Tag: medical student

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Empathy General Medical Humanities Opinion Reflection

Visual Arts as a Window to Diagnosis and Care

With the rapid advancement of knowledge and technology in medicine, physicians alienate themselves from the core purpose of their profession. A grounding in the humanities as well as a strong foundational basis understanding the medical sciences is required to establish well-rounded physicians. Art inspires medical students and physicians to observe detail they otherwise wouldn’t. With patients in the emergency room, before any physician-patient interaction can occur, the sounds of bilateral crackles, the sight of neck muscles contracting and of the nostrils flaring indicate a patient in respiratory distress. This very detail in observation is needed for split-second decisions of utmost importance in the emergency theatre.

Art is the projection of our experiences, memories and has the power to record reality and fantasy. These altogether add to the artistic memory of an artist and allow them to add adaptations based on their life’s observations. Artists have captured the human body through the pursuit of conveying human experience, of the human’s appearances, shapes, and sounds all reflecting their state of health. Artists must see the details of a picture and reproduce it, and only once they’ve mastered observational art can they move on to more abstract forms conveying emotions of the real world.

When dissections were forbidden centuries ago, artists together with doctors snuck out to examine human corpses for a closer look. This was important for them to accurately reproduce representations as they not only had to know the inner workings of the human body just as physicians did but they needed the eye for their artistic creation. Unfortunately, today the acquisition of life-drawing skills has lost its traditional importance due to increased demands for the more conceptual art forms.

In medicine, observational skills provide insight into a patient’s problem.  From observing, not only do we see it as is but we recognize patterns, are able to analyze context and make connections. Despite knowing everything about a disease or illness, learning how to see pathologies, and diagnostic criteria is important to avoid missing all the signs. The four steps of physical examination are inspection, percussion, auscultation and palpation. Inspection or observation is often overlooked but is so crucial to patient care and treatment as is to the creation of art.

The artwork of Piero di Cosimo, A Satyr Mourning over a Nymph (1495) depicts a young woman killed accidentally during a deer hunt by a spear. Upon analysis of the painting and deep observation, evident is that there is no spear wound but instead the women’s arms are covered with long cuts as if acting in self defense from her assailant. Her left hand additionally is placed in position with her wrist flexed and fingers curling inwards known as “waiter’s tip”. Fundamentally at large, di Cosimo used the girl’s corpse as a model and because as an artist he had no understanding of medicine and injury, he portrayed exactly what he saw. Unintentionally, he captured the girl’s true injuries dictating to a medical practitioner the likely theory of the young woman’s actual cause of death.

A Satyr mourning over a Nymph by Piero di Cosimo
https://www.nationalgallery.org.uk/paintings/piero-di-cosimo-a-satyr-mourning-over-a-nymph

Appreciation for paintings by physicians even reveal medical diagnoses given the structural facial characteristic changes that occur in different diseases. The Old Woman by Quinten Massys depicted an exaggerated ugliness due to the pattern of facial deformations; bossing forehead, prominent cheekbones, enlarged maxilla and increased distance between the mouth and nose all consistent with leonine faces of Paget’s disease stemming from accelerated bone remodeling. Another example is that of Peter Paul Rubens, The Three Graces, displaying symptoms of benign hyper-mobility syndrome, an autosomal dominant disease. Scoliosis of the spine, a positive Trendelenburg sign and double jointedness as well as lax upper eyelids is evident in the artists painting.

Fascinating nonetheless is that the medical diagnoses in both paintings were unknown to doctors at that time. Paget’s Disease and benign hyper-mobility syndrome were discovered just a couple years ago while these paintings existed long before them. 

Compared to artists however, doctors have stopped putting their skill of inspection into practice and with all the expensive tests available to help doctors make diagnoses, the necessity of individual, physician observation has decreased. Thus raises a question, will the dependence on tests rather than investigation through the senses define the future of medicine?

As medical students, this urges us to hold true to the art of observation. Technological advances were directed to improve patient care and not impede the physician-patient relationship. The personal touch of a doctor and the direct communication through movement, and language has been lost. Remembering the feelings of our patients allows us as future physicians to be mindful that no patient manifests the same way despite presenting with the same disease. Neither are patients aware of the manifestations of disease and overtime naturally adapt to the abnormal posture, gait, and lifestyle changes often overlooking the skin changes, mood or weight fluctuations.

When doctors are trained to “see”, observe and infer from signs alone a basic diagnosis, will they understand the whole human being. Therefore, arts education in medicine helps humanize science and connect medical theory into the patient’s journey. In analyzing art pieces, students are able to connect clinical skills and improve their ability to reason with the physiology and pathophysiology of the human body from visual clues alone causing them to become more emotionally attuned to their patients and aware of their own biases as physicians.

