How Medical School Makes Bad Doctors
When I was young, my parents would tell stories about the rigors of their education.
Not in college, but elementary school.
In addition to the relatively accelerated curriculum the students were expected to get through, they were also put through the ringer as far as testing was concerned.
Instead of take home tests or essays, in class open-book or multiple-choice tests, they were tested the old-fashioned way. A student would be brought in front of the class and asked a question. They were expected to recite their knowledge and understanding on the spot.
In fact, many specialty medical board examinations have an element of this sort we call “oral boards.” These are the real tests of a physician, but they are the outlier in their path to licensure.
Interestingly, the American Board of Radiology dropped the oral board in 2013 until realizing what a catastrophic error it had made, only to recently announce the return of the oral board starting in 2028!
But, this article isn’t about traditional testing or specialty licensing exams.
This article is about the remaining 98% of medical education.
It seems like everyone has a story about an encounter with healthcare that left a bad taste in their mouth - not to undermine the severity of the damage they may have endured.
These encounters take many shapes and involve people from all walks. But, I can only speak from the perspective of a doctor who was brought up through this educational system along with others who had similar ambitions - some of whom ended up becoming doctors.
Along the way, I have witnessed behavior and practices that one can scarcely believe.
In this piece, we will uncover how we get from well-meaning students who want to pursue the noble profession of medicine to unwitting pawns in an industry that priorities funding over patient well-being.
Before we dive into some details, I want you to think of medical education as a pipeline.
At the starting point of the pipeline you have applicants who are trying to get into medical school. Preparing ones resume and getting the appropriate scores on tests is a whole game we can dedicate another article to.
At the end of the pipeline, you have fully licensed physicians who are ready to put industry standard management algorithms into practice.
Medical schools need to select the right people to steward through this pipeline, and they have quite the task in front of them. Partly, because the medical industry is quite a complex beast. They have to select people who:
can work in a high-paced environment with many different people and staff
memorize information relatively easily
are capable of interacting with patients in a fruitful manner
willing to sacrifice their life and relationships for extended periods of time
obedient to authority, and crucially…
will not “rock the boat”
Within this pipeline you need to have checkpoints that demonstrate mastery of a set of topics and skills.
What is the most commonly used method of assessing these milestones?
The same test format every institution of higher education uses.
Multiple choice.
Because, nothing screams competence like learning the game of multiple choice testing.
Of course, there is the odd assessment in which students undergo simulated patient encounters. But, these tests are mostly theater. Nearly everyone passes.
And some of them have already been phased out of existence. Leaving only the multiple choice-based “knowledge” tests.
Humans are not multiple choice
Multiple choice testing is ubiquitous.
My first experience with this format was in grade school when local educational boards would want to gauge the readiness of students to progress to higher stages of education.
In the university, the use of multiple choice tests became commonplace. Many courses almost exclusively used it. There were some professors who recognized the rather superficial and undemanding nature of this format, and proceeded to make the exam questions exceedingly difficult to interpret and time-consuming to complete.
You can only guess how popular these professors were amongst the student body.
In medical school, the vast majority of tests were multiple choice.
It was like clockwork: a new barrage of material to memorize for 2 weeks, followed by a multiple choice exam. The ease of these tests were reflected in the average scores.
In part, this is a reflection of the selection process - by the time a student has made it into medical school, they have become exceedingly adept at studying for multiple choice exams.
It doesn’t get any better when you consider medical licensing exams, e.g. USMLE Steps 1-3. Or with in-service exams - which is a specialty specific standardized test taken by medical students who rotate through a given department.
Or indeed, professional licensing exams.
One of the most grueling exams I have ever taken was the Core Radiology exam, which is taken by graduating radiology trainees. This 2-day multiple choice exam wasn’t hard because the questions were difficult. It is hard because of the unfathomably vast amount of information you are expected to memorize. The majority of the material is not relevant to the practice of radiology.
The multiple choice exam is everywhere. But, why is this a problem?
First, the obvious problem is that humans are not multiple choice tests.
A patient does not visit your office with a set of diagnostic or therapeutic options tattooed on their forehead with options ‘a’ through ‘e.’
Second, it pushes students to memorize bullet points for a multiple choice exam rather than to understand the vast complexity of the human body. Which leads us to the third problem.
Memorization is not very helpful for the purpose of problem-solving. But, this is precisely the skill that needs to be nurtured if you want to produce competent and adaptable physicians that can use their knowledge and experience to help the unique individual that sits across from them in the consultation.
