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The third year of medical school is a pivotal experience in the lives of training physicians. In some ways, it is one of the most difficult years in training, besides intern year. In this series, I will share lessons I learned as a third year medical student and my experiences teaching third years.

The third year of medical school is the most confusing and disorienting year in the process of training to become a physician. While the first year of residency (intern year) has traditionally been the most exhausting and demanding (emotionally and physically), this year continues to lessen in intensity as the field attends further to the tolls and dangers of sleep-deprived trainees. However, the third year of medical school, if anything, is increasing in difficulty. While the responsibility and activities of interns is centered on patient care activities, the purpose of the third year clerkship is variable and highly dependent on the fickle expectations of residents, attendings, clerkship directors, and medical school curriculum designers. These expectations are unfortunately frequently in conflict with one another and include the following activities:

1. Learning the science of medical management (e.g. pathophysiology, clinical presentations, differential diagnosis, treatment, prevention, etc.) – through lectures, reading, teaching on rounds, the workup of individual patients, and tutorials

2. Learning the art of medicine (e.g. developing relationships with patients and their families, interacting with other physicians and hospital staff)

3. Learning “roundsmanship” and team work (e.g. operating as a member of a physician team)

4. Assisting with patient care (e.g. reevaluating patients, scheduling followup appointments, calling primary care physicians, calling subspecialty consultations, performing minor scut work)

5. Presenting to and teaching the physician team (e.g. learning about a subject and giving a short presentation on attending rounds)

6. Learning a broader standardized curriculum designed by the medical school that encompasses topics that might otherwise be missed between individual rotations (available in some medical schools)

7. Learning how to manage a continuity clinic (available in some medical schools)

Unfortunately, these expectations are often not explicit, or students do not know which expectations to prioritize. Accordingly, it is easy for a reasonably intelligent student with good intentions to fail during this important stage of training due to lack of flexibility, poor insight, and a lack of assertiveness. To guard against this, I offer a brief review of the most common pitfalls that third year students face:

1. Not being present.

The most common and devastating mistake that third year medical students make is to become invisible. In many schools, the clerkship final examination (the Shelf exam) may account for as much as 30% of the final grade. Having spent every year of schooling prior to this learning from books and taking tests on paper, it feels most natural and most safe for medical students to dive into the review books and Up-to-Date in order to desperately try to learn the vast amount of information that they might encounter on their clinical rotations. However, they may fail to account for the remaining 70% of their clerkship grade for which the majority derives from the evaluations written by residents and attendings that work with the students. They also fail to realize that most residents and attendings actually like working with medical students or at least feel some degree of responsibility for their education. This mistake typically manifests as the student venturing out of sight of the residents in order to read a review book in a quiet space. (At the very least, if a clinical service is quiet, the student should ask her residents if it is okay to find a place to read so that the residents know where she is and what she is doing.) Out of sight, out of mind. Once the student removes herself from the vicinity of the residents or attendings, she is no longer is available for the minute-by-minute pearls of wisdom, the observation of how patient care is coordinated and carried out, and the opportunities to engage actively in patient care as new issues and crises arise. Also, the tendency for residents is to write positive evaluations for their students, and being present provides more material to write about while being absent leaves the resident with little to say in favor of the student.

This pitfall is becoming more difficult to avoid as many medical schools redesign their curriculums in such manner that they are spending more time in the classrooms and away from the patient wards and their teams. The most common complaint of residents and attendings is that these new curricular changes result in the students never being around. Accordingly, third year students have to be very careful to cultivate expectations and let their residents and attendings know where they are or where they will be at all times.

2. Being late.

One of the crucial aspects of ensuring one’s attendance is to be on time to all regularly scheduled meetings. This usually isn’t a problem for most students, but again, students who spend more time away from their residents are more likely to be left behind when work rounds, attending rounds, or teaching sessions are shifted from their usual times.

