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!

UMAP, one organisation currently working to standardise medical student exam question content across medical schools

It’s essentially the organisation which is writing/ collecting a bank of medical student exam questions for use in ‘high stakes’ examinations, such as medical finals.

UMAP’s description of their activities can be found on their website: On the site they describe themselves as follows:

UMAP’s aim is to improve quality in high stakes written assessments across UK medical schools. UMAP runs best practice item writing sessions where clinical and academic staff come together to learn about item writing techniques and to represent their subject area in the developing question bank.

UMAP QA process

Once written, questions move on to be quality assured at UMAP question review meetings which are convened at our partner schools. Staff members with experience in assessment and who are familiar with UMAP style and technique check each question and amend as necessary to ensure the highest accuracy and conformity to question writing principles. Questions are then ready for use and are listed as part of selection documentation available to our partner medical schools.

Schools are invited to select the items they wish to use and then confirm their selections to us. Schools later return results data in an electronic format which is then analysed and uploaded into the UMAP bank. A summary of this data is displayed within question selection documentation to enable schools to make informed, evidence based, item choices.  [Accessed 4.03.09 from http://www.umap.org.uk/about/]

From their site they cover about 14 medical schools and they run an active recruitment of Specialist Registrars to write questions for their bank, most recently to our knowledge in Birmingham at a West Midlands General Internal Medicine training day.

UMAP currently publish on their site that as of October 2008 they have over 2500 questions for use in the these high stakes examinations. They acknowledge that they seem to be lacking in a few key areas, however they are currently working to address this.

What do you need to know about UMAP as a medical student? Well probably not that much. In fact all UMAP really are trying to do is generate sensible MCQ questions that are fair, and are well written. They have a reasonably complicated list of rules that a number of ME’s contributors have been talked through at a number of different times: overall though its not rocket science.

• you shouldn’t be able to answer a question just by using the investigation result or the stem on its own (e.g. a big intro and then showing an ECG with complete heart block etc.)
• The questions are aimed at core FY1 knowledge
• You should be able to guess the likely options for the answer (again straight forward)

In principle, when UMAP look at the answers for any given question, they check that these same answers seem reasonable. They also like the same level of detail for both (for example the answers should all be of similar length).

What about the stem’s themselves: again UMAP make some sensible judgements including avoidance of medical jargon, avoiding using the same words in the questions and the answers etc. They should be readable and comprehensible.

So is there any technique involved? Well yes! Look carefully at results an investigations. Its clear that UMAPs strategy will be not to spoon feed the reader. For example if an important feature is tachycardia the question may read as follows

Ther pulse rate was 124 – Rather than mentioning the tachycardia directly, or showing a picture of an ECG

The same goes for investigation reults: e.g. K+ 3.0 mmol/l (NR 3.5-5.5 mmol/l) rather than ‘hypokalaemia’

All this means is that you have to look carefully at the investigation answers, and then draw conclusions. The rest is guesswork? Not really. Simple mathematics state that you should rule out the maximum number of wrong answers, and maximise your chance of success.

Medical Educator or its wuestion writers have not contributed any questions to the UMAP quesiton bank and have no formal or informal association with the organisation. We’d be interested to hear students comments and opinions about the work done by UMAP.