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On giving advice to first year medical students James M. Lewis To cite this article: James M. Lewis (2015): On giving advice to first year medical students, Medical Teacher, DOI: 10.3109/0142159X.2015.1078894 To link to this article:

Published online: 16 Oct 2015.

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Date: 17 March 2016, At: 13:25

2015, 1–2, Early Online


On giving advice to first year medical students JAMES M. LEWIS

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Marshall University, USA

Our medical school recently initiated the One Book program for incoming first year medical students to discuss at orientation. The choice of Groopman’s ‘‘How Doctors Think’’ (2007) intrigued me because I had actually recently read the book, hoping it might improve my analytic skills in medical problem solving. Although well written, I was disappointed that the focus seemed to be more on how lawyers, surgeons, and Dr Groopman made decisions. Considering myself an expert on the book, I sent an email critique of its value as a teaching tool to the project coordinator. Two months later, to my surprise, I received a parking pass by campus mail with instructions to report at 8:30 AM the next week as a facilitator. Accepting her thanks for volunteering, I confidently skimmed the book, rescheduled my patients and found my parking space arriving fashionably late. All of the faculty professor co-teachers were already seated in front of ascending tiers of brand new first year students. As unobtrusively as possible I slipped into the last available chair while the instructor finished her opening remarks. After introductions, she unexpectedly asked each of us to recall our first day as a medical student and provide some brief but appropriate insights. Fortunately, she began at the far end of the line giving me a chance to collect my thoughts while I listened. The first physician’s overblown treatise on following your bliss was punctured by the accusation of a no-nonsense specialist that it was pompous drivel. His simple instruction was to just straighten up and get to work. The next physician was even more succinct in offering one word, ‘‘Exercise!’’ Another inspired them to remember that all they needed to do was to pass because ‘‘C ¼ MD’’. A brief, but noisy side argument broke out among panel members concerning who was or was not wearing a white coat and seeing more patients without establishing why it was relevant. The remaining panel members offered a weak consensus opinion on the importance of balancing work with something else. When my turn came to speak, both the students and I were thoroughly confused. Subsequently reviewing the literature, I found surprisingly little research on the topic of advice for new medical students. A Google search, however, came up with 61,500,000 general references. One of them could have been a recent Dilbert newspaper comic strip defining advice as ‘‘ego and ignorance

masquerading as helpfulness’’. Although the value of advicegiving may be suspect, the practice is ubiquitous. The irresistible urge of the expert to give advice is matched only by the desire of the novice for easy answers. It may be fortunate then that the fate of most advice is to be ignored or quickly forgotten. Smith surveyed the international members of the editors of the British Medical Journal, including the father of evidencebased medicine Dr. David Sackett, for their words of wisdom for new medical students (Smith 2013). He categorized their ideas into seven themes: to thine own self be true, admit your ignorance, develop a clear sense of values, put patients first, recognize that integrity is a destination not a state, and as a final thought – a prayer and a word on the importance of learning. Coverdale presented an equally complex plan to develop professionalism in students by cultivating the four fundamental virtues of integrity, compassion, self-effacement and self-sacrifice (Coverdale 2007). The research supports the impression that there may not be a universal, one-size-fits-all axiom but rather multiple sets of aphorisms with exceptions to every rule. However, at the time in front of the first years, I was unable to articulate a single coherent thought. Instead I began reminiscing aloud about my first day at medical school. Recalling that dim, long-past era, I found myself once again perched in the highest row of a similar shiny amphitheater in Buffalo, New York looking down at my new professors, talking soundlessly one by one in their long white coats. I was startled to attention when the last and apparently most important figure stepped up to the microphone and loudly asked us to stand and shake the hands of the classmates on our right and left. After the commotion died down, he told us more gently to say goodbye because by the end of the year one of us would be gone. The advice that motivated me for the next four years came as he seemed to look directly at me and said – ‘‘Be sure it isn’t you!’’ Before I could continue my exposition, the coordinator quickly interrupted with the urgent reassurance that, of course, none of them would ever have to worry. The medical school had established programs with strong educational safety nets and emotional supports to prevent student failure or discouragement. This was welcome but perhaps questionable news given current reports that up to one half of all doctors in

Correspondence: James M. Lewis, Department of Pediatrics, Joan C Edwards School of Medicine, Marshall University, 2915 Rear 3rd Avenue, Huntington, WV 25702, USA. Tel: +1 304-691-8927; Fax: +1 304-525-5400; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/15/0000001–2 ß 2015 Taylor & Francis DOI: 10.3109/0142159X.2015.1078894


