a few of the questions that replaced the feeling of relief upon finding out I would be going to medical school in the fall. Now that I have graduated from medical school and am about to begin my residency program, I can confidently answer these questions from experience.
Neither of my parents are physicians. Although I certainly conducted research on my own and received guidance from mentors, there are still several things I wish I had known before entering medical school. With those years behind me now, I provide you with several helpful pieces of information, in no particular order, to smooth your transition.
1. There is a lot of memorization:
About a week before medical school orientation, a physician for whom I have great respect told me that she hated the first two years of medical school and seriously contemplated quitting.
Because she is now a successful professional who loves her job, I was quite shocked to hear this. Just two weeks later, as I sat in a very dry lecture on ion channels, I could see what she meant.
There is a lot of memorization. I came into medical school excited about helping people and the intellectual challenge of practicing medicine, but a month into medical school, I didn’t seem to be experiencing much of either. Our classes were certainly challenging and required a fair amount of work; yet, much of the early evaluations and the board exams seemed to test rote learning rather than critical thinking. Which of these drugs will suppress a patient’s white blood cell count? Which nerve signals the muscles that allow you to extend your arm? Is corneal clouding associated with mucopolysaccharidosis type I (Hurler syndrome, due to a defect in alpha-L-iduronidase) or II (Hunter syndrome, due to a deficiency of iduronate-2-sulfatase)? (Hunter vs. Hurler syndrome is a classic favorite of board exam question-writers, though they occur in 1:100,000 or fewer live births in the U.S.)
Ultimately, you will move on to more interesting and intellectually stimulating challenges as your knowledge progresses. Eventually, you’ll develop differential diagnoses for a particular constellation of symptoms and decide which is most likely for a given patient. You’ll be asked to interpret the scientific evidence and determine which treatment is merited for your patient. Maybe you’ll ask your own research questions and figure out how to answer them.
“There is a lot of memorization. I came into medical school excited about helping people and the intellectual challenge of practicing medicine, but a month into medical school, I didn’t seem to be experiencing much of either.”
You’ll certainly be asked to help patients and families walk through difficult situations-- cancer, trauma, dementia, and more. But these can feel remote when your main task is to memorize on which chromosome the gene affected in neurofibromatosis type II is located. While I was surprised by how much memorization engulfed my study hours, it was reassuring to know that it had little bearing on my future enjoyment of the practice of medicine.
Pre-Clinical and Clinical Phases
Traditionally, medical school curriculum has been split into pre-clinical and clinical phases; during the preclinical phase, students learn the anatomy, pathophysiology, and pharmacology needed to treat patients, while the clinical phase (traditionally the last two years of medical school) focuses on developing the interpersonal and technical skills needed to competently diagnose and treat patients as a member of the healthcare team. Thankfully, medical schools have recently recognized that early clinical exposure is vital in the student educational experience. Because of this, there has been a significant effort by many medical schools to make the first two years of medical school more than memorizing thousands of PowerPoint slides.
2. Curriculum varies between medical schools
Medical school curriculum is highly structured. The LCME (Liaison Committee on Medical Education) has very detailed guidelines for how schools should function, what material should be covered, etc. Everyone applying to U.S. residency programs takes the same board exams-- either USMLE (allopathic) or COMLEX (osteopathic).
As mentioned previously, medical school had been traditionally divided into preclinical (first two years) and clinical (last two years) curricula. There are probably as many different medical school curricula as there are medical schools.
Premedical students can easily get lost in the weeds of trying to understand which curriculum is best for their learning style: Pure lecture? Flipped classroom-style small groups? A heavy emphasis on early clinical exposure, or time to focus on learning the basic pathophysiology well before picking up clinical skills?
While there are some curricula that don’t fit particular students well, the importance of this question is debatable. Variations in the structure of the curriculum will affect your daily life as a medical student. Are you worried about being prepared for your small group, or that you’ve fallen behind in watching lectures from home? Are you concerned about whether you’ll get an honors on the cardiology exam, or kicking yourself for blowing off that pass/fail renal exam three months ago now that you have to know that material for boards?
Most medical schools use a variety of teaching methods to communicate information to their students. Imagine a continuum with large group lectures at one end and small, “flipped classroom” discussion groups at the other. You may have encountered flipped classrooms during undergrad courses; there are many varieties, but the essential idea is that students are responsible for covering the content outside of the classroom and then reinforce and apply this material in small groups. At some medical schools, almost all teaching occurs in large lecture halls, while at others, almost all instruction takes place via flipped classroom-style groups. Most medical schools fall somewhere in the middle with a mix of large lectures, flipped classrooms, and medium-sized group labs or discussions.
When deciding between two otherwise similar medical schools, it can be helpful to consider which structure might work better for your learning style. Of course, this can be a challenge to predict in advance. In my case, I probably would have opted for a flipped-classroom style curriculum if I had been given the choice before medical school. However, halfway through my first year, I came to really appreciate the flexibility allowed by a lecture-based curriculum (since almost all of our lectures were video-recorded, they could be watched at any time from anywhere).
One of the simultaneously wonderful and not-so-great aspects of medicine is that (typically) healthcare providers need to be physically present. This is positive, in that the doctor-patient relationship continues to feel real, even in an era when we are disconnected in many ways.
