How do you really learn medicine? 
As I complete lap #2 in the 12 month intern year cycle, this question often rears its niggling, bemused head (okay, maybe that's my bemused head. But the question is still niggling. And I still got to use both those words!). And it especially niggles every time I meet a patient who grips my hand gratefully when my white coat enters, in their eyes an implicit trust that I will not only Tell Them What's Wrong, but I will Help Them Feel Better. For those patients, I'm a magical computer that can instill diagnostic meaning and context to myterious symptoms and physical findings, such as "My pinky toe, Doc, it's been twitching southward at exactly 5:03 pm for the past month. What's that mean?" or "Why does the corner of my right eyelash itch when I'm trying to sleep?"
In essence, for many patients I'm regarded as an auror, or a tea-leaf reader, or maybe a slightly better-dressed $1.99/min telephone psychic, taking in
the facts and symptoms calmly with just the right gravitas inflecting my "Mm-hmm", "Uh-huh" and "I see", cooking them in the white-coat-aura machine and emerging triumphantly with a Diagnosis and Treatment Plan. It's kind of like in high school, when you learned about the concept of a function in algebra, there was that annoying picture in your textbook showing a picture of a computer taking in x and spitting out f(x) . (That one's for all my fellow high school Mathletes and Math Club alumni! Long live the differential!) I don't think I ever really understood that function computer thing until now - when, presumably, after 4 years and a $150,000 education, I'm supposed to be that computer, able to spit out f(symptom) at a patient's whim. Where symptom could be anything: that vague scratch in their throat, that faint pink rash on their upper arm, the strange rumbling in their stomach after eating that street-corner hot dog (come on, patient - I think we both know what caused that one.)
Of course, not all patients adopt the pleasant world view that Doctor Knows Best. Some patients are a little more, shall we say, jaded. Or maybe skeptical is the right word. No, how about questioning? Challenging? Domineering? I-Googled-This-Yesterday-And-I'm-Not-Leaving-Until-I-Get-A-Biopsy? (Ooops, not an adjective).
The anti-climactic reality is that doctor-ing lies in between those two extremes. If you've followed
my posts, you probably have already happened upon the rather non-concealed truth that I'm hardly an auror, or a tea-leaf reader, and hopefully I look at least a little more shapely than a computer spitting out parabolas (and those weird asymptote graphs - didn't you hate those?) when handed a patient's symptom questionnaire chart. But I would also, at this juncture, clear my throat rather pointedly and turn the reader to Exhibit A, which is Myself upon the eve of our medical school White Coat Ceremony, a day where my knowledge of medicine consisted of little more than how to wear a white coat. Compared to that happy-go-lucky rapscallion, my current self possesses some symptom-processing knowledge to match those impressive undereye circles, no? Even if, ironically, I seem to have lost the ability to wear a white coat without instantly attracting some sort of stain. (I need that irritating Cheer Detergent lady who always seems to be bleaching some unkempt bachelor's socks to accost me on the street and whiten my coat. That would be a miracle.)
As I complete lap #2 in the 12 month intern year cycle, this question often rears its niggling, bemused head (okay, maybe that's my bemused head. But the question is still niggling. And I still got to use both those words!). And it especially niggles every time I meet a patient who grips my hand gratefully when my white coat enters, in their eyes an implicit trust that I will not only Tell Them What's Wrong, but I will Help Them Feel Better. For those patients, I'm a magical computer that can instill diagnostic meaning and context to myterious symptoms and physical findings, such as "My pinky toe, Doc, it's been twitching southward at exactly 5:03 pm for the past month. What's that mean?" or "Why does the corner of my right eyelash itch when I'm trying to sleep?"
In essence, for many patients I'm regarded as an auror, or a tea-leaf reader, or maybe a slightly better-dressed $1.99/min telephone psychic, taking in
the facts and symptoms calmly with just the right gravitas inflecting my "Mm-hmm", "Uh-huh" and "I see", cooking them in the white-coat-aura machine and emerging triumphantly with a Diagnosis and Treatment Plan. It's kind of like in high school, when you learned about the concept of a function in algebra, there was that annoying picture in your textbook showing a picture of a computer taking in x and spitting out f(x) . (That one's for all my fellow high school Mathletes and Math Club alumni! Long live the differential!) I don't think I ever really understood that function computer thing until now - when, presumably, after 4 years and a $150,000 education, I'm supposed to be that computer, able to spit out f(symptom) at a patient's whim. Where symptom could be anything: that vague scratch in their throat, that faint pink rash on their upper arm, the strange rumbling in their stomach after eating that street-corner hot dog (come on, patient - I think we both know what caused that one.)Of course, not all patients adopt the pleasant world view that Doctor Knows Best. Some patients are a little more, shall we say, jaded. Or maybe skeptical is the right word. No, how about questioning? Challenging? Domineering? I-Googled-This-Yesterday-And-I'm-Not-Leaving-Until-I-Get-A-Biopsy? (Ooops, not an adjective).
