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Monthly Archives: February 2010

Today, my team of fourth year medical student instructors completed a series of talks for the second year medical students aimed at preparing them for their transition from the preclinical years to the clinical years, from the books to the wards. My team’s talk, “How to see a patient,” is designed to provide the second year medical students with an approach to excelling at their first role as data collectors. Third year medical students begin their training as scouts: they have to get the lay of the land with respect to the patient’s history, the patient’s chief complaint, and the current status of that patient. However, it is possible for third year medical students and ideal for them to graduate from the role of data collector to a junior interpreter and manager of patient care. Some attending physicians and educators use the “RIME” mnemonic to illustrate this evolution: students must evolve from Reporter to Interpreter to Manager to finally Educator (not only care for the individual patient but also contribute to improving the skills of the team and the institution).

However, this evolution is not straightforward, and we sometimes lose sight of our roles. As noted by one of my friends and classmates, even as fourth year medical students we sometimes still feel the same way we did on that first day: we feel like a burden to our teams, we feel like we’re getting in the way of our residents and attendings who are the ones who are really taking care of the patients. One of the essential ingredients missing in the individual transitions from medical student to resident physician is the balance of confidence and humility. Take, for example, the relationship of medical students to nurses: sometimes this relationship is highly antagonistic. From a potential nurse perspective, medical students are below them on the totem pole of authority, and they have little experience and are just going to interrupt their work. From a potential medical student perspective, nurses are simply shift workers who care little about their jobs and are more likely to give medical students attitude then give them useful information. Some medical students worsen this potential antagonism by being arrogant and attempting to don some mantle of authority over the nurses. Some medical students never get beyond their perceived inferior role by being too humble and self-deprecating in their perception of their level of knowledge, experience, and utility.

However, contrary to what one might believe, confidence and humility are not mutually exclusive. For me, having worked in a variety of hospitals and wards and having dealt with all sorts of personalities in the workplace, I have managed to have 90% of my interactions with nurses be very helpful and collaborative if not friendly and congenial. In those crucial skill-building months of the third year of medical school, medical students need to learn to stand and deliver: they need to establish their role and space, demonstrate their beliefs and attitudes, and make alliances based around common goals and the collaborative delivery of a single service. In other words, students need to learn to how to stand their ground (don’t fight back) when facing frustration and impatience and deliver this message: “This is who I am, I am here because like you I care about this patient, I’m not here to give you more work but to work with you to help this patient get better and make things run smoother.”

Traditionally, the fourth year of medical school is often a “diastole” year: most of the required and time-intensive clerkships have been completed, students scatter to all corners of the country for away rotations, and the focus is less on grades and more on “Where am I going next?” For me, fourth year has not been much of a break. After an intense six-month marathon through Internal Medicine, Family Medicine, and Surgery, I then tackled my sub-internship on the Stroke Service in July (one of the busiest services in the hospital that ranges from the ED to the Neuro-ICU to the Med-Surg floors to the clinic), the USMLE Step 2 CK in August, three months of away rotations at Harvard hospitals, and then an epic cross-country interview season spanning four months. Last month, I returned to a “normal” 7-9 hour workday/5-6 days per week schedule collecting data from electronic and paper medical records for my research project. Finally, this month has given me a chance to breathe, reflect, and start building some tools for future learning, practice, and teaching based on the knowledge and wisdom I have collected over the past three and a half years of medical school.

Then again, this month could also mark the beginning of the great washout: this spring is the time when medical students start to rapidly lose all of the information they have crammed into their heads for three years. Most medical school teaching is structured to accommodate the same faulty principles of learning in college: it is heavily didactic and encourages students to cram and purge (after the test). Accordingly, a lot of medical students show up at the beginning of July at their hospitals with only the shadow of knowledge they had acquired in previous years. The knowledge is eventually unearthed and solidified with greater amounts of patient care experience, but this transition can be rough (in teaching hospitals with lots of supervision and redundant capacity, this is mostly rough on the learner, not the patient).

The utility of the Advanced Clinical Teaching course for me is very similar to that of the Psychology of Leadership course I took during my senior year of college: these courses provide me with the tools by which to improve my own performance and that of my team. By learning to teach more effectively and by developing “canned talks” on methods of understanding instead of pure detail, I am building a scaffold, a neural network, in my own brain within which to organize and sort the details of my past and future learning. When faced with daunting amounts of work and stress, it is easy to resort to lowest common denominators and instinctual (and often counterproductive or inefficient) methods. “Daunting amounts of work and stress” is a pretty good description for the next stage of my training: internship and residency. If nothing else, my prebuilt scaffold will facilitate better instinctive behavior: I can find the right answer, the right diagnosis, the right treatment faster and better than if I had no structure at all.