The skills of observation requires improvement and practice from physicians to both diagnose and understand the underlying concerns of a patient. Only when doctors have mastered the art of observation and trained their eyes to truly see, will they ultimately return to a world of greater human connection in medical practice.

References
McKie R. The fine art of medical diagnosis. The Observer. 2011 September 11;Culture. 
Berger L. By Observing Art, Med Students Learn Art of Observation. NY Times. 2001 January 2;Health
Christopher Cook. A Grotesque Old Woman. BMJ 2009;339:b2940
Dequeker J. Benign familial hypermobility syndrome and Trendelenburg sign in a painting “The Three Graces” by Peter Paul Rubens (1577–1640). Annals of the Rheumatic Diseases 2001 September 01;60(9):894-­‐895.
Pecoskie T. Improving patient care with art. The Spec. 2010 December 2;Local. https://www.mcgill.ca/library/files/library/susan_ge_art__medicine.pdf

Categories
Clinical Patient-Centered Care Reflection

“Listen to understand” not “listen to reply”

A two-month stint at the oncology department in a Singapore government hospital has provided me with vivid examples of the importance of doctor-patient relationships and communication. Cancer, in many societies, is still widely regarded as medical taboo – a condition people closely associate with death. While I got to witness very sensitive and depressing conversations in relation to end-of-life care, the most impactful conversation I experienced had nothing to do with end-of-life care. Rather, it was a complaint from a patient about his team of allegedly negligent doctors.

It took place in a private ward room with just Mr. C and his wife. When I first entered the room, Mr. C gave me a hostile look and asked me who I was. Feeling awkward given the cold welcome, I persisted to introduce myself as a medical student who wanted to take his history. Although reluctant, he agreed to talk to me. What started as a cold introduction turned out to be an hour-long avenue for Mr. C to vent his anger and frustrations. It became etched in my mind for the important lesson that came with it.

I understood from Mr. C that it was not the diagnosis that brought about his unhappiness, but how the diagnosis came about.  Mr. C presented with a 6-month history of progressive dull epigastric pain and loss of weight with no co-morbidities. He had no associated fevers, nausea or vomiting. The conversation went well until I asked him the question, “Did you bring this to your doctor’s attention?”

Immediately, there was a change in his facial expression. I divined from his grim expression that the news was not good. He started shaking his head, somewhat in disappointment. His wife started tearing. I had inadvertently asked a sensitive question and was caught helplessly in that moment of grief and sorrow.

Mr. C then explained that he actually went to the Emergency Department (ED) thrice as his abdominal pain worsened. Unfortunately, on the first two occasions, they sent him home after establishing that his vitals were stable with no abnormalities in his test results. He was sent home with a stack of medications but without a diagnosis.

Interestingly, Mr. C actually suspected himself that he had gastric cancer given his strong family history; he expected that he would suffer from it one day. The doctors shook it off despite his persuasion. On the third visit, however, the doctors finally admitted him and performed an endoscopy. It was later confirmed to be Stage 3 gastric cancer. It was at this point in the conversation when emotions started running wild.

The atmosphere heated up. I was shot with questions and complaints by both Mr. C and his wife.

“I would not have been denied earlier detection and treatment if doctors listened to my history,” Mr. C said.

“That period of 6 months could have made a huge difference to his disease stage and prognosis!” Mr. C’s wife added.

“Do you think the doctors have done the right thing for me?” he asked.

“Doctors never bother to hear patients out!” he shouted.

It felt as if the blame was on me, and I felt angry for a moment. I was on the edge of questioning his accusations, and refuting his comments. I was conflicted inside. On the one hand, the manner in which he was treated at the ED seemed unjustified. But at the same time it did not seem fair for me to blame the doctors without understanding what their line of thought was.

I further understood that Mr. C had explained his case to a senior consultant, who was also the surgeon who performed his gastrectomy. The surgeon brushed Mr. C off, and told him rudely to switch to another hospital if he did not like it here. It was at this point that I stood in favor of Mr. C. I actually could not believe such an insolent comment would come from the mouth of a senior doctor, whom I thought was supposed to possess the maturity and authority to handle such a complex matter.