As mentioned, once you’ve selected a cohort of would-be medical students who are exquisitely adept at studying for and taking multiple choice tests…you end up with a class that scores very highly.
Which means failure rates are very low, giving a false sense of security and confidence that you are ushering competent doctors-in-training through the stages of this pipeline.
Furthermore, institutions are dis-incentivized from failing medical students.
Why? As always, the answer lies in the money.
Medical education is an incredibly costly enterprise, and on the flip-side an incredibly lucrative one. Each medical student guarantees up to $250,000 in revenue for an institution. Each trainee brings in close to $200,000 of tax-payer funding to the hospital per year.
If you fail a medical student in the first year of education, you are looking at a net loss of around $180,000 in tuition. If we assume they would subsequently undergo the minimum 3-years of training, an additional $600,000 in funding is lost.
As you can see, not only is there a strong financial incentive to “educate” as many medical students as possible - but, to do so in a low cost and low friction manner.
This means that for every medical student that learns a new topic, we cannot have them come up in front of the class and demonstrate their knowledge on the spot.
Not only would this expose the faults in their education, but also prevent the institution from churning out a few hundred new graduates every year.
Just think of the amount of time it would take to orally test each medical student on every topic from anatomy to ophthalmology to pathology to histology.
Beyond Financial Incentives
It may surprise you to know that most people in medical school have a family member who is also a doctor. Some of whom are faculty within the same institution.
I had one classmate who was stumbling right out of the gate. Could not obtain a passing grade in the first course - anatomy.
In fact, he failed multiple times.
Was he dismissed from medical school? No.
On the contrary, he progressed to the next semester. Why?
His father was a department chief within the institution.
I have also had the displeasure of working with residents who are clearly not fit for this profession. Not simply out of incompetence. Some were sociopaths. Others, malevolent narcissists.
Crucially, they knew how to use the policies and games set forth by the ACGME (Accreditation Council for Graduate Medical Education). In combination with a generation of administrators who care more about maintaining the status quo than upholding any standards of competence and integrity, these people frequently make it through the pipeline unscathed.
As if it wasn’t concerning enough that the standard for testing competence is flimsy and game-able, we are also dealing with an administrative class who have no problem putting the lives of patients in the hands of sociopaths.
Maybe to some extent, they see reflections of themselves in these individuals. Given that administrators are so detached from patient care, they may have no qualms placing their own and the institution’s needs above those of patients.
The Cherry On Top
The uncomfortable reality in all this is that doctors and students are to some extent keenly aware of just how little they truly understand about the body and health.
Many feel deep down that most of what they “know” are simply tidbits of information or management algorithms that have become the norm by which they “practice” medicine.
In my opinion, this puts them in a rather precarious position.
On one side, you are looked to as the authority on all matters of health and disease.
On the other, you are working in an incredibly lucrative industry.
The lucrative nature comes with occupational hazards.
First, you do not want to upset any major players in this game - including other departments in your institution. Rocking the boat, as the saying goes, is a highly risky move in almost all institutions.
Second, an industry that deals with large sums of money will naturally attract legal liability. The potential payoffs are massive.
Put yourself in the doctor’s shoes:
the measure of your competence has in large part been determined by a game-able testing format - you know this, even if you don’t talk about it
you have been told how to diagnose and manage patients from dictates up high
you do not have the foundational understanding of biology to question these assertions
any deviation from industry standards and hospital policies will result in reprimand from your colleagues at best, and courts at worst
ultimately, when faced with evidence or claims in contradiction to what you were told to memorize, you find yourself in a sea of uncertainty
How do you act?
This is Fiat Medicine.
The epiphany for me was two statements that my doctor made to me:
1) "You know more about nutrition than I do."
2) "I don't work for you. I work for your insurance company."
Being retired, I now have the freedom to do my own research on medical issues. After 8 years on a diet that incorporates Keto, time restricted eating, ancestral eating, and my own personal tweaks, I've come to know who to trust. My library is full of books from a small pool of doctors who have proven to me through my n=1 study that they know what they are talking about. Unfortunately for most people, there is simply no way to invest the time to do this. They must rely on the expertise of someone that may or may not be invested in their health.
It seems to me that the prime focus of my medical education was to find what pharmaceutical products the patients’ were deficient in and prescribe it. In a multiple choice format, no less.