P&S Medical Review: Nov 1993, Vol.1, No.1
P&S Medical Review: Editors

Senior Editors

     Aaron M. Fay, P&S '93
     Stuart S. Abramson, P&S '94

Board of Editors

     Joseph J. DeRose, P&S  '93
     Rhea L. McDonough, P&S '94
     Robert B. Fogel, P&S '93
     James H. McKiernan, P&S '93
     Ray I. Haroun, P&S '94
     Charles Prestigiacomo, P&S '93
     Lynne Haven-Weiss, P&S '94
     Dianna Quan, P&S '94
     Hilary M. Klein, P&S '94
     Jonathan Rosand, P&S '94
     Matthew J. Kleinerman, P&S '93
     Angelo P. Tanna, P&S '94

Assistants

     Cynthia D. Smith, P&S '93
     Louise R. Abramson
     Paul S. Thesiger, P&S '93     

Board of Advisors

     Herbert S. Chase, M.D. (Chief Advisor), Department of
     Medicine

     George J. Florakis, M.D., Department of Ophthalmology

     John P. Koulos, M.D., Department of Obstetrics & Gynecology

     David D.Markowitz, M.D., Department of Medicine

     Lewis P. Rowland, M.D., Department of Neurology

The P&S Medical Review (ISSN pending) is a quarterly, peer-reviewed journal founded and edited by the students of the Columbia University College of Physicians and Surgeons (P&S). It is intended to be a scientific and medical journal containing review articles and original research completed by members of the extended Columbia community. It seeks to address topics of clinical concern, though basic science articles are also accepted for publication. Also welcomed are case reports and correspondences relating to current medical controversy.

Editors are enrolled P&S students who produce the publication under the guidance of a board of faculty advisors drawn from the departments of the Columbia-Presbyterian Medical Center. All articles are subject to rigorous, anonymous peer review prior to acceptance for publication; peer reviewers are chosen from the Columbia community when possible.

Authors are primarily individuals affiliated with Columbia University or Columbia-Presbyterian Medical Center, including students, house officers, faculty, alumni, and individuals similarly associated with Columbia-affiliated institutions. These include but are not limited to The Mary Imogene Bassett Hospital, Harlem Hospital Center, Morristown Memorial Hospital, Overlook Hospital, St. Luke's-Roosevelt Medical Center, and the Creedmoor Psychiatric Hospital. Instructions for authors can be found on the last page of the journal.

The P&S Medical Review is distributed free of charge to all P&S Medical students, all Columbia-Presbyterian Medical Center house officers, and to all CPMC department offices. Subscription rates are available to others. Additional copies are available upon request.

Thus, in summary, horizons for academic careers in medicine are expanding remarkably. There are major needs for greater numbers of physicians with the backing and training necessary to become `bench' and `bedside' investigators. There is as well a tremendous need for individuals with a commitment to creative achievement and problem solving in the area of health care delivery as well as traditional medical specialties.

There are two types of training in medical school which define both the intent of the educational system as well as the horizons and career directions of the student. Perhaps overly simplified, these two directions are technical training and training for careers of academic commitment and growth.

In technical training there is emphasis on mastery of necessary factual knowledge and concentration of effort and attention on a confined `core curriculum.' There is some intent that this core curriculum provide enough basic understanding to place new discoveries and new understanding into the broader array of medical knowledge. There is also intent to provide the broadest possible exposure to as many disciplines of medicine in the clinical arena as possible, with multiple elective subspecialty rotations and again, an understanding of core approaches and technologies of each of the disciplines.

In contrast for academic careers there is substantial emphasis on acquiring in-depth knowledge of one or perhaps two critically important or related disciplines which hold promise for application to the problems of medicine. This in-depth knowledge could focus, for example, on neurobiology or a combined perspective of neurobiology, neurology, clinical epidemiology and statistics. As an example, we have on our faculty a prominent neurobiologist as well as neurologists who approach neurobiological problems such as depression or Alzheimer's Disease from the perspective of its impact on the community. Trainees in such a program are given all possible support to help them identify specialized areas of interest and areas in which there is likely to be a need for creative skills and solid commitment on the part of physicians. There is a hope that the training experience in these specialized areas of interest will involve critical exposure to the difficulties and challenges in the field and also to creative experiences at the absolute cutting edge of research and understanding. Simply stated, the difference between technical training and academic training is the notion that the student being trained technically is in school to learn. The student in school for academic training is to do more than learn. This student is expected, during a period of medical education, to contribute to the field of medicine, to participate in the effort toward creative application of what is learned.