Mr. C and his wife were evidently distraught with how the diagnosis came about, compounded by the fact that he was still relatively young to suffer from stage 3 gastric cancer. He explained that gastric cancer is one of the most aggressive and treatment-resistant cancers with the highest mortality rate, as evident from the young deaths of his family members who succumbed to the illness. My heart immediately sank after coming to terms with his bleak prognosis.  I recalled what was taught in my clinical skills classes, and took on an empathetic coat to try and calm them down. I felt an ephemeral sense of shame for the apparent lack of professionalism Mr. C’s doctors had displayed. Furthermore, I was sunk in guilt for initially doubting his comments.

I continued with the rest of the history and thanked Mr. C and his wife for their time. I walked out of the room and told them, “Thank you for sharing with me. Both of you have taught me about the kind of doctor whom I do not want to emulate in the future”.

It was an eventful hospital experience for Mr. C, and a rather eventful conversation for me with him and his wife. Despite the awkwardness and negative emotions, it taught me a great deal about the nature of difficult situations, the qualities a doctor should possess, and the importance of communication.

It was no doubt a challenging conversation. It was unlike all the other conversations I have had with patients, that were full of praise for their doctors, which always reassured me of my choice to become one.  My limited exposure to issues that arise from the lack of proper doctor-patient communication caught me off guard during this particular conversation.

When I mentioned to Mr. C that I was a medical student, his facial expression and body language conveyed his bitterness and dissatisfaction. It was almost as if he had something against me. I was filled with self-doubt and hesitancy. I was unsure if I should persist with the conversation given his hostile appearance but I knew that he had a story that he was dying to tell. Mr. C’s experience at the ED has probably altered his perception of doctors, and it was worth it to hear him out.

In hindsight, I am consoled by the fact that I had that conversation with Mr. C because he gradually opened up to me, treated me as an avenue to vent his frustrations, and perhaps subconsciously, taught me a lesson or two about being a doctor. I have learned that patients are always keen for a listening ear, be it to share their joy, or to pour their sorrows. It is hence important for medical students like me to not be doubtful when approaching patients for the fear of intruding in their privacy or taking up their needful rest time. Never be afraid that you are just an unqualified medical student.

Communication is the crux of medicine. As Sir William Osler said, “The good physician treats the disease; the great physician treats the patient who has the disease.” History-taking is not just about the whims and fancies of signs, symptoms, investigations, and differentials. It is in fact a conversation, an opportunity to build rapport and trust with the patient. We are not community health surveyors ticking off boxes in our questionnaire; we are there to hear our patients out by expressing their problems and concerns. There is no better opportunity than in medical school, where you are not confined by the “rush hour” situation in hospitals, to hone these human skills.

Fortunately, patients tend to given you their trust, and willingly share their most personal information with you. This has shown me the power imbalance of the doctor-patient relationship, which arguably has been exploited in Mr. C’s case – i.e. doctors sometimes do not give patients enough attention.

Another issue that I struggled with was handling the complaints that were hurled my way. My lack of maturity was evident from my agitation, and the urge I had to refute Mr. C. Deep down, I was conflicted and defensive. Mr. C’s story contradicted my own impression that all doctors do their best for patients. It felt as if I was taking the blame on behalf of all doctors. However, I decided to stay quiet about it. I learnt that doctors aren’t  “super-humans” who will never make mistakes. It was only when I started consolidating my thoughts and weighing out the situation that I was eventually convinced that Mr. C’s care was indeed compromised by the negligence of his various doctors.

Admittedly, I handled the situation rather poorly. I reckon it was largely due to lack of exposure to such situations, especially given the sheltered, cozy environment we enjoy in medical school. Clinical interactions are based around simulated patients who, more often than not, have simple presentations that are short enough for us to take a history and perform a physical examination. Everything is staged for us to learn in a protected environment. Even in hospitals, the patients we see are recommended by interns as “cooperative enough” for us to take a history.

Medical students should be taught how to deal with complicated cases through the use of simulated patients. When I say complicated, I mean in a psychosocial sense rather than in a medical sense. The skills needed to deal with these situations are those that cannot be taught through textbooks, but through practice. These are human skills; skills that define the art of medicine. These non-scientific skills may not be as interesting as pathology, physiology or anatomy, but are equally, if not more important than the scientific aspects that students are often keener about.

Students are often enthusiastic to ask senior doctors about the scientific aspects of a patient’s presentation. Similarly, they should not be shy to ask them about approaches they should adopt when such situations arise. I am inclined to believe that most students underestimate the importance of communication, which often takes a backseat in their learning priorities.

Medical schools can no longer assume that their students are equipped with the necessary communication and social skills from just clinical skills examinations, which are often not representative of an actual hospital setting. Rather, explicit emphasis on the mastery of such complicated yet common social presentations, should be made an integral part of the curriculum.