The anti-climactic reality is that doctor-ing lies in between those two extremes. If you've followed
my posts, you probably have already happened upon the rather non-concealed truth that I'm hardly an auror, or a tea-leaf reader, and hopefully I look at least a little more shapely than a computer spitting out parabolas (and those weird asymptote graphs - didn't you hate those?) when handed a patient's symptom questionnaire chart. But I would also, at this juncture, clear my throat rather pointedly and turn the reader to Exhibit A, which is Myself upon the eve of our medical school White Coat Ceremony, a day where my knowledge of medicine consisted of little more than how to wear a white coat. Compared to that happy-go-lucky rapscallion, my current self possesses some symptom-processing knowledge to match those impressive undereye circles, no? Even if, ironically, I seem to have lost the ability to wear a white coat without instantly attracting some sort of stain. (I need that irritating Cheer Detergent lady who always seems to be bleaching some unkempt bachelor's socks to accost me on the street and whiten my coat. That would be a miracle.) As residents, we like to think we're more dynamic and critically appraising, more contemplative and (hopefully) more alive and alert than an isolated Google I'm Feeling Lucky search, But the uncomfortable part of the doctoring reality is that, even after all those tests and classes and presentations and memorizing, even though we Know Stuff and Treat Things, we residents are still doctors-in-training. The "in-training" part means that every patient encounter is still practice. And that a lot of times, we have to act a lot more confident and authoritative than we feel.
There's an infamous motto of medical training that runs like this: "See one, do one, teach one." This is not the learning style that medical schools stress in their glossy brochures, which feature the requisite multi-ethnic group of pleasantly dorky students gazing intently at a microscope or textbook (and yes, that does h
appen to be me looking at that slide of squamous tissue on page 2. The lone pair of 3-inch heels in the bunch!) These happy booklets are geared at convincing the pre-med student, whose often nearsighted obsession with getting into medical school can obscure thinking about what lies beyond, that Medical School X will give you the knowledge and tools to doctor away like a pro. What you find out, only after completing medical school, is that even if you memorize every fact and ace every test, there is still nothing that teaches you...like practicing on the real thing. Even if, for example, you were one of those annoying people who could recite the precursors to oxaloacetate and identify the exact defect of the hypoxanthine phosphoribosyltransferase pathway in Lesch-Nyhan syndrome...you still might not know that you never give Fleet Enemas to patients with renal disease. So there. Nyah.
As scary as the connecting between "practice" and "patients" sounds (and I'm not even thinking about the patient yet!), the system of medical education rests on this implicit nudging forward of residents beyond their comfort zones, of learning by apprenticeship. Of course, you always have backup - your senior resident, the attending, etc. But funadmentally, our education is based on the notion that the only way for residents to be comfortable inserting catheters and arterial lines, of performing lumbar punctures and placing chest tubes, of using a defibrillator to convert a dangerous cardiac arrythmia....is to practice. On, incidentally, real live people.
For mortals like me, who incidentally really, really warmed to that "doing no harm" theme m
entioned in the Hippocratic Oath, the notion of Just You, Some Book Knowledge, and the Patient can be terrifying. Which might explain why my heart was racing as, standing in a patient's room at 2 am, with a nurse, heart monitor and crash cart to keep me company, I slowly injected a potent anti-arrythmic medication in the IV line of an 86-year old patient whose heart stubbornly beat away at 190 beats/min. Or why, despite my sustaining a chronic sleep debt rivaling the U.S.-China trade deficit, I suddenly felt every cell in my body poised on hyper-alert as I prepared to insert a 10-cm needle into the spinal column of a patient with possible meningitis.
You learn in biology about the "fight or flight" response - the biochemical changes of the body's "sympathetic response" that happen when you face the odd grizzly bear, hungry man-eating monster, someone rushing ahead of you to grab the last pair of 75%-off cognac Frye boots. Nothing, I submit, nothing captures "fight or flight" - well, the "flight" part, anyhow - quite like Intern Year. 2008 may be the Chinese Year of the Rat, but to interns it is the Year of Eternal Adrenalin.
