Joel Adler, Studying at the University of Wisconsin School of Medicine, USA, Founded in 1848 (which is significantly before www.medicaleducator.co.uk!

First of all, thanks for asking me to do this.  Born and raised in Wisconsin, I earned my undergraduate degree in Spanish from the University of Wisconsin-Madison.  I’m presently a third-year medical student at the University of Wisconsin School of Medicine and Public Health.  I spent a year between second and third year on a research fellowship from the Howard Hughes Medical Institute.  I studied novel therapeutics for neuroendocrine tumors and clinical outcomes of surgical management of endocrine disease.  After I graduate next May, I plan to pursue residency training in general surgery with fellowship training in either surgical oncology or transplant surgery.

As you know we’re a British website, run by British doctors but we feel our information is  relevant to medical students from across the world. Do you know of any specific differences between medical training in the US and the UK?

As I understand it, the main difference is in the way we split our training.  In the US, we do a separate degree (often at a different institution) before enrolling in medical school.  The undergraduate degree can be of any course of study, as long as specific pre-medical requirements (biology, chemistry, physics, etc.) are fulfilled.  As I mentioned earlier, mine was Spanish.  Medical school is four years in length, with optional extensions for other degrees (MPH, PhD) or experiences.  But as far as the overall training of medical school, I’m not aware of any large differences.

Medical students in England have very limited professional responsibility and remain heavily supervised at all times (for example, they do not see patients unless they have been first reviewed by an attending doctor. Is this the same in the US?

We’re supervised all the way through.  Most medical schools follow a traditional format: the first two years are classroom instruction with sporadic clinical experience, and the final two years are clinically based with less formal classroom instruction.  In the final two years, most supervision is performed by resident physicians.  Responsibility increases with time, but we are certainly supervised at all times.  There’s usually no requirement for signoff before seeing patients, but we are typically observed in our interactions and signed off at that time.

Do you get many opportunities to do practical procedures? If so, what sort of things do medical students in general have the opportunity to do?

Procedures are certainly possible, and are dependent upon the clinical clerkship.  Most students have a fair deal of experience in delivering babies, suturing, starting IVs, intubating, and drawing blood.  Other more advanced procedures typically come in the fourth year once we have chosen our specialties and spend time working in those specific areas.

In the UK we focus heavily on observed clinical history taking and examination for many of the assessments. Is that something you identify with? And are you familiar with the term OSCE?

Absolutely.  The emphasis on this varies between schools, but the majority of school will do some OSCE testing in the first two years in order to prepare for the third year.  During the third year, grading is a mix of clinical performance, a written exam, and OSCE-style testing.  The emphasis is typically much more heavy on observed clinical day-to-day work, and the OSCE serves as a final exam to ensure that you are competent in areas that weren’t observed.  For example, I’m currently rotating on an inpatient medicine service that is very heavy on GI and hepatic disease.  During the OSCE, I suspect I’ll have some stations involving either pulmonary or cardiac disease.  They seem to be good ways to assess skills, but they tend to be rather artificial situations.

Many UK based medical students wont have heard of the USMLE. What are your views on it as a standard across the US? (in the UK each medical school sets its own exam standards).

As far as a standardized exam, I feel it’s fine.  Nobody looks forward to taking them, but many schools provide adequate support and guidance to prepare for the test.  The scores are typically used by residency programs when considering applicants, and all parts of the USMLE must be passed before a full medical license is granted.  It’s nice to have standard exams to make sure that we’re all covering similar material.

The USMLE comes in three “steps”.  Step 1 focuses on pre-clinical knowledge (basic science, pathophysiology, basic treatment and diagnosis) and is usually taken between the second and third years of school.  Step 2 is actually two parts: clinical skills (a day-long OSCE-style examination) and clinical knowledge (a day-long written examination on clinical decision making).  That is usually taken during the fourth year.  And finally, before a medical license is granted, Step 3 is taken during early residency.  It focuses on advanced clinical skills and decision-making.

Joel, we’d like to say a big thanks for taking part in our interview. Its great to hear things first hand from an American student. Finally is there anything that you like to use as a US student that we might not be so familiar with over here in the UK?

I’ll share some of the things I use often for studying and caring for patients.   I use my iPhone constantly, usually for Epocrates and the Johns Hopkins Antibiotic Guide.  I also like MedCalc.  On the computer, I love using Evernote to keep track of things to study – I can just open up the program on my phone and studying during downtime.  I use Papers (Mac only) to keep my PDFs of articles organized.

Thanks again for your time Joel, and good luck in the forthcoming OSCEs, exams and that USMLE!

No problem.  My pleasure to answer them!

The 7 key reforms listed on the site are as follows:

• “Require insurance companies to cover pre-existing conditions so all Americans regardless of their health status or history can get comprehensive benefits at fair and stable premiums.”
• “Create a new Small Business Health Tax Credit to help small businesses provide affordable health insurance to their employees.”
• “Lower costs for businesses by covering a portion of the catastrophic health costs they pay in return for lower premiums for employees.”
• “Prevent insurers from overcharging doctors for their malpractice insurance and invest in proven strategies to reduce preventable medical errors.”
• “Make employer contributions more fair by requiring large employers that do not offer coverage or make a meaningful contribution to the cost of quality health coverage for their employees to contribute a percentage of payroll toward the costs of their employees’ health care.”
• “Establish a National Health Insurance Exchange with a range of private insurance options as well as a new public plan based on benefits available to members of Congress that will allow individuals and small businesses to buy affordable health coverage.”
• “Ensure everyone who needs it will receive a tax credit for their premiums.”

Some of these concepts will be unfamiliar to our British and European students. How much will this cost the US taxpayer? $65 billion is just the start. It will be interesting to see if the medical training comes under closer scrutiny under the new regime.

The New England Journal goes a step further than some in its coveage, publishing a “results style” table that looks more at home with in randomised control trial analysis than in a commentary on healthcare policy.

The essence is that healthcare is becoming more important priority for those in the US when ranked alongside other issues such as employment, war in Iraq, education, defence etc.

That said, its undeniable that healthcare is playing an incresing part of election strategy in the US. How long till we here in the UK actually see a tangible difference in healthcare policy from the leading political parties (Labour/ Conservative) on issues such as these.

Sound bites from a health savvy politician in any televised debate could potentially leave the oponent with egg on his face after any exchange.

Probably the most heavyweight stat is this

7% Republican Voters Surveyed said that expanding healthcare coverage across the US was important

in contrast to

94% of Democrats Voters Surveyed said that expanding healthcare coverage across the US was important

Who said that politics was boring. And we haven’t even mentioned stem cells…

We fully support the increasing awareness of clinicians to the wider issues in healthcare. Read the original article from the NEJM here.

J Bateman