Dr. Rangel posted another critique of the Stanford curriculum reform (there’s a contest going to come up with a better name than “The Stanford Model”), and while I can kind of understand where he’s coming from, there are several important points that I’ll try to clarify. We’ll do the email-reply format, just for clarity.

bq(quote). While some students are perfectly happy doing the 200 hours of specialized academic study there are some who would rather volunteer at a clinic for the homeless, or help build a house for Habitat for Humanity, or learn Spanish, or even practice yoga! DocShazam expands on this point.

It’s not just typical “academic research” that’s supported academically. We’re allowed to do community service, work in a clinic, or hell, learn Spanish. And if we do some clinical research at the same time (it has to be approved by a faculty review board), it can count toward our concentration, too.

bq(quote). Then there is this puzzle I try to understand. It’s curious that so many Stanford medical students find it necessary to do so much independent study and extracurricular activities that up to 70% of the them were having to take five or more years to graduate from a four-year program. There are two main problems with trying to do too much during medical school. The first is that the more time you spend in medical school the more debt you accrue (or are most of these students independently wealthy?).

We’re not having to take five or more years to graduate from a four-year program, we’re choosing to take more than four in a program that’s specifically flexible and not a strictly four-year program. If it were truly a four-year program and 70% of us were taking five years to graduate, then I’d definitely worry. Also, we’re actively encouraged in many ways to stay around longer and do research or other activities. First, once you pay for four years’ worth of tuition here, tuition drops to 10%. Second, we get “paid” (translation: have a decrease in our loan debt) for approved research programs or for TAing classes. Generally students spread the research project out over several quarters, or get “25% TAships,” meaning the TA position only requires 25% time, so you only get 25% of the normal amount. Finally, Stanford gives extraordinarily generous financial aid packages to all of its students; the average student debt is somewhere around $70,000; this is lower than other private schools (~$95,000 indebtedness) and even lower than out-of-state UCSF.

bq(quote). The other problem is that those few years of your life you spend in medical school should be totally devoted to medical study… students are in medical school to study for the ultimate benefit of their future patients. … Than again, Stanford medical students may cherish idealism as a physician trait but (ironically) it doesn’t seem to impress the very target of this whole crazy endeavor . . the patient! The patient sitting in the ER with crushing chest pain doesn’t care if their physician took some extra time to study “Environmental Issues” or “Public Health Policy”.

I think Dr. Rangel and I start off with similar ideas about the role of the physician, but diverge further down the road. He’s completely right. Duty numero uno (and in fact, the sole duty) of the physician should be to improve the health of his or her patients. No disagreement there. It’s how we define “improving the health of patients” that brings me into conflict. In my view, I can’t reasonably argue that I’ll be improving the health of my patients without looking more globally. (I might as well just cut and paste my med school personal statement at this point, but I’ll resist the temptation.) Absolutely, hands down, my number one goal is to come out of medical school with the knowledge, experience, training, and ability to be the best resident I can be, for the benefit of my future patients. But how can I remain actionless when I see the same problems over and over? Lack of insurance. Alcoholism. Teenage pregnancy. Abuse. I’d argue that I’m doing a disservice to my patients as a whole if I don’t learn the health policy and how the system works. Or why lead poisoning and other environmental factors are so dangerous. Or even how to communicate with patients in Spanish. Believe me, in no way do I say this as some sort of rationalizing about Stanford’s curriculum (I rationalize enough to know when I’m doing it). But, at least for me, I don’t feel like I could say I’m in the patient’s corner unless I learn how to be an advocate and an activist. For other classmates, I think they probably feel the same way about doing research to develop new therapies, procedures, or educational or analytical tools.

Why now? Why not once I’m a resident? Or even a clinical student? Because we’re creatures of habit. I’m afraid– frightened –that if I don’t get these values and skills and education in my head now, they’ll never seep in. I’ll be too busy as a resident. And once I get out of residency, and into some sort of regular practice, maybe I’ll be too old to change my ways. Maybe I won’t. Who knows. But I do know that I’ve got the energy and the time (and the debt) now. And I’ve learned that once you start expecting things in your future, life ends up disappointing you, so I might as well work on what I know I can do now.

When the man comes staggering in to the ER with acute angina or a pneumothorax, policy won’t be on my mind; his health and his treatment will. But I think part of the reason we’re where we are today is because most physicians in the past have entirely focused on medicine, while largely ignoring greater social and political issues that directly contribute to health, morbidity, and mortality, for fear of seeming somehow “subjective” and therefore, unscientific and untrustworthy. Remember, it was mainly public health that caused the great life expectancy gains in the 20th century, not medicine. Shouldn’t we know how that happened? And as for the question, “Why physicians,” they’re in a unique place in society to affect change. It’s probably not fair, but physicians still have a level of prestige and authority in the US that public health researchers or policy analysts simply don’t.

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