I've heard the beginning of residency called a steep learning curve. I am finding that it feels, at times, more like a learning cliff. You slam yourself against it repeatedly and attempt to find some handholds on your way up, while girding yourself for some inevitable slides back down.
I can only hope that it is not a Sisyphean adventure. I am told that it is not. It is, of course, partly just the usual "learning the ropes" that comes with a new job. On top of that it is confronting the vast bounds of ignorance that you previously knew you suffered from, but successfully were able to ignore. On top of THAT it is navigating the social dynamics intrinsic to any tightly knit group of coworkers who have to learn to work together for 80 hours a week (plus all that time hitting the books trying to make sense of what just happened).
I did manage to have an interesting conversation with an attending about just that latter topic, the 80 hour work week. Of course there are still those who decry its limitations, and I would say that I used to be one of them. However now that I am confronting the realities of both that work week and trying to raise a 3 month old, I much better understand the reasons for the changes. It is simply impossible to lead a balanced life in the modern age, take care of all the other aspects of life, and work much greater than 80 hours a week unless you are the sort (and more power to this sort) that doesn't need to sleep very much at night. For those who have married their job, instead of other people, perhaps more can be asked. But for those of us with families, it would be too much. I think it would impart a kind of spiritual sickness on the experience of residency for those like myself that would be devastating for the profession as a whole.
There is a fantastic piece in the New York Review of Books that describes some of the changes that led to the modern residency. To be sure, these comments apply as much to internal medicine as to my own discipline, pathology. The academic hospital environment has been compromised by the economic requirements of what is, fundamentally, a large corporation. It should be required reading for anyone entering residency (really, anyone entering medical school).
That said, I am still somewhat of an advocate for Malcom Gladwell's 10,000 hours to becoming an expert mantra. 160 hours down, 9,840 to go.
Saturday, July 18, 2015
Tuesday, March 10, 2015
Fourth Year Blues
I have been told by many that I should savor my 4th year medical school year. I have had a few months off already, and now have three in a row coming up. I will, of course, be using it for research. Others travel abroad. Some work on volunteer projects. A choice few will fill that time with coursework.
But this 4th year Spring is, in large part, deadspace. A big gap in the rush towards residency. I realized a few days ago that, at this point, I have fulfilled all the requirements that will make me a doctor. I have taken all of the tests, sat in all of the classes, spent all the time on the wards. There is a one week course at the very end that I need to take, but it is largely a formality.
And yet, I do not get my degree until May. Until that time I am just like any medical student in the hospital, 3rd or 4th year. I cannot write orders, I cannot write notes that count for billing purposes, and I cannot do any work outside the hospital as an M.D., patient care or no. While I have all the freedom in the world, I also have little real responsibility and no opportunity to up my game before being slammed by residency.
This seems foolish. Why would such an expensive system waste such valuable time? In all honesty, I can't figure out the reason. Perhaps it's that the home institution, with its students already matched with residencies, has little incentive to continue to invest time and effort in them. Perhaps more likely, the fact that we are not formally MD's makes us a legal liability and therefore we cannot be given intern level capabilities. Equally possible, perhaps this is what generations of students have demanded: an eye in the storm.
Regardless of the reason, it doesn't have to continue. Waiting for a degree prevents students from taking the next steps in their education when they are ready. It makes the hospital less efficient. It limits an educational opportunity. Residency can start in June, that's fine. We can still walk across the stage in May. In the interim, though, let's recognize the progress we have made for what it is and grant the degree when it has been earned, be that in April, March, or even January! The potential uses of the ensuing time would likely be as varied as they are today, perhaps more so, as some former students might use their new credential in creative ways. Let's unleash this trapped potential.
But this 4th year Spring is, in large part, deadspace. A big gap in the rush towards residency. I realized a few days ago that, at this point, I have fulfilled all the requirements that will make me a doctor. I have taken all of the tests, sat in all of the classes, spent all the time on the wards. There is a one week course at the very end that I need to take, but it is largely a formality.
And yet, I do not get my degree until May. Until that time I am just like any medical student in the hospital, 3rd or 4th year. I cannot write orders, I cannot write notes that count for billing purposes, and I cannot do any work outside the hospital as an M.D., patient care or no. While I have all the freedom in the world, I also have little real responsibility and no opportunity to up my game before being slammed by residency.
