Saturday, October 30, 2010

Lessons from the Bedside

When we donned our pristine white coats three years ago, we were told that we were about to embark on an exciting journey of lifelong learning. We have only just begun. In four years we are expected to transform from civilians to student doctors charged with taking care of patients. During the process, we become like-minded beings, equipped with the knowledge and skills to think and act in a particular way. We also become problem solvers, who are programmed to quickly work through differential diagnoses. Most of this reshaping happens at the bedside, where our patients guide the trajectory of our development into physicians.

In medical education, we are grounded in two years of preclinical education, when the basic sciences marry the clinical medicine. We start with the basics and build a foundation, fact by fact, during a series of structured, small groups, labs, and exams. A problem-based approach is applied to simulate what we will experience in the world of patient care. With our glossy syllabi, objectives, and neat clinical cases, we venture forth, mastering the pathophysiology of disease, highlighting every word and digesting the well packaged information, fully aware of the expectations, while completely sheltered from the reality of patient care.

When we transition to the clinical years, reality hits us hard. We are indoctrinated into an entirely new culture, where we feel alien in our short white coats and lack of experience. In recognizing our limitations, we also remember that we are bestowed with the responsibility of taking care of human life—a great privilege and challenge. We quickly realize that lessons from our early doctoring class have little place in the world of 10-15 minute clinical encounters and overflowing emergency rooms.

“Human lives are just plain messy,” my medicine attending once told me.
He is right. Although the first two years prepare us with an extensive knowledge base, nothing can truly prepare us for the reality of the clinical years. The complicated pathophysiology of disease pales in comparison to the intricate complexities weaved in the stories of our patients.

As we serve patients during the lowest points in their lives, we become acquainted with the intimate details of their histories. In managing my patients, I have seen a spectrum, everything from the IV drug user who overdosed to the wife abused by her partner to the patient dying from his metastatic cancer to the homeless patient with HIV to the victim of nonaccidental trauma to the pregnant patient actively using meth. The spectrum of disease pathology is oftentimes grounded in social pathology that exposes us to the dark sides of human nature and cruelty of society. When we see the intersections, we are reminded about the fragility of life and complexity of managing diseases.

In these encounters, we fumble through our words, break down emotionally, and struggle to understand. With new admissions and high patient turn-over, there is no time to process and we are not equipped with the coping skills to process the gravity of what our patients tell us. We initially fall back on the pearls we were taught during our first year of medical school to express compassionate words that merely fill the silence and void that separates us from our patients. Slowly, we outgrow our discomfort and we begin to learn, gaining valuable experiences. And despite our inadequacies, we are humbled, when our patients turn to us and call us “doctor,” a reminder that we are growing. We may not see the change, but our patients recognize the doctor in us.

Although the reality of patient care challenges us, the best lessons in medical education rest in our patient encounters, where disease takes on a human form and becomes cemented in our memories. On the wards, we are oftentimes assigned patients based on the learning value of their presentation. The “active patients” represent the gold, a source of intellectual stimulation, full of learning issues and “pimping” topics. Interestingly, when the diagnosis and assessment have been made and the plan is implemented, many physicians feel there is limited learning to be garnered from the “rocks” of the service.

As students, we adopt these patients as our own patients. Physicians, teams, and nurses switch, but the medical student remains, representing the one constant for these patients. We outlive the transient teams, oftentimes relating more to our patients than to the long white coats that surround us. And each day we arrive like clockwork to preround, round, and check-in on our patients. In following patients through their hospital course, we learn more than just the details of managing disease, we learn how to become healers through lessons that can only be experienced.

As medical students our learning represent a series of firsts, where our first exposures to disease manifestations and patient encounters shape our subsequent learning, oftentimes reinforcing the concepts that were introduced during the preclinical years. Initially, we lack the ability to actively apply our knowledge in the moment, while everyone around us processes and works at rapid paces. We lag behind because we are constantly readjusting to new environments with limited experience.

At the times, the process can be numbing. As a student, your role remains somewhat undefined. Your primary job is to take care of patients and learn medicine, in all it shades—the language, the skills, and the details of the culture. Many of us place unreasonable expectations on ourselves. We always forget that we are nomads, traveling from one rotation to another every couple of weeks, whereas our fellow residents and attending physicians have far more extensive experience.

The uneven learning differential skews the expectations. And we oftentimes remain uncertain, unprepared, and overwhelmed by the constant pressure of being evaluated. We strive for completeness and efficiency, streamlining our patient’s stories into one-sentence sound bites—the one liners. Like a shadow, we follow our intern around, unsure where we are supposed to go. We are driven to impress our team by referring to obscure references or citing the evidence-based medicine. In this process, many of us take on a new identity, while losing a piece of ourselves. But no one really teaches us how to learn.

In speaking with fellow medical students, we agree that the clinical years require a great deal of relearning; we have teach our selves how to be self-directed learners. Aside from the occasional didactic session or presentation from the attending, we are responsible for our learning. We spend our spare moments reading and reviewing the literature. At the end of the day we remember very little and our patients represent the best teachers. Education comes from managing our patients, even when we are just beginning to figure out the basics.

When we look at ourselves in our soiled and overstuffed white coats three years after beginning this journey, we can acknowledge how far we have come in such a short amount of time. We have become somewhat conversant in the medical language and familiar with the details of the medical culture. More than anything else, we have gained unique experiences that have changed us. The budding physician in us is slowly emerging.

With one year standing between me and residency, I feel frightened and excited. As I move forward, I know I will always feel unprepared. However, I will always remember that my patients will continue to be the best teachers.
There are many lessons I have learned. They can be best summed as follows:

1. Be present for your patients.
2. Listen to your patient.
3. Do what is right.
4. Be true to yourself
5. Treat your patient like you would want to be treated.

Although these principles are fundamental, these lessons are sometimes forgotten. Such lessons have a central role in the education of not just medical students, but also represent an integral part of the lifelong learning we will experience in our careers.

This essay was recently published in the San Francisco Medicine Magazine.