Date

Yesterday I finished my last non-standardized exam of medical school, Block 12 of M2. Today I chose to call my apartment complex office administrator a "cryptofascist" so it's okay, I can admit it -- I need a break.

It's been tough not writing much of anything public for the past two years, but when you're mixed up in the bowels of the preclinical medical education all you can really do is complain about them. Figured I'd spare you all that, and use this opportunity to thank everyone who had to put up with me irl in the meantime.

There's a whole brand of writing about what medical education is "really like," blogs upon blogs by med students about med students for med students, Netflix specials, books with preciously dramatic titles about the process, writing careers created and destroyed on the subject of depicting Life In Medicine. I just got done with one part of the process, and so my goal is to either provide a unique perspective or heap more red meat upon the pile. My thoughts are organized into three main points.

### 1. How well you can do is mostly already decided.

Anyone who has ever learned a foreign language is familiar with the experience: you bust your ass for four years in classes and manage to attain a certain grasp of the grammar and vocabulary, only to travel to the country where that language is spoken and find third graders conjugating circles around you.

As your relatives and seniors and administrators will tell you, medicine is a lot like that -- there are a lot of new words, new concepts, and it's only a matter of time before you accidentally provoke one of the natives and end up in a screaming match about pronunciation of the word "duodenum." Just me? Anyway, the novelty that allows us to romanticize medicine as a culture won't be distributed evenly among your classmates. We don't like to talk about it, but there are undergraduate programs dedicated to producing competitive premeds and med students. (In my first research internship, my labmate came from one of these programs nearby, and could list the names, mechanisms, and common side-effects of all the beta-blockers on the formulary of the local hospital. It was just part of the curriculum. He was a sophomore.) I'll illustrate the challenge with a sentence.

$$CTX\phi$$ is a filamentous, lysogenic bacteriophage whose genome encodes the cholera toxin.

What does that sentence mean to you? If you have a strong background in microbiology, probably quite a lot. If you don't you'll probably have to look up every word in the damn thing before spending 20 minutes figuring out what it really meant in its own context. My background isn't biology, it's IT, so here's another sentence:

git-remote manages the set of repositories whose branches you track.

This sentence means a lot to me because I'm familiar with the software this is describing and the problem it was invented to solve. But you can see where git acquired its reputation for being condescendingly terse.

So med school is a lot like taking a hundred or so high-achieving test-takers and having them all learn a brand new programming language. We all have the capacity, and technically we'd all be starting from the same point, but those with software experience would have the clear advantage of having learned dozens just like it. You could make outlines all day, and anki cards like "{{c1::$$CTX\phi$$}} is a {{c2::filamentous}}, lysogenic {{c3::bactgeriophage}}..." but it won't help you with understanding the context. It's just something that takes time and patience. So if you're reading this and you've just been admitted to med school, I really wouldn't recommend trying to finish the entire Brosencephalon deck before day 1 (holy crap) or reading Robbins or whatever. You'll probably pass either way, and what's going to matter more is staying sane during those first two years. If you're someone who won't settle for anything but pediatric neurosurgery, I don't know what to tell you -- but let's be honest, this advice isn't for you, so you're not reading it.

### 2. It's not about you.

Don't take it personally. On the first day of classes one of our administrators smugly pointed out that the cost of our education to our school far outpaced the funds they received from tuition, that they actually lose money by educating us -- teaching medical students is essentially charity work and so to suggest that any part of it be improved was simply ungrateful. (I recommend NOT comparing this to a fire station opining that they actually lose money by fighting fires, despite receiving federal funds to do just that.) I merely want to use this section to point out that your education is the last priority of a medical school. After all, if you learn everything you're supposed to and pass Step 1 with a 280, you're the only one who will benefit; whereas if you fail a block (and can't successfully remediate) the school will enjoy another year of your tuition money, and if you fail your boards in the current system, the school gets to boast about its reputation of producing physicians motivated to contribute back to the growing need of rural primary care. There's nothing particularly malevolent about this -- you just need to realize they already have your money, and so their efforts to improve your education will be roughly in line with the efforts your undergrad dining hall put in to improve their vegan selection. It's just not prudent.

It's become fashionable to reminisce about the times when medical students used to help run the various services of the hospitals, when there wasn't such a schism between "student of medicine" and "student doctor", the latter term having largely fallen out of favor for liability reasons. Clinical experience in the first two years of medical school is now condensed to field trips where you show up for a few hours and stand in everyone's way while they try to do their jobs, and this leads to a sort of chicken-or-the-egg debate about which function of an academic medical center is more important: the patient care or the education? The two goals at this point couldn't have less to do with eachother, and any amount of time spent learning at one of these places will cement in your consciousness the existence of the managerial class serving as a functional "carton" -- whose job is to keep the eggs in line. You'll be taught how to counsel grieving patients by HR representatives who have never counseled a patient, your learning style will be criticized by academics whose educational history at no point included medical school, and your requests that the recorded lectures be posted in a reasonable timeframe will be met with remonstrations that against all evidence, you really would learn best by sitting in a dilapidated lecture hall for four hours a day.

And again, this isn't a result of some conspiracy to annoy us. The system has just been set up in such a way that medical students are a burden on everyone involved in the process. You can imagine what this does to the mental health of medical students in general, but that's a post for another day.

### 3. It actually does work

Depending on what you mean by "work" I guess. There are clearly massive problems with healthcare today beyond the schooling (namely that not everyone has access to it), and just like I've mentioned earlier, they're largely the result of everyone involved acting in their own best interest. But it's no secret why America is facing a shortage of primary care providers: they simply don't get paid that much, or at least not enough to want to work in the areas where they're needed. And while normally I'm the last person you'll find apologizing for the actions of a class of people who get to choose their tax bracket at the end of third year, we have to recognize that the debt accrued from the exorbitant cost of med school compounded alongside the same from whatever name-brand five-star-resort premed program most of us came from is a weight many of us will bear for a long time if we're not careful. To cut a long tangent short, I think immense paychecks are going to drive physician recruitment until both healthcare and education see some cohesive leadership, both of which will involve lots of time, political organization, and maybe CRISPR-ing human empathy into Paul Ryan. We'll see what happens.

But during the past 2 years I've made a network of collegues whose backs I'll have for the rest of my career in medicine. Despite the unreal pressure to perform academically, survive on loans, and generally to stand out in this poodle show, the guys and gals in my class are consistently looking out for eachother. Far from the expectations of avaricious gunners popularized by shows like "Scrubs" and the weaponized anxiety of Student Doctor Network, I've found those peers in the best position to benefit off our unpreparedness, and those with the best grasp of the material and how it can be leveraged to crush our board exams are making and sharing elaborate study guides, challenging administrators to improve the educational superstructure, and generally not taking shit from the powers that dictate our future. It's honestly one of the most encouraging things on my mind right now, and I'm confident that this is the generation of doctors who are fed up with how their generation is being treated and ready to change it.