This seems foolish. Why would such an expensive system waste such valuable time? In all honesty, I can't figure out the reason. Perhaps it's that the home institution, with its students already matched with residencies, has little incentive to continue to invest time and effort in them. Perhaps more likely, the fact that we are not formally MD's makes us a legal liability and therefore we cannot be given intern level capabilities. Equally possible, perhaps this is what generations of students have demanded: an eye in the storm.
Regardless of the reason, it doesn't have to continue. Waiting for a degree prevents students from taking the next steps in their education when they are ready. It makes the hospital less efficient. It limits an educational opportunity. Residency can start in June, that's fine. We can still walk across the stage in May. In the interim, though, let's recognize the progress we have made for what it is and grant the degree when it has been earned, be that in April, March, or even January! The potential uses of the ensuing time would likely be as varied as they are today, perhaps more so, as some former students might use their new credential in creative ways. Let's unleash this trapped potential.
Tuesday, February 24, 2015
Yield
I managed to somehow end up at a roundtable discussion recently on the topic of funding reform and the future of science. Of course there was some of the usual clamor for more funding, as there has been and always will be. There was also some productive discussion of reforming scientific funding in the biomedical sciences, particularly scientific training.
Many opinions were aired, but there were a few insights that I thought resounded most clearly above the hubbub of what is, of course, a very political question.
1) Cull the herd: Do not allow students to continue Ph.D. degrees if they are unlikely to be successful. There was one individual who offered a clear comparison between what is done in the biomedical sciences and what is done in economics. The benefit of this are, at the very least, less delusion from students thinking that they might be able to go on in academia and less crush for grants when Ph.D.'s go on to apply for faculty positions. The cost is less cheap labor available to PIs in the biomedical sciences.
2) Numerator vs. Denominator: How do we avoid the simple problem of increasing Ph.D.s and constant (or decreasing!) funding. Are there operational efficiencies that can be achieved or some kind of restructuring of granting mechanisms that allow for continued scientific output, career stability, and stable costs? Interestingly the fundamental nature of this question was often overtaken by discussions of how nice individual programs might be in terms of some elements of this equation (e.g. a career track for core lab administrators might permit both continued scientific output and career stability... but at what cost?)
What is the cost, what is the return? In the end, this is an economic question. We in science are at risk of confusing the return to ourselves as the return to the investor. As academics, perhaps this is forgivable. We are, after all, obsessed with the deep questions of science. How does the cell work? How does the genome lock in a frozen, endlessly replicated organic molecule, the blueprint of life? How does cancer evolve? How can we better treat disease? What is good for us in our quest must be good for society, should we successfully answer these questions.
But the fact of the matter is much more complex. Graduate school is not a zero sum game, nor is economics. But the allocation of federal funding, sadly, is. The questions above are never fully answered, they are only answered in part. An attention to yield is paramount. As should be obvious, the yield equation is not the sum of impact factors of all the papers written by a set of investigators. It is the sum of the benefits to the individuals of the nation (the world?) over the centuries.
Whether or not we have stable careers is irrelevant latter sum of benefits, except inasmuch as stable careers allow researchers to do fundamental work (I think that they do, but to less extent than we might claim). What is more relevant, as far as federal funding is concerned, is the fact that a Ph.D. that is underutilized may be a wasted investment. In addition to the costs of funding the Ph.D., society has lost the other work that that presumably intelligent and capable individual could have achieved in that time in another line of work. Depending on the person, this may represent hundreds of thousands of dollars of loss. If they by exiting the academic track in fact exit the job market completely, the loss may even reach the millions.
The fact is, academic departments have become poor arbiters. They are loathe to say no to a student's progression, in part because the student is a low cost laborer for an investigator in the department. Until the departments bear some of the cost of this training, they will not be good stewards of federal training dollars.
The NIH would be right to try to clamp down on Ph.D. training funding at the federal level (among other poorly optimized investments). In the global perspective a Ph.D. pipeline of a bore so vastly wider than the R01 funding pipeline is a low yield investment to society at large. I say this as someone who, as a future investigator who came through in the time of high funding of trainees, will be hurt by the loss of cheap labor welling up below me. However this affects much more than any future lab bottom line, it also influences the credibility of the scientific enterprise as a whole. It is an incredible privilege to do what we do, and to keep doing it we must be good stewards of the public's trust.
