Transcript has been lightly edited for clarity and readability.

Kerry Whittemore: Welcome to M.ED, Medical Education for the Practicing Clinician. I'm your host, Dr. Kerry Whittemore, a pediatrician with the University of Utah Health. This podcast is brought to you by The University of Utah School of Medicine. This episode is going to be focused on learning experiences of a senior medical student. Today on M.ED, I'm excited to introduce you to our guest, Garrett Christensen. Garrett is a fourth year medical student at the University of Utah School of Medicine. He completed his undergraduate training at the University of Utah with a degree in Biology, and is interviewing for orthopedic surgery residency programs. Garrett is going to talk to us about his experiences in the clinical years of his medical training, specifically the third and fourth year. He'll discuss receiving and giving feedback from clinical preceptors and the importance of communicating a clear set of expectations from preceptors to medical students. He'll also give us some pointers on how to be a better physician educator. Enjoy. 

KW: So Garrett, why don't you just start off by telling us a little bit about yourself, where are you from and how'd you end up here in Salt Lake City?  

What's your "Why?"

Garrett Christensen: I grew up down in a small town in Southern Utah called Diamond Valley, about 20 minutes or so away from St. George. And it's a really small town, no stores, everyone has horses and sheep and things like that. I grew up riding horses off the back porch up into the mountains. 

I loved growing up there, until I got to be 16, and then I wished I was down in St. George, with all my friends. Sports took over my life and my high school years, and it was around high school when I started thinking seriously about career options, and I really don't have a good story for how I ended up in medicine per se. One of the big things was I just got lucky with a family friend who was involved in physical therapy, so after high school I applied to be a physical therapy aid, and got assigned to the post-operative orthopaedic floor at the hospital down in St. George. You might have seen this after a total knee or hip replacement, I was the guy who wrapped the seat belt around the patients and walked the patients around the hallway. 

KW: While you were in high school?  

GC: This was after high school, when I started college. At the time, my mom was an accountant and I thought about being an accountant, taking over her firm. I was working for my mom at her tax firm and also doing physical therapy work. 

KW: And going to school down in St. George?  

GC: Yeah, down at Dixie State. I quickly realized that I liked medicine and working with patients a lot better than I liked income tax.  

I worked about a year as a physical therapy aid and worked with this big team of doctors, surgeons, and physical therapists. I really enjoyed that, and I started shadowing different types of doctors, such as family medicine doctors, surgeons, and ENT doctors. After six months, I thought "I'm going to go to medical school." After talking to people about school, going to the University of Utah sounded like the best option as far as being competitive for getting into a medical school. So I decided to come up to the University of Utah. When I got here, I found an awesome job as an anesthesia technician. I thouhgt it would lead into med school and becoming an anesthesiologist, but I quickly found out that anesthesia wasn't my thing. But, I found myself drawn to watching surgeons, so it was cool because I could bounce from OR to OR, and I wasn't tied to any operating room. 

I found myself really intrigued by surgery and looking back, it all was starting to make sense. I grew up in a small town, very hands-on. I loved doing woodworking, and working on machinery, taking care of the landscaping, and playing sports , so I felt like surgery was a good option, but I didn't know what type. When I started medical school, I thought I would do general surgery, maybe ENT, maybe Orthopedics, some surgical specialties. I thought Orthopedics is the most competitive of those, so why don't I just reach out to some orthopedists and try to do research and network. That way, if I choose something else, I will already be competitive. I emailed about 10 orthopedists here at the university and surrounding areas, just kind of cold, I didn't know any of them, and only one of them replied.

KW: About doing research with them?  

GC: Yes, about meeting up, doing research, watching them in the operating room and things like that. One of them replied to me, Dr. Peter Chalmers, who has become my biggest mentor and advocate, and I worked a lot with him over the last four years doing research. He's let me in his operating room and it's been amazing. I'm now applying to residencies and doing virtual interviews. 

KW: What are you going to be a resident in and what's your goal?  

GC: I'm doing orthopedic surgery. Rank lists are due in about a month, and then match day is a couple of weeks after that.  

KW: Am I allowed to tease you about becoming the high school athlete that then goes into orthopedics like you?  

GC: Sure. I'm totally into the ortho jokes.  

KW: Do you know how many females go into the ortho field?  