I have learned the importance of giving patients the space to talk. For example, in my encounter, I was close to interrupting Mr. C when he was complaining about his experience. Having done so, however, would have prevented me from comprehending the entire situation in context. As medical students, we need to appreciate the difference between “listening to reply” and “listening to understand”. Practice the latter, not the former. Never be too quick to cut off your patients halfway through, and jump to conclusions. Let them tell their whole story, and you will be surprised to find that it contains most of the answers you need.

Photo Credit: Ky

Categories
Innovation Lecture

Drinking from a Fire Hydrant: Musings on Active Learning in Medical School

Almost everyone has seen a doctor at some point in their lives. Yet, for most, what actually goes on in medical school remains a mystery. Chances are that if you’re reading this, you have experienced the delightful experience that is medical school. Sleeping in late, eating well, and relaxing with friends and family on the weekend are just a few of the joys that we medical students get to experience. Just kidding. Medical school, as most of us know, is beyond challenging. At my school, faculty members fondly liken the medical school experience to drinking from a fire hydrant. As medical students, our pre-clinical days are comprised of hours and hours of lectures and power points. Then, when class is all over, we get to top off the day with several additional hours of studying. It’s challenging, it’s overwhelming, and at times, it seems downright impossible.

Part of what makes medical school such a unique challenge is the fact that medicine is a tactile discipline and yet, pre-clinical education is traditionally taught in a classroom setting. In response to this dichotomy, the University of Vermont’s Larner College of Medicine recently made headlines by announcing that it would become the first public American medical school to completely eliminate lectures from its curriculum, joining private Case Western Reserve University School of Medicine in Ohio (https://www.washingtonpost.com/news/to-your-health/wp/2017/07/29/medical-school-without-the-sage-on-a-stage/?utm_term=.6847516c2b31.) This change, which is expected to be fully implemented by the year 2019, comes in response to concern that the traditional lecture format does not promote knowledge retention and instead relies on “passive” learning where the learner is not actively engaged in their education. To draw an analogy, passive learning is like being fed while active learning requires learners to pick up the fork to feed themselves.

Although the University of Vermont and Case Western Reserve University seem to be the only two institutions whose medical schools have committed to becoming completely lecture-free, it’s interesting to realize that other schools have moved towards a more active learning format as well. In my school, the College of Osteopathic Medicine of the Pacific (COMP) , students pick their own small groups. These small student-led groups meet several times a month and work together to complete assignments and discuss scenarios that are based upon real clinical scenarios. Northwestern University’s Feinberg School of Medicine is one of several schools that employs a problem based learning curriculum, and in 2015, Harvard Medical School also restructured their curriculum to become more problem-based. Ultimately, medical school curriculums exist on a spectrum from passive to active curriculum styles and the continuum seems to be shifting to favor active learning styles at many medical institutions.

Moving away from a traditional lecture setting certainly presents its own unique challenges that affect learning. The non-lecture curriculum requires more self-reliance on the part of the students, who must teach themselves new material. The small groups used at COMP, for example, are completely student-led. A faculty member may pop in for a few minutes to make sure that the group is running smoothly, but often these faculty members are not experts in the subject matter at hand and are present to deal more with administrative issues than to teach content.  It also means that students are required to participate in groups, whereas many schools may have optional attendance for lectures. Perhaps the biggest challenge of the active learning curriculum, however, is the necessity for different personalities to work together to achieve a common goal. The traditional classroom setting involves one teacher who employs a specific style to reach multiple students. In the active learning curriculum, small groups are often used, in which each member has a different personality. Students in these groups must work together, sometimes despite personality differences, to master the curriculum and achieve common goals. Although the group setting closely resembles the team-based approach taken in most healthcare settings, it can undoubtedly be frustrating, especially for someone like myself who tends to be more introverted and likes to study on his/her own. In my personal experience, the members of my small group were incredibly supportive and had a variety of strengths, yet there were many days when I couldn’t wait to return to the comfort of my own room to be able to really learn the material myself. Sometimes trying to learn unfamiliar concepts with others was a distraction, and despite the best of intentions, small group was like the blind leading the blind when we were all confused on certain concepts. There were some times that the small group felt comforting, like someone holding my hand, and other times when it felt too overwhelming, like someone pressing my face up against that proverbial fire hydrant. Ultimately, I felt like the combination of both lectures and small groups was actually more dynamic than relying solely on one or the other. While the University of Vermont and Case Western Reserve University have both made the bold move to abstain from lectures altogether, they join the company of many medical schools, both allopathic and osteopathic, that have recognized the importance of active learning for the medical school curriculum. Let me know what alternatives your medical school offers to traditional lecture-style learning!