As a postscript, should I mention that I don't really believe in the Ph.D. as a degree anyway? Degrees end up being carrots or sticks that PIs can wield against their trainees when they have already become excellent candidates on the job market. Viable Ph.D.s will already have publications and poster presentations to prove the merits of their productivity. The Ph.D. defense has become a formality that we should abolish. Degrees in general, and the Ph.D. in particular, too often become a tool to preserve privilege of elites, and become a dangerous replacement for real competence.
Many opinions were aired, but there were a few insights that I thought resounded most clearly above the hubbub of what is, of course, a very political question.
1) Cull the herd: Do not allow students to continue Ph.D. degrees if they are unlikely to be successful. There was one individual who offered a clear comparison between what is done in the biomedical sciences and what is done in economics. The benefit of this are, at the very least, less delusion from students thinking that they might be able to go on in academia and less crush for grants when Ph.D.'s go on to apply for faculty positions. The cost is less cheap labor available to PIs in the biomedical sciences.
2) Numerator vs. Denominator: How do we avoid the simple problem of increasing Ph.D.s and constant (or decreasing!) funding. Are there operational efficiencies that can be achieved or some kind of restructuring of granting mechanisms that allow for continued scientific output, career stability, and stable costs? Interestingly the fundamental nature of this question was often overtaken by discussions of how nice individual programs might be in terms of some elements of this equation (e.g. a career track for core lab administrators might permit both continued scientific output and career stability... but at what cost?)
What is the cost, what is the return? In the end, this is an economic question. We in science are at risk of confusing the return to ourselves as the return to the investor. As academics, perhaps this is forgivable. We are, after all, obsessed with the deep questions of science. How does the cell work? How does the genome lock in a frozen, endlessly replicated organic molecule, the blueprint of life? How does cancer evolve? How can we better treat disease? What is good for us in our quest must be good for society, should we successfully answer these questions.
But the fact of the matter is much more complex. Graduate school is not a zero sum game, nor is economics. But the allocation of federal funding, sadly, is. The questions above are never fully answered, they are only answered in part. An attention to yield is paramount. As should be obvious, the yield equation is not the sum of impact factors of all the papers written by a set of investigators. It is the sum of the benefits to the individuals of the nation (the world?) over the centuries.
Whether or not we have stable careers is irrelevant latter sum of benefits, except inasmuch as stable careers allow researchers to do fundamental work (I think that they do, but to less extent than we might claim). What is more relevant, as far as federal funding is concerned, is the fact that a Ph.D. that is underutilized may be a wasted investment. In addition to the costs of funding the Ph.D., society has lost the other work that that presumably intelligent and capable individual could have achieved in that time in another line of work. Depending on the person, this may represent hundreds of thousands of dollars of loss. If they by exiting the academic track in fact exit the job market completely, the loss may even reach the millions.
The fact is, academic departments have become poor arbiters. They are loathe to say no to a student's progression, in part because the student is a low cost laborer for an investigator in the department. Until the departments bear some of the cost of this training, they will not be good stewards of federal training dollars.
The NIH would be right to try to clamp down on Ph.D. training funding at the federal level (among other poorly optimized investments). In the global perspective a Ph.D. pipeline of a bore so vastly wider than the R01 funding pipeline is a low yield investment to society at large. I say this as someone who, as a future investigator who came through in the time of high funding of trainees, will be hurt by the loss of cheap labor welling up below me. However this affects much more than any future lab bottom line, it also influences the credibility of the scientific enterprise as a whole. It is an incredible privilege to do what we do, and to keep doing it we must be good stewards of the public's trust.
As a postscript, should I mention that I don't really believe in the Ph.D. as a degree anyway? Degrees end up being carrots or sticks that PIs can wield against their trainees when they have already become excellent candidates on the job market. Viable Ph.D.s will already have publications and poster presentations to prove the merits of their productivity. The Ph.D. defense has become a formality that we should abolish. Degrees in general, and the Ph.D. in particular, too often become a tool to preserve privilege of elites, and become a dangerous replacement for real competence.
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