In many fields of fundamental science and mathematics, it is widely understood that the most creative contributions are made by individuals in their twenties. Individuals in this expansive phase of maturation are more open to new suggestions and more able to challenge out-of-date thinking or identify an issue that will change a field than even individuals ten years older. Some aspects of medical school might be viewed as doing the utmost to prevent such thinking or individual development. But once a student seeks an academic career, characterized by growth, changing focus, ideas and creativity, then the essential ingredients of medical education are altered. It is better to have short term exposures to specific areas of concentration which may last for one to three months (an elective period), than to have no such exposure. More often, it is the longer term or repeated commitments which really formulate the educational background necessary for academic careers and creative futures. My enthusiasm for short term exposure relates to the high frequency with which one short term exposure to an excellent environment results in this subsequent longer term commitment and resultant full growth. A student's hesitation to commit to an individualized adventuresome education and career directed training can be easily overcome by one exciting experience!

There are several adages that I have used over the years in trying to advise young people on how to choose the setting and direction for initial efforts and educations they embark on this type of training.

The first of these adages is to pursue a direction which is one level more basic or more fundamental than that at which you ever wish to work when your career is mature. Such a more fundamental approach does not necessarily mean an emphasis on laboratory research. Fundamental training in clinical epidemiology, informatics or medical education involving no laboratory exposure will also lead to quality. Such an experience in training at `one level more basic' equips a person in the best possible fashion to pursue career development at exactly the level that they envision for themselves. In truth, what is fundamental to a discipline today will be in the main line of that discipline tomorrow. What is in microbiology today will be infectious disease in medicine tomorrow. What is involved in theoretical clinical epidemiology today will be therapeutics in clinical trials tomorrow.

The second adage is to seek an environment where discussions focus on primary issues rather than application. Is the individual with whom you work or the laboratory where you intend to spend time involved in what you perceive to be issues that are conceptually new for the field of study? As an alternative, are the individuals in the laboratory only pursuing new applications of already established concepts? Is the laboratory only looking at the effect of some new fundamental agent, issue or idea on some biological or clinical system? Or, does the individual or program intend to understand the determinants which make the system or the problem work as it does? One wants to be involved in asking the question why rather than how much or to what extent.

The third adage is to involve yourself very early in peer review. Discuss your thoughts and ideas broadly with individuals in the environment, both field leaders and people at your own level. Some of the most unproductive and disappointing careers have been those of individuals who decided there was a risk to sharing ideas or who were held back by fear of criticism. There is a misconception that progress is made principally through placing oneself in a room, closing all the doors and windows, and thinking hard about a problem. The truth is that there are a million good ideas which are `cheap' and to some extent of relatively little interest. The important thing is not who has the idea, or if there is an idea, but what idea you decide to pursue. If there are a million ideas out there about a given subject, which is the best idea? What is the idea that can be pursued with the methods available and can lead to an answer that will be unambiguous and conceptually important?

Finally, among my adages is to find a committed mentor to help guide your creative educational experience and hopefully, to continue to relate to you well after the period of direct relationship. Most successful contributors to medicine will speak with tremendous affection about one or two or perhaps as many as three individuals who had a pivotal role in `shaping their career.' Do not miss the point; mentoring is more than having a role model to imitate. A mentor is a person who supports and helps identify your creative thinking and your avenues for contribution. The best of mentors have the time, emotional energy and the sincere desire to foster you and your career directions. Such individuals are not hard to find, but often because of many commitments and demands, they will need prodding and encouragement by the student to serve in a mentoring capacity.

In truth, the best way to find a mentor is to talk with a former trainee. Ask the mentor to name prior trainees. Ask or find out what these trainees are now doing. Successful mentors and teachers are consistently successful. They take pride (as hopefully you will) in their students. Often, a committed mentor will describe his or her students' creative contributions as vividly and directly as their own.

The horizons have never been brighter and the pathway is one of self commitment!

Acknowledgment

The author expresses appreciation to Dr. Glenda Garvey for her critical and helpful review.