For better or worse, none of my ranked programs are “easy” programs, and I expect to work hard and work long hours in exchange for amazing learning experiences with excellent clinicians and teachers. I don’t expect to have the same sort of reading time I have had in medical school or the same amount of time to prepare presentations for my teams, so my methods of learning and teaching have to be honed to a sharp point before starting my internship.

I am very happy that I have developed what I believe is a good series of 15-minute wards/whiteboard based talks focusing on key topics in Neurology. These talks are designed both for medical students and interns who do not plan to pursue Neurology training as well as though who may be developing an interest in Neurology. The aim is to develop methods of understanding and provide an anchor for future self-directed learning, not deliver large amounts of detail. My current teaching portfolio currently includes:

• Introduction to Neurology
• Altered Mental Status (Differential Diagnosis/Initial Approach)
• Stroke (Recognizing the Signs/Stroke Mimics/Approach to Treatment and Management)
• Headaches (Differential Diagnosis)
• Increased ICP (Differential Diagnosis/Approach to Treatment and Management)
• Seizures (Differentiating Causes of Loss of Consciousness/Differentiating Causes of Transient Neurologic Deficits/Determining When to Treat)
• Spinal Cord Disorders (Differential Diagnosis)
• The Essential Neurologic Examination (for the Non-Neurologist)

Future topics in Neurology I hope to cover before intern year:
• Vertigo (Differential Diagnosis)
• Dementia
• Movement Disorders
• Multiple Sclerosis

I also hope to develop talks for major topics in Internal Medicine before intern year begins. If nothing else, I hope to have a foundation upon which I can rebuild what I have learned and rapidly incorporate new knowledge as new patients arrive at my door.

This month, I am taking an Advanced Clinical Teaching course taught by our Internal Medicine Program Director, Chief of the Charity Hospital system, and one of the best teachers I have ever had: Jeff Wiese, MD. He describes the course as an “Inside the Actor’s Studio” approach to clinical coaching, not teaching, as he asserts that medicine is a performance sport. The ultimate goal is to help us evolve from the earlier phases of teaching (where the motivation is self-reaffirmation of extent of knowledge and external validation though commendation and teaching awards) to the last phase of teaching (where teaching is only about helping your learner develop the skills and understanding to become a better clinician for his or her patients).

His first axiom of teaching is “Understanding is more important than truth.” This, for me and a great number of clinicians and scientists, is difficult to reconcile with the innate compulsion to strive for perfection in knowledge and practice (that theoretically is a selection criteria for medical school, at least until medical students start believing “P=MD”). However, I believe it is the essential foil to the most common, paralyzing mistakes in teaching medicine: the temptation to fill lectures with every nuanced detail and exception, and the inability to empower students. Knowledge is not empowering. Trying to convey large amounts of knowledge can, in fact, be very disempowering as it reminds learners how much they do not know. Understanding and developing methods of understanding are empowering. Without fully recognizing it, this is exactly what I sought to accomplish with the Doctors Ought to Care school health education program I co-led as a second year medical student: we were reshaping lesson plans to give young people the tools with which to better their health, stay motivated, and learn more.

Reflecting on this past week and the weeks ahead, I am thrilled by this month’s potential: I am going to be a much better teacher and a much better clinician than I otherwise would be. If nothing else, this month is giving me the time to build a repertoire of lesson plans, talks, and methods (including “advanced organizers”) to address areas of Neurology as well as the areas in Internal Medicine I find most important to my future practice. A few months ago, I was tempted by delusional hopes of being able to read all of Adam and Victor’s Principles of Neurology or Harrison’s Principles of Internal Medicine before starting my intern year. This is a result of the ways I have been taught previously: that there is so much knowledge out there and that I simply do not know enough. Even if I had the time for that, though, most of that knowledge would have been stored in short-term memory and would have disappeared by the time I started my Neurology residency. Now, as I develop methods and “canned talks”, I am learning, retaining, and understanding more than I otherwise could. I have already developed talks on the differential diagnoses of headaches and spinal cord disorders (one subject I have never previously had a good grasp on). I am hoping to cover the major topics in Neurology by the end of the month and to have somewhere between twenty and thirty prepared talks (spanning Neurology and Internal Medicine) by the time I start my intern year. I have not felt this motivated to learn in a long time.

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