On the other hand, it is unlikely that those of us in medicine will end up with the flexible or remote-working arrangements that have become more common in other fields, such as tech or advertising. Because of this, I tried to take advantage of the flexible studying arrangement of my preclinical years while I could. Sometimes this meant spending a long weekend at home with my family and watching lectures from hundreds of miles away. At other times, it meant sleeping in and watching lectures until 3 AM-- I felt like I could pay better attention at 1 AM than immediately after lunch at 1 PM. This also allowed for some flexibility to be involved in student groups. For example, during my second year of medical school I did outreach to community organizations for our student-run free clinic. Recorded lectures allowed me to meet with employees from local nonprofits during their normal work hours, then go back and watch lectures at night or early the next morning.
This is how the curriculum worked for me, but everyone is different. Students should consider their own learning style while remembering that they will be more adaptable than they expect. There will likely be many situations later in life where content delivery is not tailored to your learning style, and mastery is still expected.
“At some medical schools, almost all teaching occurs in large lecture halls, while at others, almost all instruction takes place via flipped classroom-style groups. Most medical schools fall somewhere in the middle with a mix of large lectures, flipped classrooms, and medium-sized group labs or discussions.”
3. In general, medical schools are very cooperative rather than competitive
Many pre-meds experience an atmosphere of ruthless competition in undergrad. Their peers are notorious for hyper-competition and perfectionism. And, given that most medical students and physicians are former pre-meds, these traits carry on over time. But most of us also notice that the environment is dramatically less competition-friendly and more collaboration-friendly once we reach medical school.
In my experience (which friends at more than 10 other medical schools have corroborated), classmates were often my best resource, whether studying for the upcoming anatomy exam or board exams, or getting the lowdown on expectations for the upcoming trauma surgery rotation. I still remember reviewing a life-saving slide deck entitled “The Odyssey of The Puppy Lymphocyte” around 2 AM on the night before a histology exam, for which I was very unprepared. This was created by my classmate Mindy, and explained T- and B-cell maturation using cute puppy and kitten photos. I learned my preferred method of studying for boards from a friend.
I learned how to ask my resident “Can I go home now?” and how to “pre round” on patients first thing in the morning from a student in the class ahead of me. My first week of third year was the first time I actually met this student, but I had reviewed his shared electronic flashcards thousands of times during my second year.
There are several reasons for this increase in collaboration. One is that the proportion of people being accepted into the next step of training is much higher in medical school than it is for pre-medical students. Approximately 92-95 percent of graduating US allopathic seniors match to a residency program in a typical year, while in recent years only around 40 percent of applicants to U.S. medical schools have been accepted.
Second, medical schools recognize that healthcare is a team sport and actively encourage collaboration among their students. I’m sure there are many other reasons for this change, but the final one I’ll list here is that you’re likely to make lifelong, wonderful friendships within your medical class, and it’s difficult to not help each other out during this time.
4. It’s perfectly OK to not know which field of medicine you want to practice
“Oh! What kind of doctor are you going to be?” is a question you’ll have to answer hundreds of times before graduating medical school. Often, people look at you like you’re a bit foolish if you respond “I’m not sure,” as if you are spending all this time and money to go to medical school without a plan for what you’ll be doing afterward.
In reality, it is pretty rare to find medical students who know exactly what they’ll be doing for the rest of their careers, and it’s probably better for most of us to avoid becoming emotionally committed to a particular field too early. When I started medical school, I told people I wanted to be a urologist. However, the basis for my decision was based on much more than meeting a urologist who was very charismatic and enthusiastic about his work. Many of my friends changed their speciality target multiple times throughout medical school. Keep in mind that sharing your plans to pursue a specialty can create pressure to follow through with it, even after you’ve realized that it is not a good fit.
“most of us also notice that the environment is dramatically less competition-friendly and more collaboration-friendly once we reach medical school.”
5. Stay on top of wellness
Last on this list, but certainly not least, is the importance of staying well. Depending on who you ask, wellness has different meanings. If I could go back to my first year, I would remind myself to get enough rest and cultivate relationships and hobbies outside of medicine. Medicine has a noble tradition of self-sacrifice and putting the needs of patients first. This is a good thing in many ways; healthcare should be about the patient, not the providers.
However, this impulse can become pathological when we fail to care for ourselves and become unable to provide excellent care for others. Despite my fond memories of living on frozen Trader Joe’s burritos for six weeks while studying for Step 1 of my board exams, I probably would have done better had I been more intentional about wellness. Adequate sleep, exercise and cooking a meal now and then will not ruin your chances of success; they will probably improve them. Increasingly, physician burnout is recognized as a challenge to our healthcare system. Set yourself on a healthy track as soon as possible.
When Breath Becomes Air is a beautifully-written memoir by a former Stanford neurosurgery resident who died of lung cancer at age 38. In addition to his reflections on literature, life as a physician and a patient, and death, he vividly describes life as a medical student.
AAMC What to expect from the American Association of Medical Colleges
Jake Groenendyk is a native of Sioux Center, Iowa. He attended Covenant College in Lookout Mountain, Georgia, and graduated with a B.A. in Biology, followed by an M.D. from Washington University in St. Louis. He is now an internal medicine resident at Northwestern University, and in his free time enjoys reading, running, and cycling.