Blog | Thursday, July 30, 2015

Becoming a clinician--observations from third year students

The transition between the basic science years and the clinical years in medical school are jarring, mystifying, exhilarating and thought-provoking. Yesterday, I did an hour conference with approximately 30 medical students. About half started their clinical year 5 weeks ago, while the remainder have only 3 weeks left before they finish the year. They gave me permission to share our discussion. We focused on their (and my) observations about the adjustments they were making. The following list is not complete, but rather what we talked about for an hour. We welcome your comments on additional observations.
1. Clinical students work independently, talking with patients, examining them, and developing their own assessments prior to presenting/discussing those findings with residents and attending physicians. The students found this both exhilarating and scary. Several endorsed the “imposter syndrome“. Patients see students as learning physicians, but they actually understand that students are on a trajectory and they are not imposters. This transition is a challenge for many students, interns, residents and newly minted attending physicians. We discussed and acknowledged the feeling. But we also observed that thousands of students have gone through the process and succeeded.
2. Students must learn to ask for help. Those physicians in position to help understand that the students need help. Not asking for help is a huge mistake, but brand new 3rd year students start out feeling intimidated. Successful students learn how to ask and receive excellent help.
3. One quickly learns that you cannot invent the stories that patients tell you. Many stories are incredible. The best physicians appear non-judgmental, although we all have judgments. To get the best story, we cannot appear to be judging patients. Students, interns, residents and physicians cannot really share their interesting or incredible stories with non-medical people. What we find interesting and worthy of discussion bores or disgusts our “regular” friends. I suspect that is one reason 3rd year medical students often appear boring to their non-medical significant others. Our story telling to our peers is therapeutic and necessary, but only in our own groups.
4. Once you start the clinical years you begin receiving calls, texts and e-mails from friends and relatives about their medical problems. This phenomenon never ends. The students were happy to hear that this is a common problem and that they needed strategies to answer such inquiries. Everyone else sees us as experts.
5. Third year students enjoy reading about the clinical problems that their patients have. Adult learning observations support this phenomenon. Reading about medicine during the first 2 years is a job; reading about your patients becomes an obsession and that obsession is necessary, enjoyable and rewarding.
6. Beware cynical health care workers. Beware having cynicism intrude into your personality. We discussed why cynicism develops. We discussed patients trying to manipulate us. One student shared a thought that I had given him. We should trust all patients, but we should always verify their difficult to believe stories. We also talked about the problems of pain and opiate seeking patients.
7. A great observation from a student – Doctors use Google – a lot! She realized that she had always had doctors on a pedestal assuming perfect knowledge. The third year exposure confirms that we physicians are human. We stressed that having physicians look up drug doses or information about a diagnosis while rounding is a very positive trait. We also all agreed that physicians do not live on a pedestal.
8. Medical students should act like medical students, understanding the systems expectations of their knowledge and behavior. They should not act like residents or attending physicians. They should work to become great medical students and prepare for the next step in their climb.
9. We discussed the difficult exposure to mortality. Some students shared their observations of watching a patient die. These episodes impact us dramatically. At first they are very difficult; they never become easy, but we learn to accept mortality and strive to make all deaths good deaths if at all possible.
10. Understand that the retrospectoscope trumps everything. When something bad happens to patients, we always obsess over our actions and decision making. We must learn to own our mistakes and learn from them.

Throughout our careers we always fret about possible mistakes. We often overestimate our potential for having been able to prevent bad outcomes.

We must share our experiences with our colleagues and as colleagues we must be supportive. We must learn from our mistakes and our colleagues mistakes. And we all make mistakes.

The session was informative and therapeutic. The students recommend that we do this again. They really appreciated learning that they were not the only ones who had these feelings, doubts and mental exercises.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.