Saturday, 28 August 2010

Another GAMSAT snoozefest from the desk of Dr. Thunder.


Yeah I know. I have an unhealthy obsession with GAMSAT. But I'm not just trying to be a bollix. It concerns me that the GAMSAT graduates I've worked with, and the senior GAMSAT course students I've taught, have been, in my opinion, less capable than their tradition course counterparts.

I've expressed that view on here numerous times. Each time the comments section has been filled with people telling me that I'm a dinosaur, and my email fills up with people saying much worse.

So, I decided to have another look through the published evidence to see if I've missed something. Though this entry won't be anything close to a literature review.

For those who have never heard of GAMSAT, it is an admissions test for admissions to medical school. It's used in Australia, Ireland and the UK. Only graduates of other degrees can sit this exam. It tests rational thinking, scientific knowledge and written skills. Looking at sample papers, it's a straight forward enough exam if you put in some work, and have some scientific knowledge. Looking at the message boards on the net, it's pretty obvious that a lot of people are doing very well in this exam after a minimum amount of study. It's also obvious that a lot of entrants to medical school are scoring less in the science section than in the other sections.

Having said that, I'm a great believer in evidence. In fact, it's become an obsession of mine in the last 2 years since I set up a journal club where I work, got involved in published research and did a masters degree with a significant stats component.

But I just can't find the evidence for GAMSAT. It doesn't seem to correlate with med school results, whereas school leaving exams correlate very well (in the UK where this type of study has been conducted).
I also read another study showing that GPA in a previous degree is a better indicator of med school performance than GAMSAT.
Yet another study shows applicant selected by their GAMSAT results are less empathetic than those who enter via the traditional route.
Then there's the study showing that GAMSAT grads are much more confident in their knowledge of cancer medicine than their tradition counterparts, but they actually know less.

I didn't leave anything out in my search. I assumed there was a sentinel GAMSAT paper, on which the widespread adoption of this exam was based. But I couldn't find it. That doesn't mean it doesn't exists, as I used Pubmed, which is a relatively new plaything for me.

I have to say that all the above rings through with me and a lot of my colleagues. I find GAMSAT grads and students to be extremely confident, regardless of how little they know. I have also long said that they have less empathy than I would have hoped. They themselves tell me the opposite is true, but I have yet to see this in practice.

That is, of course, not to say they're all bad. I've worked with some fantastic GAMSAT grads and students, who will go on to be much better doctors than me.

But I'd like to see a more evidence-based approach to med school applications. Does a degree really give people more "life experience"? I did a degree before med school. But I got more life experience outside of that....playing in bands, being involved in martial arts/boxing clubs, being involved in charities, being ill, being in relationships, summer jobs and my life in general. I don't think a few extra years studying and going on the piss has given me any more life experience.

We're also often told that their extra knowledge of other fields is an asset to medicine. Sure, a recent resident of mine was a previous IT grad, so he could fix the computer when it went down, and we were able to access blood results again. But his 3 years at uni studying computers will mean he spends 3 years less as a paediatric consultant, which would have been more useful to the world in general.

Some of the unis are telling us that their GAMSAT grads are getting higher marks than the youngsters. Maybe they are. But when the traditional entrants reach their age, they'll know a shed load more medicine.

It seems that GAMSAT was actually brought in to widen access to medicine. I think that's fair enough, if we're trying to widen access for ethnic minorities for example. But trying to widen access A) Should not include widening access to people who aren't as bright as they should be to get in and B) Shouldn't happen at the expense of producing quality doctors.

I can't see how it widens access based on socio-economic status, as it requires incurring the extra debt of two university courses. GAMSAT courses in Ireland, in particular, involve course fees of about 100,000 euro.

In Ireland, too, it has had the effect of restricting the expansion of places to those completing secondary school. Those kids work their asses off during their teenage years, while everyone else is pissing about, getting drunk and trying in vain to get laid. It takes a lot of discipline and focus to give up your high school years and hit the books. You've got to be bright, focussed and a bloody hard worker to do it. I want to see more of these people in medical school, not people who blitzed GAMSAT because they have a biomedical sciences degree.

I expect my email inbox to fill up again. But I can cope with that. I'm just hoping one of the emailers might tell me why I should support GAMSAT. I'm not closed minded. We tell students that evidence is so important in medicine. I just want to see us live by our own rules.

Dr. Thunder.

Friday, 6 August 2010

Who remembers their first emergency call?

I think experience hardens us all. Nowadays, when I hear the emergency pager go off I stay pretty calm, and I know what has to be done. I know I have the skills to offer a high standard of care, and I know that I have a world class ICU in the same building to help out.

But this sure as hell wasn't the case when I was an intern. On the nightshift, having only been a doctor for 5 days, the emergency beeper went off. This doesn't necessarily mean a cardiac arrest. It can just mean that a patient is heading for one if something isn't done quickly. Much of a muchness for a scared junior doctor, though.

I heard the odd noise, and realised it was the red bleeper attached to my belt. The one I'd hoped might never go off. "222 ward 12" the screen read. When you get the location of an emergency as an intern, your first thought is "I hope I'm far enough away from this so that someone else gets there before me".

I was on ward 11 at the time. Next door. Dammit.

Anyway, no time to dilly dally. I strode into ward 11, trying my best to look confident as I walked over to the group of nurses surrounding a very very pale looking man in his 70s, who was desperately struggling for breath.

medical school just hadn't prepared me for this. What the hell was wrong with this guy?? I knew a whole load of causes of breathlessness. But he was going downhill quickly, and I didn't have time to do a "medical school" history and examination. You know the ones I'm talking about...the examinations where you listen for renal artery bruits and ask about hobbies in the social history.

First thing I decided to do was speak to him, and try to reassure him. But I couldn't. At least I couldn't get his name right. I kept mispronouncing his relatively simple name. I just got tongue tied. Needless to say, this inspired a world of confidence in me.

Why aren't the rest of the arrest team here yet?

I started some nebulisers, and asked the nurse to give him some intravenous steroids. Of course, his cannula wasn't working any more, so I had to put one in. My hands were shaking. My success with inserting drips was patchy at best. But I'd never been under this kind of pressure. I couldn't see a vein anywhere. So, I just rammed the needle into the part of his antecubital fossa where I knew there should be one! Thank god it worked.

But he was still struggling. And I wasn't really sure what to do next.

SURELY the team must be on the way. This guy needs aminophylline and ICU and central lines!!!! And we should probably intubate too!!!!

With that, my Registrar and Senior House Officer (SHO) burst in. Looking at their sweaty, shaking, stammering intern they must have thought something awful was going on. But as I recounted the story, and the SHO examined the patient the registrar said "Ah, he'll be fine. Just keep going with the nebulisers, we'll get a portable chest x-ray, do a blood gas and ring me with the results. That was a nice easy one for your first emergency. Well done, kiddo".

A nice easy one!?! Surely it doesn't get worse than this??

Then the ICU registrar turned up, to see if we needed him. My Registrar said "Nah, it's nothing major. No need for you to be involved".

So, there I was, living an event that will always stay with me. Yet it was "Nothing major" and "a nice easy one" all at once.

To be fair, the registrar was right. In terms of what I deal with in neonatal ICU or in paeds ED, it's not much. But it was one of the scariest experiences of my career.

So, was it just me? Or did anyone else loose half their circulating volume in sweat at their first emergency, and feign a stroke with their inability to speak?

Dr Thunder