3. Failing to learn something taught with emphasis.

In general, most residents like students and want to see them succeed. Furthermore, on a more self-serving level, students that perform well reflect positively on their residents (as teachers and role models). Residents will use different strategies to help their students perform well in the eyes of their attendings. The most obvious manifestation of this is a resident rehearsing a verbal presentation with a student for attending rounds. The resident will often point out key details for the student to highlight or describe a particular way in which the important information should be conveyed. Unfortunately, some students do not pay enough attention to these explicit rehearsal or teaching sessions. I have too often seen clear evidence of disappointment and disapproval on the faces of senior residents when a student fails to convey important historical details or examination findings or when he botches the presentation structure. While it is not always reasonable for a student to be able to remember everything advised by his residents or to be able to perfectly recite a script handed down by his resident, it would behoove him to be extremely attentive when a resident sits down with him to prepare for a performance. Similarly, when a new skill or concept is taught with emphasis, this becomes a marker for improvement for the student; failure to internalize this new lesson accordingly is detrimental to his subsequent evaluation by that teacher.

4. Being too proud.

Third year medical students are smart: they have clearly achieved excellence in order to make it to this stage, and their proximity to their recent preclinical coursework and Step examinations provides them with a wealth of book knowledge. However, most third year students have minimal amounts of clinical experience and little awareness or knowledge of how medicine is actually delivered. While most third year medical students are aware of this fact and accept it with humility, a select few have difficulty accepting the advice, moulding, and criticism that inevitably comes from residents and attendings. Everyone has room to improve, but not everyone is willing to change. These students unfortunately develop a shell that blocks out criticism and advice, discounting criticism as the product of a resident or attending that “had it out for me.” Unfortunately, these future physicians are also the future recipients of law suits and disciplinary action. Given that most residents and attendings are saddled with excess responsibility, it takes a lot of activation energy to produce constructive criticism, so advice or criticism given is rarely fictitious.

5. Lacking confidence.

While some students fail due to pride and overconfidence, most students trend in the opposite direction: they feel like imposters in a new and alien environment. Bombarded by questions from their residents and attendings, the habitual answer of the overwhelmed is “I don’t know” as it would seem to be the easiest and quickest way of cutting short the torture of feeling helpless and unknowledgeable. Students cope with this in many different ways (some more maturely than others), but typically the best recommendation given to them by residents and attendings is to commit to an answer or decision and yet still remain flexible to learning and changing.

6. Sandbagging or upstaging a fellow student.

At my medical school, showing off and upstaging fellow students or residents was called “sandbagging,” as though one were physically dropping a sandbag from offstage onto an unsuspecting colleague. The most common form of this is when a student answers a question directed at another student. In the stressful environment created by the wards, students all too often feel pressure to perform and look smart in front of their residents and attendings, and this can breed distasteful manifestations of competitiveness. This tendency is unfortunately fostered by some residents and attendings when they don’t direct their questions at individuals. Nonetheless, trying to look good at the expense of others inevitably reflects very poorly on one’s character as few people would want this type of person as a colleague.

7. Being unkind or cruel.

Lastly, students sometimes too easily pick up on the bad habits of residents and attendings. In particular, residents and attendings will occasionally remark unfavorably, joke, or complain about other people (who may be obstructing or causing detriment to patient care) in a private setting when students are present. However, residents and attendings have gained experience and training in tempering their feelings in such manner that it does not affect their interactions with these other parties; these expressions behind closed doors are, in some ways, safety release valves. Many students, however, have not learned or developed these skills and balancing measures. Students then may sometimes actly rudely or unkindly to others as they “side” with their residents and attendings. However, this type of behavior is never acceptable at any level of training or practice and should be guarded against at all times. One of the most important tasks for all physicians is to bridge gaps in understanding with patients, families, and other staff members (e.g. nurses, technicians, therapists) in order to lead and direct the best care possible, and the avenues by which this may occur are obliterated once rudeness and meanness color the interaction.