GC: It's definitely fewer than males, but it's getting better. I don't have numbers off the top of my head, but I know that when I look at faculty, there's very few females, but when you look at applicants and residents, there's several females in each class and there's only six residents per year here. It's not equal yet, but trending in the right direction. 

What are the benefits of having a mentor?

KW: It sounds like you have a great mentor. How has that made a difference in your medical school training? That's something really hard to find. 

GC: I agree. When I look back on medical school, I think the single best thing that I did was really try to find a mentor, and it's turned out now that that mentor really has changed my life. My entire application is so much stronger because of my mentor, and not only that, but when I think of mentors, most people think of doing research and watching you in the operating room or watching you in clinic taking care of patients, and I think that's really important, but I think more importantly is, I want to see what your life is like: Do you go on vacation, have hobbies, have a family and a life?

When I reached out to my mentor, Peter Chalmers, he said, "Let's meetup and talk for 10 minutes. I want to see what you're interested in, and then I can potentially put you on a research project with myself and some residents." Unfortunately, some medical students are very unreliable, especially with research, so I think faculty have their guard up. I initially told him I want to do whatever you can put me on, I'm most interested in this type of orthopedics. He put me on a project and I was talking to both my attending and resident, and they gave me work to do, similar to a chart review. I said, "Well, I know that medical students have this reputation of being kind of flaky and changing their career trajectory. I think that they think this will take two months for me to do, so why don't I finish it in two weeks?"  

KW: You're such an overachiever. 

GC: Well, I didn't think of it like that. I thought they needed a reason to keep mentoring me, and if I'm just doing the bare minimum or if I'm flaky, there's no reason for them to invest energy. I did the project in half the time that I thought that they were expecting, which really helped me. They said that was a lot quicker than they expected. So I asked, "Can I do research with you in between first and second year when we have all this time off?" I really think that that was when I went from just a medical student to being their medical student. I did research with them full-time for the whole summer. 

KW: Were you able to get that funded because I know that's a big thing if you have to lean on fees. 

GC: I got a big grant from the orthopedic department, which they give to some medical students interested in doing orthopedic research, so I was lucky to have essentially no paperwork. There are some programs where you have funding through the school, but with talking to some of my classmates, you have a bunch of lectures you have to go to, and you have paperwork you have to do. For me, I applied for the funding and they gave it to me, and then I did the research and that was it.  

It was helpful doing research that summer. Peter Chalmers invited us over to his house to have dinner and we talked about life and training, and I think that was when I was able to see myself having this career in research. The other interesting thing Peter did for me is he gave me challenging projects. Some medical students get bored doing chart review after chart review.

Peter was invited to write a book chapter, and he asked me if I wanted to write this book chapter and he'll edit it and we can both be on the authorship. I, of course, said yes. I didn't know anything about that pathology, so it took me months of doing lit review and learning about the topic and picking my mentor's brain. I wrote the book chapter, and of course wasn't a perfect book chapter, so Peter took time from his schedule to edit it and things and talk to me about what to do when writing a book chapter.  

I totally understand mentoring takes a lot of time for faculty, attendings, fellows, and residents, so I don't expect everyone to do that, but I think that those are some of the key things that I've seen my mentor do that really helped me explore orthopedics and decide that that's what I wanted to do. 

KW: So other than the summer when you didn't have other things you had to do in med school, how did you find time to balance all that with the other medical stuff you had to do, which there's a lot in and of itself. 

GC: Because I did a lot of research, it was a big part of my application. I often found myself choosing to do more research than anything else, and I certainly could have done much better on my exams for all the required rotations. I certainly could have studied more for upcoming patients, but I felt like the most important thing was keeping communication open with my mentors and doing research. I felt like I was learning so much and I was showing my mentors that I was very serious about that, and I knew that that would help me in the long run. 

Some things have to go, some things get hurt as other things do better, and I felt like I prioritized research and my mentors and sort of learning more about my field that I was starting to commit to, rather than giving every ounce of time towards the specific rotation I was on. For me, it was just every single day thinking about how I can divvy up that time so that I can be the most productive in the long run,.

KW: Do you know what you want to do in the orthopedic field or where you see yourself practicing?  

GC: My mentor is a shoulder and elbow surgeon, and so if you asked me to choose, I would say shoulder and elbow surgery, but that's me being very naive to a lot of fields, and wanting to follow in my mentor's footsteps. I really love research and teaching so I foresee myself being in academics. Where that ends up being, I'm not sure. I would love to be in Utah long term, but will that happen? To be determined. 

