To Know Thy Name

The practice of medicine in a busy academic hospital often involves a degree of anonymity. The daily experience of any given inpatient includes an endless, unpredictable parade of nameless scrubs, white coats, and suits, each entering the modified and impersonal bedroom with a specific agenda: to obtain vital signs, to examine the body, to ask questions about the recent illness, to discuss discharge planning. Many, if not most, of these individuals will introduce themselves: “Hi, I’m John, I’m your nurse for today.” “Hi, I’m Ann, one of the medical students on the team taking care of you.” “Hello, I’m Dr. Thompson, a nephrologist.” However, a considerable number of patients cannot manage to recall the names of the doctors and nurses who take care of them in the hospital: there are too many of them, and it isn’t easy to remember much when you’re sick. Many patients also have trouble remembering or spelling the names of primary care doctors or specialists they see in the clinic. Instead, these individuals fit into a role: the cardiologist, the physical therapist, the night nurse. Is this an inevitable failure of human memory or a lack of sufficient effort on our part to make our names known to our patients?

On my part, I find it difficult to hold on to names unless I have associations built around an individual’s identity. For example, I can remember the name of an interviewer I am going to meet tomorrow because I know there is a specific context in which I will be speaking with her. In the absence of these associations such as when I’m meeting someone without prior arrangement, the best way for me to remember a name is to learn a person’s name while shaking his hand. Almost without fail I can remember a name if learned in such fashion. However, if I don’t shake someone’s hand (especially if I am meeting many people at once), there is a significant chance that I will forget that name. In the hospital, it is not uncommon for medical personnel to decline to shake the hands of their patients (or even colleagues) for concern about the spread of germs. If others follow the same method of storing names in memory as I do, then it isn’t difficult to see how it would be easy to forget recently acquired names.

There is some measurable appeal to anonymity in the hospital: it’s harder for trouble to arrive at your doorstep if it doesn’t know your name and address. I’ve closely observed the many attending physicians with whom I have worked and noticed a wide variety of approaches to the simple task of introducing oneself: some walk into the patient’s room and start the interview and exam without ever mentioning their name, while others go so far as to give each patient a business card (with a photograph). Exposing one’s name has the logical benefit of spreading one’s reputation among the patient populace (i.e. recruiting new patients among friends and family members of the patient), but it also exposes one more readily to the manifestations of patient frustration, litigation (e.g. pick a name and sue), and potentially excess interpersonal contact (i.e. too many phone calls and e-mails). A fellow medical student alerted me to a built-in feature of the iPhone that allows one to turn off one’s caller ID so that one’s calls show up as “Blocked” on the recipient’s cell phone: this is shared among medical personnel as being a useful tool for making calls to patients and their families. In many ways, our interactions with patients and their families must fit into small, discrete boxes of time and effort: there cannot be a trail or a route of communication that leads back and permits future interactions that are not initiated by the doctor.

On the other hand, giving one’s name to another person is a powerful gesture: it is a gesture of trust and connection. Names carry a great deal of weight in every human culture, else parents would not agonize over the task of selecting the right names for their children. Introducing oneself gives the other person access to one’s social network: in the context of the medical system, the giving of a medical provider’s name is a transaction that permits the repetition of medical services in the future. Beyond the business implications, this gesture also can clearly state an intention: “I am here to take care of you now, and I will take care of you in the future should you need me.” I always introduce myself to every patient under my care and find pride when they include me or refer to me as their primary “doctor.” However, I am in a privileged, protected position as a medical student because I do not have a longitudinal practice: patients cannot find me. Nonetheless, there are a few patients for whom I have taken extra measures to provide my name and contact information: the patients whom can benefit most from my ability to seek and find meaningful medical information or the right people to help address complex medical issues (that also interest me). Recently, though, I found myself thinking as I gave a patient my contact information, “I might be practicing medicine here in the future. If you are in need of a neurologist, I would be happy to take care of you or find the people who can.” Here is my name.

Filed under: Apollo's Experiences, Medical School

What am I to You?