Fellow residents, what mistakes have you seen students make? What advice would you give to them to avoid common pitfalls as third year medical students? What measures should they take to succeed in becoming excellent physicians?

The Context

Today, one of the our attendings gave a solid overview of the major families of dementias. With the skills of a talented and effective instructor, he queried the audience of residents and students to help him fill out the content of a table designed to help differentiate between the presentations, test findings, and treatments for the different types of diseases. He was able to keep the audience actively engaged and participating, but at one point he asked a question that was met with silence. I volunteered the answer, and he turned to me, somewhat surprised that anyone knew the answer. I explained (that he shouldn’t be so impressed): he had mentioned the answer in a previous talk given several months ago, and I just happened to have a set of notes from that discussion open on my iPad which I was annotating and expanding with the lessons learned from today’s talk.

While it’s not so impressive that I was able to ascertain the answer, impressing someone was not the point for me: the fact is that I had that information and was able to quickly access it, even if it wasn’t readily accessible in my own brain’s memory bank without the assistance of my notes. This raises a major question for lifelong students of medicine: Is it better to try and store as much information in one’s memory as possible knowing that there will be limitations on the amount of information that can be remembered, or is it better to store some (perhaps a large proportion) of that information somewhere it can be easily and quickly referenced? If secondary storage of information is worthwhile, then should clinical information be trusted to a few easily-accessible resources (e.g. a pocketbook, online medical search database) or should it be digested and recorded into a personal notekeeping device (i.e. a notebook)? To approach these questions, we must first understand the nature of knowledge and how it is gained.

free your mind

The Student’s Dilemma

While we would like to think of knowledge learned as being the truth and that truth is an absolute, for better or worse the learning of medical knowledge is not this simple. Since medicine is based on scientific principles, there is a constant effort to strive for refinement of knowledge towards the best approximation of the truth, but in the mind of a humble scientist there is also the necessary acknowledgment that a better or more truthful explanation may arise to refute his or her prior claim. Simply stated, medical knowledge changes, evolves, and hopefully improves with the advance of medical science. Nonetheless, there is also the knowledge derived from practical experience (or story or wisdom) that enters the learner’s mind in the form of a “gospel” taught by more senior physicians. In many ways, this information is equally important and perhaps carries equal weight because this information is based on direct encounters with individual people that have the full force of a clinician’s mind reviewing the entirety of their unique cases. Nonetheless, something that is gospel must be preached (with strong language, without wavering, and lacking an acknowledgment of uncertainty), and one only has to preach when there are those who do not believe what is being said. In other words, truth does not need to be questioned, but this does not fit the description of anything in medicine. As such, physicians and patients alike must live and function with great uncertainty regarding what is known, what is not known, and whether or not what is “known” is actually meaningful (or “truthful” as charted against a constantly changing measure of what is true).

I will give an example here: I remember either a Neurology attending or fellow once explaining to me that the mild weakness found on ipsilateral limbs in a patient with a unilateral stroke could be explained by involvement of the fibers descending in the anterior corticospinal tract (which travels ipsilaterally and does not cross in the medulla). This descending fiber tract contains somewhere between 10-20% of the corticospinal tract fibers, varies in size between individuals, ends in the thoracic cord, and likely provides innervation to muscles of the neck and upper limbs. Anatomically, this explanation seems to make some sense. I asked another senior Neurology attending this question in a different patient with a similar presentation, and he stated definitively, “It never happens.” In perusing various Neurology textbooks, I cannot find any information corroborating the first explanation. The traditional textbook that most clearly addresses this question, Neurology: A Queen Square Textbook”, states “Of corticospinal fibers, 10% remain uncrossed, their neurones of origin outlining an ipsilateral somatotopic map, a point of little apparent clinical significance.” Why then, does this fiber tract even exist? There are some studies that suggest that the presence of this “accessory” pathway may aid motor recovery from lateral corticospinal tract damage as in stroke [1] or spinal cord injury [2].

