“Bootcamp” and the purpose of the 4th year of medical school

Disclosure: I serve as a track director for some of the below described activities for our MS4 students, and was a director for the curricular redesign at Utah from 2008-2011.  I wouldn’t say I’ve had a big financial gain from this, but I definitely have had “skin in the game,” so to speak.

This afternoon we wrapped up Week 3 of our 2nd annual “Transitions to Internship” course for our soon-to-graduate 4th year medical students.  The University of Utah implemented a curricular transformation in 2009; a key part of this change involved the creation of tracks during the 4th year based upon student specialty choice.  We spend part of the academic year providing direct mentoring to our students about the residency application and interview process and in April we have a four-week internship preparedness course.  As part of these changes in the 4th year we have also provided more clear structure for the students regarding recommended and required courses during the 4th year.  While there has been a historical debate about using the 4th year as an opportunity for professional development versus personal development.  Students have unique individual needs based upon specialty selection, background, academic performance to date, long-term interests…in short, a plethora of factors (many of which are not controllable) influence what constitutes an “ideal” fourth year.  A new facet is brought to this dialogue by the recent ACGME mandate for direct intern supervision while on-call as residency program directors have an immediate and salient interest in the content of the fourth year curriculum. Most recently, the proposed core Entrustable Professional Activities (EPAs) have sought to describe a minimum core of skills, attitudes, and behaviors that should be present in interns on Day 1.

Not surprisingly, as someone who works closely with our 3rd and 4th year medical students, I have pretty strong opinions about the 4th year and how it would be used in a perfect world.  Ideally, it serves as a capstone year for career development, with both optimized clinical involvement and non-clinical leadership and learning opportunities.  I tend to agree with the surveyed program directors cited above who counsel against students spending a significant portion of their 4th year doing rotations in their future specialty; the truth is, they have the rest of their lives to do those things.  What I do want them to do is graduate as a well-rounded physician with a broad medical knowledge foundation that will serve them well in that chosen specialty.  My general surgery advisees know that means that I’m going to tell them to spend time in the ED, with anesthesiology, and with medical subspecialties- all things that are relevant to their future practice but that they are unlikely to have dedicated time to study once they start internship.  I tell them to do ONE month of surgery sub-internship, with the intent being to truly prepare them to be an intern in surgery, and one month of ICU service (because it will be valuable their first night on call).  I believe the addition of an intern prep course/ bootcamp to the curriculum is invaluable, and I appreciate knowing that my students are leaving here with a certain baseline set of skills that I can document.  If I could advise them to do a month-long leadership elective- something I am passionate about- they would do that.  My interest in students having a leadership elective option has become even more strong over the last few years as my own career has evolved; that month I spent in Austin working with the Texas Medical Association lobbyists as an MS4 has proven invaluable in my role on the SurgeonsPAC Board since 2011.  Blogger’s note:  See, I wasn’t just goofing off in Austin the month before graduation, though I don’t know of a more beautiful place in May.

And audition electives?  Honestly, I would make them go away if I were queen of the medical student world.  I thoroughly understand the arguments for and against, but at the end of the day…they’re costly, and in my own specialty they seem to not be terribly high-yield.  Those two months I spent doing them as an MS4 simply helped me learn that I didn’t want to be an intern at either institution I spent time (which maybe does have some value after all).


Why academic surgery: thoughts for medical students

One of my key areas of interest, and an active area of research for me, is the barriers to careers in academic surgery.  I’m honestly pretty excited about some things I’m looking into and learning on that front, mostly because I want to keep my colleagues, my mentees, and for that matter myself from being part of the attrition statistics.

A few months ago I was asked to write a blog post for the Association for Academic Surgery with the intent of convincing medical students with career intentions in surgery that academics is a great way to go, and that many options for a career in academic surgery are out there.  Since I just returned this evening from the Society for Critical Care Medicine Congress, I’m using this as an opportunity to cross-post my own work.

Sure, you’re a medical student who is interested in a career in surgery.  You hear people talk about  “academic surgery,” but you’re not entirely certain what that means.  More importantly, why should you consider academic surgery as a career?

The historic academic surgeon shows little similarity to the modern academic surgeon.  The conventional definition was that an academic surgeon was to be a triple threat- clinician, educator, and researcher. Part of that definition as a researcher was to be a basic science researcher; clinical research and outcomes, education, global health- none of those things were on the radar screen of possibilities for credible research.  Fortunately, times have changed and the definition of scholarly activity has broadened tremendously.  A simple review of the program for the Academic Surgical Congress demonstrates this increased breadth, with tracks dedicated to basic/ translational research, clinical trials and outcomes research, global health, and education.  In addition, many now consider administration to be a fourth facet to the ideal academic surgeon.  Although that does increase the theoretical demands placed upon academic surgeons, there is also growing recognition that the idea of someone demonstrating excellence in all four domains is less likely; promotion and tenure criteria at many institutions are being adjusted commensurate with that injection of realism into the process, now asking for recognition in perhaps two of the four domains.  This new view of academic surgery opens up many options for academic surgeons, and even within the career of many of the leaders of the Association for Academic Surgery we’ve seen the creation of a bigger tent as young surgeons innovate in their scholarly activity.  My take-home message for a junior resident or medical student contemplating the concept of academic surgery is that it is a career increasingly defined by those who are in it, with expanding acceptance of alternative forms of scholarship.

On to that next question- why academic surgery?  Certainly there are a few prerequisites that you should meet before you commit to a career in academics.  When I review the characteristics of the most outstanding, committed academic surgeons I know, they share a few key qualities.

  • They are innovative.  Regardless of their field of scholarship, they are always pushing the boundaries and looking for new and better ways to do things.  If you are risk-averse, you are unlikely to be happy advancing scholarship in your field, and if you’re not going to advance scholarship in your field, a career in academics is likely a non-ideal fit for you.
  • They are passionate about their chosen career and all facets of it.  Yes, all surgeons are passionate about surgery.  But among the true greats in academic surgery, you find that they are passionate about surgery and scholarship.  You’ll also find that their enthusiasm is infectious!
  • They are committed to academic surgery and they are tenacious in their promotion of the field.  In order to succeed in academic surgery, you need to be both a mentor and a mentee.  The best academic surgeons have never shied from either end of that relationship, and have used both roles as opportunities for growth.
  • They are always teaching.  Think about that person who really influences you in medicine and surgery- they are the person who always has a few moments to teach about clinical care, the state of research, the state of education.  When you engage them on those topics, not only do you get the benefit of their wisdom, but you also get to watch their faces light up when the talk about those things that get them intellectually or technically excited.

While a career in academic surgery might be viable if you don’t meet these criteria, you’re certainly more likely to succeed if you have these qualities.  Don’t be frightened off by them, either- with a good mentor and genuine enthusiasm for what you pursue, they’re not that difficult to develop.

Should you become an academic surgeon?  My answer at this point in my career is a resounding yes!  The field has so much to offer, and the idea of being on the leading edge at all times is irresistible to me.