The funny thing is that you start glimpsing a logic to the system, the veracity to the "see one, do one, teach one" principle. A procedure, done even once, takes on the aura of charted territory: despite - or perhaps because of - that initial terror gripping you before the first attempt, the imprint of the experience and its lessons are indelibly marked in your brain. And thus, another piece of the impenetrable, mysterious black box of medicine becomes visible. Terror and adrenaline is ultimately replaced by calmness, confidence, that serene feeling of This is familiar, and I know what needs to be done here.
I
t's this demeanor of calmness, I have found, that instantly identifies the knowledgeable, good doctor. (And I'm not talking about that strained "I'm calm! I'm really
calm! I'm so calm! Where's my inhaler?" expression that we interns tend to wear on our face.) Case in point: A month ago, I remember being called on a patient complaining of chest pain; arriving at bedside I found a patient who looked pale, clutching her chest and wheezing for air. I was handed an EKG that showed an abnormal, very fast heart rhythm and tell-tale signs of cardiac ischemia. The nurse then informed me, "Her blood pressure's dropping - and she's going down on her oxygen." Despite having attended three cardiology luncheon talks that week, at that moment the only thought that ran through my head was Help! I need a doctor!
Much like a mirage, only except real, my senior resident appeared in my peripheral vision, walking to the nurse's station to file a chart. I pounced, breathless, shoving the EKG in his face: "Mrs.-Bates-chest-pain-she's-tachycardic-EKG-bad-she-looks-terrible-blood-pressure-dropping-think-she's-having-an-MI-help!" And he calmly surveyed the E
KG, calmly reviewed the vitals, calmly entered the room,calmly examined the patient and patted her on the shoulder as he calmly, effectively reassured her, "Mrs. Bates, we're here - we're going to help you,", calmly instructed the nurse to bring the crash cart inside along with 2 1-Liter bags of normal saline, camly drew up a syringe of metoprolol, while calmly instructing me on the key clinical pearls of the differential diagnosis and treatment of tachyarrythmias. This was the James Bond of doctoring: so calm, cool and in control he made Buddha look tense.
In the end, the g
ood news about learning to be a doctor is that If You Seek, It Shall Come. As you go through the experiences...watch your super-human senior residents achieve the impossible (ie. convince the patients to eat the low-salt renal diet tray? That's pretty much the litmus test of "impossible". I bow down.)...and, yes, practice...you begin to find out that more of the mysterious black box is becoming your readable tea leaf.
Which is maybe why, when I got called a couple of days ago on a patient with chest pain and a heart rate of 180, and another wheezing patient with oxygen saturations of 82%, I found myself actually striding directly to their rooms, my feet avoiding their usual detour to the resident-on-call. Instead of the usual stream-of-consciousness panicked chorus of "oh no oh no what do i do oh no oh no where's the resident help!", rational and logical thoughts of differential diagnoses and treatment plans were carefully building like Lego block towers in my head. (Okay, maybe more like a Lego hut, or a hill. But still. Progress.) "Let's get an EKG now - we'll draw a Chem 7, and please also have crash cart in the room," I found myself saying. In what, I suddenly realized, was an oddly calm voice.
Who knew?
There's an infamous motto of medical training that runs like this: "See one, do one, teach one." This is not the learning style that medical schools stress in their glossy brochures, which feature the requisite multi-ethnic group of pleasantly dorky students gazing intently at a microscope or textbook (and yes, that does h
appen to be me looking at that slide of squamous tissue on page 2. The lone pair of 3-inch heels in the bunch!) These happy booklets are geared at convincing the pre-med student, whose often nearsighted obsession with getting into medical school can obscure thinking about what lies beyond, that Medical School X will give you the knowledge and tools to doctor away like a pro. What you find out, only after completing medical school, is that even if you memorize every fact and ace every test, there is still nothing that teaches you...like practicing on the real thing. Even if, for example, you were one of those annoying people who could recite the precursors to oxaloacetate and identify the exact defect of the hypoxanthine phosphoribosyltransferase pathway in Lesch-Nyhan syndrome...you still might not know that you never give Fleet Enemas to patients with renal disease. So there. Nyah.As scary as the connecting between "practice" and "patients" sounds (and I'm not even thinking about the patient yet!), the system of medical education rests on this implicit nudging forward of residents beyond their comfort zones, of learning by apprenticeship. Of course, you always have backup - your senior resident, the attending, etc. But funadmentally, our education is based on the notion that the only way for residents to be comfortable inserting catheters and arterial lines, of performing lumbar punctures and placing chest tubes, of using a defibrillator to convert a dangerous cardiac arrythmia....is to practice. On, incidentally, real live people.