A common response among learners to these conflicting messages is to give up. The tendency is to lose faith in attempting to achieve the ability to “know.” Accordingly, many choose to defer to those who do “know,” or at least believe they do. The appeal of following guidelines stems from this tendency: in theory, a panel of “experts” have pooled together their knowledge and provided recommendations to follow. In this climate of uncertainty, most people choose to follow. But what makes the experts “experts” in their fields? Often they are the physicians, scientists, or physician-scientists who are pursuing active research or have extensive experience with a particular clinical issue. At best, they are driven in their desire to know by the awareness of the incompleteness and changing nature of knowledge and also by the idealistic hope that it is possible to improve knowledge and thus improve the practice of medicine. Ideally, they additionally generate new evidence to contribute to the current knowledge of disease and treatment in the form of clinical trials, updated reviews, case series, and more. At worst, they may be the ones who are simply preaching the loudest and most forcibly.

I, and many others, would argue that this method of learning and practicing medicine is too passive and not sufficiently adaptive. Consulting (to the exclusion of other sources) searchable databases such as UpToDate potentially leaves one’s mind at the mercy of a few opinionated authors. It is not enough to practice medicine as directed by the Cochrane reviews alone. It is no longer enough to practice medicine based only on the anecdotal and experiential wisdom passed down by prior generations of physicians. And it is largely impractical for any individual physician to stay abreast of the latest developments in every field of medicine, let alone in his or her own field with regards to the numerous studies being published every week. Not surprisingly, it is important, then, to find a balance between all of these sources and types of information and information acquisition.

The Notebook

In my opinion, a notebook is the most essential piece of a physician’s armamentarium. It is more important than the stethoscope, scalpel, or any other tool. Why? The notebook represents a projection of the physician’s mind, and no matter the specialty, the physician’s mind is still his or her greatest asset and most effective tool in treating patients. The notebook serves a number of important roles for the physician:

[1] Facilitation of memory encoding

A lot of educational theory and research is based on the many ways different individuals learn, particularly with regards to methods emphasizing visual, auditory, and tactile sensation. Incorporating multiple modalities, such as writing notes while listening to a lecture and watching a slide presentation, is thought to improve memory retention. Accordingly, it helps to write down what is learned, whether on the wards, at the white board, during morning report or noon conferences, or at grand rounds or conventions, as this should help you more firmly implant the knowledge into your hippocampi.

[2] A database of references and the knowledge “family tree” (e.g. lineage)

Because of its origins and the way knowledge works within medicine, the lineage of knowledge remains an important distinction that marks one’s identity as a physician. Since much of medical teaching is based on the experiences of physicians whose careers may last half a dozen or more decades, one’s teachers inspire considerable reverence from the trainees who follow them. However, physicians may encounter several “schools of thought” throughout different stages of training and may find that their own minds are battlegrounds between competing ideologies. Accordingly, I find that it is very important to chart and document from whom one learns a new tenet of medicine (be it a resident, fellow, senior attending, clinical trial, visiting lecturer, clinical trial, review article, textbook, etc.). In the aforementioned example, I cannot remember who asserted to me the notion that damage to the anterior corticospinal tract can result in ipsilateral weakness. As such, I cannot ask him or her how that knowledge was obtained, and it thus holds little water against the assertion of the other attending or my current review of the available literature. If you keep track of your learning and keep references to your sources (e.g. the name of a physician who gave a lecture), it is possible to track how your thinking and understanding of the field evolves over time, particularly when new data is incorporated from new studies or encounters with physicians trained in another school of thought.

