Doctorly

It’s nice, for a change, to actually feel like a doctor during my time as a third-year medical student. At the end of my twelve-hour extended duty shift yesterday (after having spent most of those twelve hours with little to do but read medical references on my iPod Touch), I finally had the opportunity to admit a patient from the Emergency Department to the general Pediatrics floor. The patient, a spunky young kid with whom I could conduct much of the interview while in the company of his parents, had burns from a cooking accident covering much of his face. The medical issue appeared quite straight-forward (a simple accident with a very low index of suspicion for intentional injury on the part of the child or his caretakers), and I was able to smoothly conduct the interview and physical exam (and build an appropriate differential diagnosis that ruled out abuse or self-injury). At one point, the parents even remarked with admiration to the intern with whom I was working when I whipped out my otoscope from my belt to examine the boy’s nose, throat and ears: “That’s so neat! How professional!”

I was actually caught off guard when the resident on duty asked me to admit the patient: during this past week on Pediatrics, my attempts at assertiveness and at assisting my team seem to have been given the cold shoulder (whether intentionally, unintentionally, or just as a result of the circumstances at the time), and I had been starting to feel underwhelmed and disconnected. While on my (adult) Neurology rotation, although I was largely inexperienced and naive in the clinical setting, I still felt as though I were an integral member of the treatment team because the attending physician, the residents, and the interns viewed me and my fellow students as such and demanded the responsibility to match. The Neurology and Psychiatry departments with which I have previously worked were also smaller and seemingly more personal than Pediatrics, despite the reputation of pediatricians as the most genuinely nice doctors with whom we (students) will work. When my (future pediatrician) fiancée had mentioned to me that she is planning to do her sub-internship in Medicine instead of Pediatrics, I was at first confused until she mentioned that some of the physicians advising her classmates had noted that there is often less independence and autonomy for medical students in Pediatrics services than in Internal Medicine services (sub-internships are done during the fourth year of medical school as an opportunity to function with the responsibility of a first year resident). I have definitely felt that way so far: the attendings seem eager to teach and the interns are quite pleasant, but I think the residents provide less direction and fewer teachable challenges than on my previous rotations. I think this is partly because my Pediatrics clerkship is structured such that we only spent 10-14 days in four different sites/services/teams, so the residents have comparatively less responsibility or emotional investment in the medical students. This rotation seems to be a “smorgasbord of exposure” to a variety of experiences that provides little depth or intensive training in any one area: indeed, we have to keep a patient log that requires that we see one patient in each of fourteen different areas of Pediatrics (e.g. cardiology, endocrine, gastroenterology, well visits, etc.) or complete a structured teaching exercise for the areas we miss on the wards.

Last night’s experience was also remarkable in that my actions were not scrutinized: I did not have to present the patient to a physician (resident or attending). The intern dictated the patient’s history to the attending physician, and so I was able to conduct my tasks with autonomy: interview and examine the patient, speak with the parents, write the admission note (history & physical), and place that note in the patient’s new chart. I will eventually present my note to a preceptor (physician) to evaluate my note-writing, but my purpose and function yesterday was independent of oversight. As a medical student, one usually presents to the resident on “work rounds” (during which one’s mistakes are corrected), and then one presents a more polished version to the attending later in the day on “attending rounds.” These two presentations are valuable teaching experiences that involve “pimping” (quick tests of knowledge base), exploration of the student’s clinical reasoning, and didactic teaching about diagnostics, treatment, and management of the patients. These experiences are very important for learning, especially with patients that are more complicated than the one I admitted last night. I value these experiences greatly, but it was nice (for a change) to be trusted to complete a simple task and actually provide assistance to the Pediatrics team (by relieving the work burden on the interns and residents). And additionally, it’s nice to be praised for good work too!

[If nothing else, I think that it would be great if medical students had more structured opportunities to have autonomy on simple cases on each core clerkship to build confidence, hone efficient interview and examination skills, and potentially develop some positive impressions of the field (e.g. seeing patients that are happier or are in better shape).]

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