For mortals like me, who incidentally really, really warmed to that "doing no harm" theme m
entioned in the Hippocratic Oath, the notion of Just You, Some Book Knowledge, and the Patient can be terrifying. Which might explain why my heart was racing as, standing in a patient's room at 2 am, with a nurse, heart monitor and crash cart to keep me company, I slowly injected a potent anti-arrythmic medication in the IV line of an 86-year old patient whose heart stubbornly beat away at 190 beats/min. Or why, despite my sustaining a chronic sleep debt rivaling the U.S.-China trade deficit, I suddenly felt every cell in my body poised on hyper-alert as I prepared to insert a 10-cm needle into the spinal column of a patient with possible meningitis.You learn in biology about the "fight or flight" response - the biochemical changes of the body's "sympathetic response" that happen when you face the odd grizzly bear, hungry man-eating monster, someone rushing ahead of you to grab the last pair of 75%-off cognac Frye boots. Nothing, I submit, nothing captures "fight or flight" - well, the "flight" part, anyhow - quite like Intern Year. 2008 may be the Chinese Year of the Rat, but to interns it is the Year of Eternal Adrenalin.
The funny thing is that you start glimpsing a logic to the system, the veracity to the "see one, do one, teach one" principle. A procedure, done even once, takes on the aura of charted territory: despite - or perhaps because of - that initial terror gripping you before the first attempt, the imprint of the experience and its lessons are indelibly marked in your brain. And thus, another piece of the impenetrable, mysterious black box of medicine becomes visible. Terror and adrenaline is ultimately replaced by calmness, confidence, that serene feeling of This is familiar, and I know what needs to be done here.
I
t's this demeanor of calmness, I have found, that instantly identifies the knowledgeable, good doctor. (And I'm not talking about that strained "I'm calm! I'm really
calm! I'm so calm! Where's my inhaler?" expression that we interns tend to wear on our face.) Case in point: A month ago, I remember being called on a patient complaining of chest pain; arriving at bedside I found a patient who looked pale, clutching her chest and wheezing for air. I was handed an EKG that showed an abnormal, very fast heart rhythm and tell-tale signs of cardiac ischemia. The nurse then informed me, "Her blood pressure's dropping - and she's going down on her oxygen." Despite having attended three cardiology luncheon talks that week, at that moment the only thought that ran through my head was Help! I need a doctor! Much like a mirage, only except real, my senior resident appeared in my peripheral vision, walking to the nurse's station to file a chart. I pounced, breathless, shoving the EKG in his face: "Mrs.-Bates-chest-pain-she's-tachycardic-EKG-bad-she-looks-terrible-blood-pressure-dropping-think-she's-having-an-MI-help!" And he calmly surveyed the E
KG, calmly reviewed the vitals, calmly entered the room,calmly examined the patient and patted her on the shoulder as he calmly, effectively reassured her, "Mrs. Bates, we're here - we're going to help you,", calmly instructed the nurse to bring the crash cart inside along with 2 1-Liter bags of normal saline, camly drew up a syringe of metoprolol, while calmly instructing me on the key clinical pearls of the differential diagnosis and treatment of tachyarrythmias. This was the James Bond of doctoring: so calm, cool and in control he made Buddha look tense.In the end, the g
ood news about learning to be a doctor is that If You Seek, It Shall Come. As you go through the experiences...watch your super-human senior residents achieve the impossible (ie. convince the patients to eat the low-salt renal diet tray? That's pretty much the litmus test of "impossible". I bow down.)...and, yes, practice...you begin to find out that more of the mysterious black box is becoming your readable tea leaf.Which is maybe why, when I got called a couple of days ago on a patient with chest pain and a heart rate of 180, and another wheezing patient with oxygen saturations of 82%, I found myself actually striding directly to their rooms, my feet avoiding their usual detour to the resident-on-call. Instead of the usual stream-of-consciousness panicked chorus of "oh no oh no what do i do oh no oh no where's the resident help!", rational and logical thoughts of differential diagnoses and treatment plans were carefully building like Lego block towers in my head. (Okay, maybe more like a Lego hut, or a hill. But still. Progress.) "Let's get an EKG now - we'll draw a Chem 7, and please also have crash cart in the room," I found myself saying. In what, I suddenly realized, was an oddly calm voice.
Who knew?
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2 comments:
Congratulations, Dr.K, on giving us this beautiful insight into the growth of an M.D. graduate into a doctor. Thoroughly enjoyed it!
Sundara
so there's hope for the rest of us following a few years behind, eh? thanks, j:)
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