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Jun. 22, 2010

It’s Not Only What You Know

by Linda Brodsky

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Dana is finishing her surgical clerkship this week. Has it really been eight weeks? It went by so fast. Well at least for me it did. I don’t know about Dana, because she has surfaced for air (and some time talking on the phone) only a few times during these past several months.

But as I listen from afar, I hear the memories stir that I have stored of my first patient encounters in the daily dramas of her medical student life. Getting to the “wards” (as we used to call the patient floors, a term left over from the open hospital wards that characterized a hospital almost a century ago) was a real milestone. And it meant that you were going to meet real, live, actual (not simulated) patients. That alone was awesome and frightening.

And to the uninitiated, no matter how close to medicine she/he may have been, no longer are the scientific facts and concepts enough to guarantee your success in this new environment. There is a large and rather complex layer of people that comes between the student and the patients. This layer is known as the “service.” A service, in a medical school/university teaching hospital, consists of many types of medical students, resident trainees at different stages of training, and the attending or staff physician. The attending (or staff) doctor is the doctor who has completed all her/his training and is now responsible for the patients on the service. He/she teaches at the medical school in a clinical capacity. He/she is the ultimate decision maker. That’s a lot of responsibility.

But in order to teach and take care of patients at the same time, a large cadre of helpers/learners is available to help the attending. Each has a different role that may change daily depending on the situation. One example is on round. On rounds (going around and seeing the patients two or three times a day to check on their progress) the student may present a patient at one time, or the chief (most senior resident) at another. Knowing when to do what can be very confusing and stressful. Another example is helping in the operating room. Knowing what and how to do something which might seem as simple as holding a retractor, can be a major life challenging experience! Let that retractor slip at a critical point in the operation, and significant harm might result. What lecture covered that in the pre-clinical years?

Thus, new skills come into play at this point in the student’s medical school journey. Social skills. Skills needed to assess a situation and respond quickly and correctly to the social cues of a totally new environment. When do I speak up? When do I volunteer to see a patient? How am I supposed to present this patient? Was I too long-winded? Did I leave out any pertinent information? Did I speak loud enough and with enough authority? When do I tell the surgeon my arm hurts and if I don’t get a rest soon, the retractor might slip?

Sometimes, when I was worried about all of these other things that go into becoming a doctor, the medical concepts I learned would fly right out of my head. I might stammer or think that I looked kinda jerky. And I guess sometimes I did. And yes, sometimes the retractor slipped, but the surgeons always saw it coming and I don’t remember any harm (even the time I fell asleep holding the retractor on a liver during the removal of a gall bladder at 4 am!) And somehow I made it.

I am sure Dana has had some of these experiences. I know that she thinks that she is unique in her mis-steps, but that just isn’t so. I hope in the next post she will tell you about her first clerkship and how she felt about stepping into a whole new world of learning how to take care of patients in the social system we call health care.

About Linda Brodsky

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