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J. M. Lewis

practice today describe themselves as burned out in an occupation with the highest rate of suicide in the nation. The most recent data on burnout in US medical students, residents and physicians in the first five years of practice is drawn from 2011a to 2012 national survey (Dyrbye et al. 2014) using the Maslach Burnout Inventory consisting of three subscales: emotional exhaustion, depersonalization and a sense of personal accomplishment (Maslach 1996). They also inquired concerning symptoms of depression, suicidal ideation and fatigue in the previous twelve months. The medical students scored the highest in almost every category: burned out 55.9%, positive screen for depression 58.2%, suicidal ideation 9.4%, and high fatigue 57.7%. These disturbing numbers were significantly higher than a similar aged control population. The effectiveness of individual strategies such as mental health services, stress reduction and mindfulness to reduce these alarmingly high rates has not yet been proven. There are, unfortunately, indications that rate of burnout in practicing physicians is actually increasing (Peckham 2015). Organizational interventions, such as shortening work hours, to address the contributing system factors in curriculum and training are being developed and evaluated. Two examples recently published include revisions of guidelines to improve medical school program support (Vogan et al. 2014) and to identify emotional predictors of depression in medical students (Wimsatt et al. 2015). My approach to the 2015 One Book project based on Sweet’s ‘‘God’s Hotel: A doctor, a hospital, and a pilgrimage to the heart of medicine’’ (2012) has changed. Knowing the high incidence of burnout I hope to be more empathetic and helpful to the students I meet. Understanding the subjective but singular nature of advice I have discovered what I should have said last year: You have just received an excellent introduction to the confusing advice and conflicting ideas that will be a constant in your life as a doctor. What you have heard today is not an evidence-based algorithm for success in medical school, but simply the suggestions of a self-selected sample of physicians who believe that have learned something of value. But only you over time can discover what is true for you. Although, you already know about the value of working hard, soon you will discover that your path through medical school, residency, fellowship, and beyond will become difficult in unexpected ways. Your worthy goal to become the best doctor you can be will compete with your struggle to become the best person, son or daughter, husband or wife, father or mother that you can be. Every patient you see will


demand your full attention and expert knowledge insist on competent skills and hope for a compassionate attitude as they share their lives with you and rightfully expect answers. You will experience unimaginable successes and heartbreaking failures that will change you irreversibly. Today, as I look out and up at you, what I see clearly on every face is undiminished happiness sensibly mixed with a trace of apprehension. That feeling is the joy of realizing your first true step toward becoming a physician. Find that joy of medicine in your heart every day and do the things in your life that help keep it strong. Because you are going to need it every day, the best advice may be this paraphrase from the Psalms ‘‘This is the day the Lord has made – let us rejoice, be glad in it and kind to one another.’’

Notes on contributor JAMES M. LEWIS, MD, is a Professor of Pediatrics, Joan C. Edwards School of Medicine at Marshall University.

Acknowledgments I thank Amelia Beatty for secretarial assistance. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the article.

References Coverdale JH. 2007. Virtues-based advice for beginning medical students. Acad Psychiatry 31(5):354–357. Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shahafelt TD. 2014. Burnout among US medical students, residents and early career physicians relative to the general population. Acad Med 89(3):443–451. Groopman J. 2007. How doctors think. Boston: Houghton Mifflin. Maslach C, Jackson SE, Leiter MP. 1996. Maslach burnout inventory manual. 3rd ed. Palo Alto: Consulting Psychologists Press. Peckham C. 2015. Physician burnout: It just keeps getting worse. Medscape. Jan 26. Smith R. 2013. Thoughts for new medical students at a new medical school. BMJ 327(7429):1430–1433. Sweet V. 2012. God’s hotel: A doctor, a hospital, and a pilgrimage to the heart of medicine. New York: Riverhead. Vogan CL, McKimm J, DaSilva AL, Grant A. 2014. Twelve tips for providing effective student support in undergraduate medical education. Med Teach 36:480–485. Wimsatt LA, Schwenk TL, Sen A. 2015. Predictors of depression stigma in medical students: Potential target for prevention and education. Am J Prev Med. [Epub ahead of print]. doi: 10.1016/J.AMPRE 2015.03.021.

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