MDs: Advice for the Next Generation

This past weekend, I had the opportunity to meet with local medical students as part of an American College of Physicians (ACP) mentorship brunch. I sat with a small group of second year medical students ready to impart my “wisdom.” Mostly, I wanted to be available to answer questions the students had for me. But I knew there were certain thoughts (a few of many) I wanted to share:

  • You may not recognize the medical field you once knew when you first decided to embark on this path. After all, several years pass between the time you make the decision to become a doctor and when you actually start practicing medicine. When I first went into med school, I knew of wealthy primary care doctors who spent 30 minutes or an hour with each patient. Keeping your mind open and not getting too hung up on expectations of what medicine should look like will serve you well and help curb future burnout.
  • Think outside of the box. This has nothing to do with the least likely diagnosis in a case and more to do with the practice of medicine. It’s ok to think creatively. Medical training, at least when I went through it, does little to encourage innovative ideas. If doctors don’t get creative, other interested parties will be eager to impose their ideas on your care of your patient, often with their own self-interests in mind. This can be great (for example, a useful new device or protocol). But it is often done with less knowledge of the unique complexities of the actual practice of medicine. Doctors know what doctors do better than anyone else. As a group, we are incredibly bright, but we can’t make much progress with our heads buried in the texbooks.
  • Balance it out. It is easy to fill 24 hours a day (or more) with medicine. If you can learn to balance school with other positive activities you have always enjoyed, you won’t feel overtaken by this life of medicine later. Even if it is just dabbling in that activity now and again when you find some time, it will be worth it.
  • Watch your digital footprint now. I was – luckily – never faced with this worry as a student. Following doctors who exhibit professionalism online can give you a better understanding of how to use the web in a productive manner and avoid the pitfalls of a web presence. Sometimes you just need good examples.

What words of wisdom do you have for the next generation of MDs?

A Surgeon, an Anesthesiologist, and a Med Student. A story.

I recently discovered a blog written by a surgeon who works in South Africa. His writing style is excellent and it is worth reading. One of his most striking (and as a warning, graphic) posts is what I came across first. But his most recent (not-to-be-taken-too-seriously) posts about the relationship between surgeons and anesthesiologists triggered a fond remembrance of my three-month rotation through surgery in medical school.

It was my third year of medical school. I had already completed a few weeks of my surgery rotation and found myself frequently scrubbing into cases with one of the more notable surgeons on staff, whom I will dub Dr. X for the purpose of this blog. He was known among the students as being intimidating – stature not-withstanding – and his European accent just exaggerated the effect. He had a gruff, no-nonsense temperament. I am not even sure I ever saw him smile. There was no playful banter during his cases, no music. Just seriousness.

In one particular operation, I was in charge of retracting the liver. This was no easy task for a young woman with thin arms. It was not a gentle, retraction, trust me. I had to use two hands, if I remember correctly, and exert a constant upward force for a long time as cuts were being made, sutures were being tied, and explorations were being done. I recall feeling the pulse of the heart transmitted to my hands. My job was to retract and I was going to do it steadily without a peep, like a good medical student.

But I also recall the bright lights of the OR and feeling warm. I recall not feeling quite like myself. Tiny sweat droplets started to form behind my mask. Then the worry set in. I had, by that time in clinical rotations, heard stories of medical student colleagues passing out, most of the time due to inadequate food intake prior to a long case. Any student who hears that story fears having a similar fate. I thought it would never happen to me, though, because I always made it a point to eat. In fact, this was my first case of the day and I had had a substantial breakfast.

Breakfast had not been enough that day, apparently. I felt as if all the blood was slowly draining out of my head to support the muscles keeping me standing and holding that retractor. I thought to myself, “Am I going to pass out? Should I say something?” Everyone was so focused and I wasn’t supposed to be the patient in this case.

My best judgment kicked in. “Joe?” I said. Joe was my quiet, but also no-nonsense, only-talk-to-me-about-important-clinical-stuff chief resident. He was diagonally across from me, at the patient’s thigh. He didn’t respond. Or did he? “Joe?” I said a little louder. “Yeah,” I finally heard him say. I was able to get the words out of my mouth. “I don’t feel well.”

It had been quiet in that OR until I said those words. Then in my muffled hearing, there were many voices, mostly indistinct. The surgeon was yelling something like “Step back! Step back!” The problem was that I was standing on a stool. In my state, I would have fallen backwards to the ground. So I didn’t step back. I felt like I couldn’t move, anyway, but I had to hold on to that darn retractor…. Oh, great. I just pissed off the surgeon.