[3] A launchpad for inquiry

Sometimes the hardest thing to remember is a question. And yet, as physicians, questions arise in our minds constantly: much of our role as clinicians mimics the modus operandi of the detective. Furthermore, the ingrained abundance of intellectual curiosity is one of the distinguishing features that differentiates physicians from other health care providers. Nonetheless, our attention is also constantly bombarded by numerous competing interests (pages, e-mail messages, patients and families, other care providers, etc.). There are countless times that I had a question I wanted to ask someone giving a talk which vaporized prior to the talk ending and also numerous occasions when I identified something I wanted to look up which I later forgot about. In order to help further develop your own knowledge base, improve the care of your patients, and perhaps even generate questions that might advance the field as a whole, it helps to write down the questions that come to mind as soon as they arise. This can help identify knowledge areas that you can expand and enrichen, detect problems in your clinical practice that might be useful to address (e.g. Why isn’t there a standardized protocol for (blank) here?), and develop potential ideas for research.

[4] A map of the mind

Last but not least, the notebook can serve as a measure and organizational tool for the knowledge one has already acquired. Keeping one’s thoughts and memories organized is a very important precursor to developing an easily and quickly accessible knowledge bank. The primary objective is to make your brain an efficient and effective database of knowledge and to use that knowledge to guide actions (e.g. the practice of medicine) in a meaningful way. The notebook should not serve as a replacement for the mind’s memory stores, but rather, it should serve as a visual aid (to trigger memories of learning from direct visualization and also to help guide a mind-only “memory palace”-style search if the notebook is absent) and as a hierarchical “site map” or “table of contents” that helps you keep track of what you know so far and what you don’t know.

I hope I have at least begun to convince you that the notebook and the active engaging and recording of lessons learned are essential for physicians at all levels of training. In my next installment of this series (The Battle for Your Mind), I will discuss different methods modern physcians can use to keep notebooks.

References:
1. Shelton, F, and Reding, MJ. “Effect of Lesion Location on Upper Limb Motor Recovery After Stroke.” Stroke. 2001; 32: 107-112.
2. Priestly, JV. “Promoting anatomical plasticity and recovery of function after traumatic injury to the central or peripheral nervous system.” Brain (2007) 130 (4): 895-897.

The day has come and gone: after four variably long and short years, we have finally graduated and now bear the title of doctor. Has it really happened? Has anything changed? It doesn’t seem so, but perhaps the changes will come gradually and imperceptibly: naïveté and idealism may fade, biases and beliefs may become fixed, and we may grow forever more distant from our unglamorous pasts. Nonetheless, as a close friend and newly-minted physician put it, I hope the wonder of what we have become and what we can do for our patients and their families will never fade.

One of the administrators organizing commencement was correct in saying bluntly, “This isn’t for you, it’s for your parents.” Nonetheless, there were a few very personal, very exposed moments. Perhaps unexpectedly, one of these was the taking of the Oath. For Tulane’s ceremony, the new graduates took two oaths: the traditional Oath of Hippocrates (which some consider outdated) and a modified oath written specifically for Tulane graduates. Having some small experience with public speaking, my inclination was to face the audience I was speaking to while repeating the two oaths instead of facing the words on the paper. In doing so, I found myself making eye contact with several more experienced physicians who also were standing to reaffirm their commitments to maintaining the integrity of the profession by repeating the oaths. Some I knew very well, others hardly at all, but I felt at that moment (more than at any other part of the ceremony) that I was truly joining a brotherhood of healers, of like-minded and like-hearted people. After saying the traditional oath, the graduates remained standing to say the new Tulane oath which is more in tune with contemporary ideals and principles (e.g equality in providing care regardless of race, sexual orientation, etc.). A number of the more experienced physicians remained standing: they were Tulane medical graduates too, and although they had not spoken this new oath at their graduation ceremonies, they decided to stand and hold themselves to the principles they taught us as our attendings and mentors during the past four years. This, to me, was the greatest reminder of the special fact that I am graduate of the Tulane University School of Medicine, a member of the “Katrina” class that defied logic and fear to return to this troubled city (my hometown), and a disciple of the great men and women – the physicians and healers at Tulane – who have shaped me and my classmates into the physicians we have become. In the words of Mark Twain, “May we live so that when we come to die, even the undertaker will be sorry.”

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