KW: You're from a small town in Southern Utah. Do you see any way you could ever work there and be in academics? I feel like that's challenging. 

GC: My wife and I aren't necessarily seeking to go back to southern Utah, we both love northern Utah. Honestly, if you were asked about our dream life, it would be to end up in Heber, Midway, Park City, Salt Lake, somewhere in that little corridor. We're both from small towns, and it would be really cool for me to end up in a smaller town to live in and then work down here at the U or potentially work part of my time in Park City or Heber, and then part-time down here. 

KW: There's lots of hurt skiers in Park City that need their foot fixed.  

GC: That's the beauty of it, right? Good population and mountain bikers in the summer, so it's good in both seasons. 

KW: Yes, my husband's been one of those hurt mountain bikers. 

GC: I've seen a lot of them in the ED. 

KW: Do you have any mentors outside of Salt Lake that have shown you any way to be an orthopedic surgeon, not here, or has COVID made that impossible?  

What was your experience participating in a rural rotation?

GC: I have other mentors, but not necessarily in my particular field. I did a rural rotation through the Rural & Underserved Utah Training Experience (RUUTE) program down in St. George in general surgery. My mentor was Dr. Ryan Lewis, a general surgeon who works part of his time at Intermountain Hospital and part of his time at a private surgical center down there. He showed me what his life was like. He would talk about his church responsibilities, coaching his kids teams, and also working really hard and having a busy call schedule. I was able to see—not necessarily in my chosen orthopedic field—how doctors in general can structure their life. I also loved watching him manage this really interesting balance of private practice and also working at a hospital. It was great getting out of Salt Lake and seeing a different hospital system. There's no trainees there, so it was me and my attending all the time. 

KW: You're probably more just with the attending and not with the residents and fellows. And how was that different?  

GC: I loved it because he could basically give all of his teaching energy to me. As medical students, we understand the hierarchy of teaching: the attending's number one job is to teach the resident because they're close to practicing, and then with whatever time is left over, you can talk to the med students. Down in this rural community, it was just me and my attending, and so he could meet me really well at my level. He would get a page, for example, from an ER doc about a possible appendicitis patient. My attending would ask if I would want to check on the patient and let him know whether or not I thought the patient had appendicitis. So I would go alone; there wasn't a bridge of me talking to the resident and the resident talking to the attending. I was able to see my attending's thought process for determining who has appendicitis and I could just talk with him. I found it really valuable to do those rural rotations away from all the trainees here at the university. 

KW: And did you see anyone that you went to high school with, or family, friends, or anyone like that?  

GC: I saw a lot of people that I knew from high school. 

KW: Did you get any pressure from them, "Hey, you should come back and practice here, why are you going to stay in the big city?" Anything like that?  

GC: Not necessarily. When people ask me, I say, "We really like Salt Lake, we like the area, but we don't know where we'll end up." 

KW: For sure. Nobody knows. One other thing is that med school is expensive. So I was just looking at the University of Utah, the in-state tuition is $42,600. The in-state cost of attendance for four years is $256,000 and that's known without interest that you're going to pay over many years. Do you feel like that impacted your choice of what you wanted to do at all versus family medicine or maybe talking to your classmates, do you think that makes an impact on what specialty people go into?  

How has the cost of medical school played a role in making decisions about the future?

GC: Talking to classmates definitely does. For me personally, I would have done some surgical specialty regardless, and I feel really lucky that orthopedics gets reimbursed well. One of my best friends is a medical student in another state and pays out of state tuition, something like $75,000 a year. It really is crippling for these out-of-state students. In-state is around $45,000 a year, so I'm very lucky that my wife works full-time at the university, and I get half off of in-state. 

KW: I wasn't going to bring up that fact, I didn't want the other med students to be mad. 

GC: It's well known, but I think it definitely does play a role in people choosing some specialties, especially if they're on the fence between something like family medicine and another specialty. They would be happy in both careers, but one pays a third more, which ends up being a lot over the course of your career. 

