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!

EMQ’s are being increasingly used in research and papers have recently been published on their success in the USMLE. Its likely that many medical schools will adopt this N from many approach. An EMQ is simple: its a series of typically 6-10 answers, used a number of times with different question stems.They first cropped up in 1993 after work by Case and Swanson. Read more about EMQ’s and their development here.

Distracters

Distracters are being used to throw students off the scent, and in some ways discriminate from good and bad students. An example would be describing a history of a rash affecting the flexor surfaces and giving on e of the answers as psoriasis. Seeing the two together can lead to the assumption this is the correct answer. This is an example of a good discriminator, but EMQs can easily be written in such a way that the more capable student gets it wrong!

Take an example EMQ from our new section dedicated to them on the login site.

“A 64 year old homeless man presents after being found exposed under a bush shelter by paramedics. He is ‘tided over the night’ by the emergency department staff with an IVI of 5% dextrose. The next morning he is confused, and ataxic. On examination he has nystagmus. Which of the following is treatment is most likely to be effective?”

Students classically then have to pick from a range of answers:

• Aciclovir
• Ciprofloxacin
• Buscopan
• Omeprazole
• Gluten free diet
• Peg Interferon alpha
• Mesalazine
• Vitamin B Complex

Here’s the Answer from the main site:

“Nystagmus, and ataxia are features of cerebellar disease, with the addition of confusion this triad is suggestive of Wernickes Encephalopathy (vitamin B1 deficiency- thiamine). Risk factors: poor nutrition (+/- alcohol).

Thiamine is important in carbohydrate metabolism and the Krebs cycle: it’s vital to remember that dextrose presents a carbohydrate load, the excess of which cannot be effectively metabolised , leading to cell death.

Hence the treatment: Vitamin B complex: initially this is given as Intravenous Pabrinex © for 48-72 hours.”

The EMQ here does a number of things: You could use your knowledge of drugs alone to answer the question: An antiviral (acivlovir), quinalone antibiotic (ciprofloxacin), an antispasmodic (buscopan), a Proton pump inhibitor (omeprazole) a gluten free diet (!), etc.

Aciclovir would initially seem attractive for a possible encephalitis- there are some things that fit: confusion, other CNS signs? This is a form of a distracter-look at the history, and the role of the glucose drip.Here the answer has been worked through by correctly recognise the triad of opthalmoplegia, confusion and ataxia that isin keeping with the diagnosis of Wernickes.

So, we can see that EMQs look initially pretty intuative, but more are being written, and expect them to be coming to an exam near you soon.

You can work through some examples of EMQ’s to prepare for your medical finals with different question structures on the subscription section of our site.