In a quick series of events, someone grabbed my retractor and another held me by the waist, guiding me down to lay on the floor. Then my knight in shining… er, scrubs, came to my side. An older, seasoned Greek anesthesiologist held my wrist and felt for my pulse.

I slowly started to hear more clearly and see more clearly.

“What’s the blood pressure? “ Dr X barked.

“80s systolic, but it is coming up,” the anesthesiologist said about me. (This was just by palpation of my wrist, mind you).

Not the medical student. I mean the patient. I don’t care about the medical student.”

Either I was suddenly brave or there was a lack of blood flow to the area of my brain related to inhibition, but at that moment, I said, “I heard that, Dr. X.” It was silent in the room except for a giggle from a nurse. I would like to think he was smiling inside, too.

There is always some level of embarrassment after an episode like that. I had to scrub in a few more times with Dr. X and wondered if he questioned my ability to stay upright during a case. Luckily, our relationship was not tarnished. In fact, I believed he had developed a a little bit of respect for me as a student (though he was not one to admit such things), particularly when I took over the role of a scrub nurse who was not immediately available at the start of an emergency case. I had observed Dr. X well enough to anticipate his needs and had developed enough confidence in working with him that I boldly interrupted a motion he was doing during that expedited surgery which would have resulted in a puncture wound to his hand. His response to that, by the way? A gruff “Hmmph” while continuing his work.

I often wonder what it is about the OR that encourages distinct personalities to come out or become amplified. Whatever it is, I fondly remember that anesthesiologist who tended to me when I was lightheaded, despite the fact that there were other nurses around to do so. But I have to admit that I also had a soft spot for that surgeon who was hard to crack.


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Scalpel, Forceps…Pen?: The Role of Creative Writing in Medical Education

A recent article in The Wall Street Journal reported a trend on teaching humanities in medical school to comply with a recommendation to teach compassionate care. While clinical acumen is important, empathy is a trait that really enables a physician to connect with his/her patient, thereby improving the healthcare experience of that patient. The argument for teaching courses like “narrative medicine” – where students write about their experiences – along with anatomy and pathology, is that exploring and understanding the human side of medicine will enable these doctors-in-training to grow into compassionate physicians.

Writing about medical training is not a new concept, however. I had a chance to sit down with physician-author Emily R. Transue, MD*, who started Mind, Body, and Pen, a creative writing class for medical students that is offered every winter (an ideal time for self-reflection in the Pacific Northwest). She has been teaching this class voluntarily for eleven years at the University of Washington Medical School. In fact, she has had to cap class enrollment to 15 students due to high interest and to optimize the experience for both herself and her students.

“Writing is about honing and maintaining skills for empathy,” Dr. Transue says. She argues that the vast majority of students who apply to medical schools are actually quite empathetic. However, during the course of traditional medical education, empathy can be “beaten out of them…. There is little opportunity for self-expression, and [medical students and residents] don’t have a sense of permission to be affected by experiences.” Dr. Transue’s class gives them that permission. It allows students to process some of the challenging aspects of becoming a doctor. By writing about the death of a patient or the strain on a young marriage, students have an avenue to help bring emotions and feelings “outside of their heads.” In addition, the medical students, who are notoriously competitive, listen to pieces written and read aloud by their peers and have to resist the urge to “one-up” each other. It encourages focused listening and reflection on another’s emotions.

If medical students are inherently compassionate, at what point are the skills for empathy being squelched? Dr. Transue feels the answer may actually be in the culture of residency. Medical residents are role models for impressionable medical students. Historically, the prevailing culture has been one of proving your worth as a physician. This means being a “gunner” at all costs. Not showing weakness. Being a sort of superman in the face of extraordinary circumstances (life, death, illness, sleep-deprivation, strained relationships, depression). Medical students are learning the ropes – more than just the clinical ones – from these residents and the cycle continues.

Humanities courses can allow medical students to maintain their already empathetic nature. But to continue to preserve it, exercises that allow for reflection of clinical experience in real-time would be valuable in residency, as well. It is during this stage that burnout rates are high and critical decisions are being made regarding specialty choice. One might argue that courses similar to Dr. Transue’s creative writing class could increase the likelihood of residents choosing to practice in primary care fields.

*Emily R. Transue, MD is the author of : On Call: A Doctor’s Days and Nights in Residency and Patient by Patient: Lessons in Love, Loss, Hope, and Healing from a Doctor’s Practice. She practices at The Polyclinic in Seattle, WA.