KW: Yeah, for me personally, so I'm a general pediatrician, and I thought going into med school that that's probably what I wanted to do. Family medicine are basically the lowest paid specialties, so I purposely only applied to state schools from where I'm from, which is New York, and then where I ended up going, which is McGill, in Montreal, Canada because the Canadian med school tuition is so much less. It's kind of sad that I applied to zero private schools, because I was like, "Why am I going to pay double the amount if I want to be a pediatrician?" And it ended up working out great. But that's part of the calculus to begin with. 

GC: Yeah, definitely. I talked to a few undergraduate students that asked me questions about getting into medical school. One of them was accepted to three schools, one cost $45,000 in Kansas, and one cost $72,000 in Phoenix. I said "Depending on what you want to do, and if you don't know what you want to do, I think it would be in your best interest to go to the cheapest because I think the education at all these programs is good."

KW: Right, for sure. Back to how you've been taught over these last couple of years, can you think of some great, other than your mentor, some other great attendings or residents you've worked with and what has made it stand out how they've worked with you from the student's perspective?  

Any advice to share with attendings about how to better train medical students?

GC: I'm one person and these are my preferences. But after talking with some friends, I think that these suggestions would be well-received by medical students:

• Pimping: From my perspective, back in the day, that's the only thing they would do and they would just try to belittle you. I think there was this, in my opinion, over correction. Now, I find a lot of my faculty are too easy on me. I'll go an entire month and I won't get "pimped" at all. For me the best learning I had was when we came to a fork in the road on treatment with a patient, and the attending me what I wanted to do. They would make me commit, make me think. I think there's been a little bit of an over-correction to where a lot of faculty just tell you what they're thinking instead of trying to make you think through the process. I think that we could use the Socratic method better and ask questions in ways that don't belittle students who don't know anything. 
• Challenging assignments: I think there's a tendency to give medical students the easiest patients, and I think that's good in the first couple of months of third year because you've never seen patients. But when I think back on my third year and fourth year, the patients I learn the most on are complex and you're thinking through things that you wouldn't have to think through with an easier patient, such as nutrition, medication, IVs, POs, etc. It's okay to give a medical student fewer, complex patients. 
• Personal life: I really like it when my attendings show me a little bit about their personal life, and talk about their family, their kids, what they do outside of work. That's valuable for the morale of the team. Medical students want to know that we can do what you're doing, if that's something we're aspiring to do. We don't just want to emulate attendings professionally, we want to emulate their life and how they live personally.
• Feedback: I dislike getting feedback on the last day of the rotation because then you have no time to change anything. That's certainly not faculty's fault—I think medical students could do better at eliciting feedback. But I think that feedback in the middle of the rotation would be helpful so I know my attending is starting to trust me with patients and we're building rapport, and I don't have to just guess that I'm doing things right.

• Clear expectations: I think that medical students don't know what's expected of them. I'm not telling anyone how to be a preceptor, there's different styles of precepting, and they're all good and valuable. But the number one thing you can do on day one, is to introduce yourself and set expectations. I've had some attendings for example, print off an expectation. I find it really valuable because some faculty just want you to shadow them, some want you to be with the resident, some want you to have your own patients and do everything including orders, notes, things like that. 

KW: From an attending's perspective I'm thinking of how personally, you don't know if you trust the medical student yet, with your patients. I always have the medical students see the kids by themselves and write the notes, but I also I am like "Hmm, this patient has some complex social dynamic and the family is a certain way and I don't know if I trust you." Part of it is getting a rapport with the students and seeing where their knowledge base is at before you let them go full throttle with your patients. 

GC: Of course. That can be put in your expectations as well, you could just say, "Since we don't know each other, why don't you work with me this morning and we'll see all of our patients together, you can write every other note and talk to every other patient and every other patient I'll do." Then you have that first-hand knowledge of, "Okay, I saw them do essentially a whole visit by themselves and I trust them" 

I think if you had told me that on day one, I would feel really good about that being the expectation; knowing you're going to watch me first hand and see how things are, and then you'll adjust based on what you see. 

KW: A lot of pediatrics is screaming two-year olds, so I like to have the students see those too, because I'm like, "This is part of it too. If you think you might want to do this," how to conduct an interview while the kid is crying and how to examine them while they're crying. Stuff like that. 

KW: This is super helpful, and a lot of the people who listen, are physicians and hopefully we can be better educators, so thank you so much for joining me and good luck with the match and residency and all that, I'm sure it will turn out well. 

GC: Thank you so much, really appreciate it.