As the final months of medical school approach, it surprises me how much my role has changed in the lives of my patients, my classmates and school mates, my family, and the physicians with whom I work. As a third year medical student, I at times lamented our sorry state of existence: we served as scut monkeys for the interns, lightning rods for upper-level residents and attendings who needed fodder for making an example or simply a transient and “safe” target for displacement, irritating space invaders and time wasters to the nurses, and inadequate messengers for demanding patients and their family members who wanted an occluded IV infusion alarm turned off, or a second breakfast, or quite legitimately, a realistic estimate as to when the doctor would come visit. More often than not, however, I remember having a more positive influence:

• as an assist to the interns and residents who could be trusted with obtaining key information, examining and interviewing patients accurately, discussing issues with consult physicians, and even writing orders (or the equivalent in the Operating Room: cutting and suturing).

• as an ally to the nurses who could rely on us to help with everyday tasks and ensure that important observations were brought to the attention of the residents and attendings (usually translating into new written orders or order modifications).

• as a proxy for the physicians when they otherwise didn’t have the time or opportunity to counsel and educate patients (including one time when a rather belligerent patient “fired” the rest of the medical team). My fiancée, currently on her Medicine subinternship (a fourth year clinical rotation where the medical student has similar responsibilities to a first year resident), recently counseled a patient who had many questions about her complicated medical condition and the tough decisions being made, and when the resident came in to see and counsel the patient, the patient told him, “That’s ok, she (my fiancée, the medical student) already explained everything to me and answered my questions.”

• as the consistent “doctor” to patients who otherwise are visited by a dozen different residents, specialists, nurses, and therapists each day (who have many more patients to see than me). Some of my attendings said, “I’ll know you’re a good medical student if I ask the patient ‘Who’s your doctor?’ and he points to you.”

• as an enthusiastic student to the attendings who sometimes depends on us to ask good questions, stimulate discussion, or simply remind the medical team that we are working in an educational institution and that we have a mission to preserve and expand the fund of medical knowledge and use this knowledge to the benefit of mankind.

• as an equal practitioner of certain aspects of the “art” of medicine: empathizing with the patient’s suffering and anxiety, equilibrating to the moods and attitudes of the patient and her family, knowing when to smile or frown or laugh, using physical contact in the right ways and at the right times to strengthen the doctor-patient connection, maintaining an appropriate demeanor and veneer, expertly managing the giving and receiving of knowledge with the right tempo and cadence, knowing and expressing what you can and cannot do for the patient, and showing constancy in providing hope and guidance through the most difficult of times.

All of these are potential roles for the third year medical student. I have happily assumed all of the more positive roles, and I reluctantly find minimal value in the more negative positions if only to be able to show the red badge of courage to the naturally cynical and more senior generation of physicians who believe that today’s young doctors are too soft and pampered. My disclaimer and proclamation: I survived the Charity Hospital system.

Now, as a fourth year medical student, I have shed some of the less desirable roles and gained a few others: marginally more experienced teacher to third year medical students, cautious and suddenly more aware health advisor to family members, potential future colleague to residents, and potential trainee and employee to attendings and residency programs. From this vantage point, I’m starting to glimpse the coming transition to physician status, one which is commonly reported by first year residents to be hardly a noticeable transition in personal qualities at all – only a transition in personal responsibilities. Accordingly, I plan to use these final seven months to brace for the next new role: doctor (without quotations).

Filed under: Apollo's Experiences, Medical School

Finding a New Home

Like many of my classmates, I am entering the interview stage of my final year in medical school. I just completed a one month away rotation (or exchange clerkship) at one of the programs I am very interested in: it was nice to have the opportunity to have an extended look at the inner workings of the training program, the work environment and culture, and the attitudes and styles of practicing medicine of the residents and attending physicians.

A few pieces of advice given to me by the faculty and residents at this program have resonated strongly with me:

• First, don’t feel that you have to prove anything when you visit programs to interview. If you have been given an invitation, you have already met their qualifications, at the very least on paper. Instead, they will be doing their best to sell their programs to you.

• Secondly, perhaps the most important thing you can do on the day of your interviews is to get a sense about who the people are, especially the residents. Most of the learning during residency comes from your senior residents and colleagues. Furthermore, after three years, you’ll probably be a lot more like them in thinking, attitudes, and personalities.

Good luck, everyone!

Filed under: Apollo's Experiences, Medical School