Categories
Emotion Empathy General Humanistic Psychology Narrative Patient-Centered Care Psychology Reflection

Immigrant’s Suitcase: Ordinary people with the will to do extraordinary things

A mother separated from her missing husband flees a war-torn country, her homeland, to provide a brighter future for her children. She’s a dentist by training and practiced dentistry back home; but here, here she’s cleaning homes for a living. Why? When she left her home with her four children by her side, headed to a safer place, to America, what was in her suitcase? Alongside the picture of her missing husband and the few possessions that remained after the destruction of her home, in her suitcase, she has hopes and dreams, fears and doubts. She looks to her children for strength, but she’s terrified every time she looks them in their eyes. She is not optimistic, but she is hopeful; she looks the odds straight in the face and proceeds anyway. Because hope is not logical, it is powerful.

She’s cleaning the home of a happy family; the father is an engineer and the mother is a doctor and the children play piano. Their life, their hopes, goals and dreams are dependent on the stability of their country, but they cannot see it. The same hands that used to place crowns to relieve the pain of the suffering are now scrubbing the floor of another woman’s bathroom. But hope is powerful, and she lives through the dreams of her children. Two of her daughters want to be doctors. Her third daughter wants to be an artist. Her son is eight and he loves math. In her suitcase, she brought with her the dream of a better education for her children. “In Syria, we ate grass. In Egypt, we didn’t have food. In Indiana, I love school.” These are the words of her eight-year-old son.

A man runs to catch the bus. He can’t miss the interview; he really needs this job. It is his third interview in as many days. His last job got him enough money to get his family off the streets for a couple weeks. But motels are more expensive than he ever imagined. He’s homeless. His family is homeless. This wasn’t a possibility he considered when he graduated with his MBA. He had a great job, but the hurricane took everything away. And he hasn’t been able to get back on his feet. He catches the bus and pays the $1.75 in quarters. He checks the email that he printed; the interview is in room 4015. He runs up the stairs; he really hates being late. As he enters his interviewer’s room, a bead of sweat runs down his forehead. What’s in that bead of sweat? Desperation and nervousness, humiliation and self-pity, purpose and resilience.

His interviewer gives him the job offer. He smiles and shakes his head. A tear runs down his face. He can’t take the job; he can’t manage the branch that makes most of its revenue through alcohol sales. Another day and another interview, but his family remains homeless. He needs the job, but rejecting the offer was an easy decision. He believes that although alcohol may have small benefits to people and society, the harm it causes is much larger than its benefits, and wants to play no part in its distribution; he will not be a co-creator in the intoxication of his neighbor’s mind.

A young woman sinks into herself on the examination table. Her husband is holding, squeezing her hand. The doctor is still talking. He looks very sympathetic. The young woman just learned that she has a cancer growing inside of her lungs, an aggressive cancer. The doctor thinks ‘we can fight it.’ The young woman’s mind is overwhelmed into quietness. All she can think about is her daughter’s play after school that she doesn’t want to miss, even for this. The doctor brings her back, ‘Do you feel comfortable about our next step? I think that’s the best place for us to start.’ The young woman shrugs. What is in that shrug? Fear and uncertainty, peace and tranquility, ambivalence, a need for normalcy, a desire for time to make meaning.

The young woman is herself a physician, trained and licensed as a radiologist. She knows enough about cancer and the late stage non-small cell lung cancer she has been diagnosed with to know that the longevity of her future has been called into question. And yet this is not the topic of discussion with the doctor. Instead, he discusses treatment options, which is fancy talk for a long list of big words in different orders and combinations. When asked about the next step, she shrugged. She shrugged because there didn’t seem to be room for her in that room. (Insert young woman with terminal cancer here). Although it is more comfortable for the doctor to rattle off treatment options, the patient wants to take time to acknowledge the inexorability of our life cycle. To the doctor, it was the end of a beginning, and they were, together, supposed to begin a new chapter of strength and resilience. While he rattled off treatment options, she just wanted to catch her daughter’s play after school, and she was running late.

In the words of HL Menken, ‘For every human problem, there is a solution that is simple, neat, and wrong.’  Without taking a moment to explore what’s inside the immigrant’s suitcase, the homeless man’s bead of sweat, the sick young woman’s shrug, we stand a sorry chance to witness, help, and learn from ordinary people with the will to do extraordinary things. This is the power of narratives; the power of listening. I call myself to look inside the suitcase, to investigate the bead of sweat, and to ask about the shrug; I call myself to listen.

I find myself in an imperfect world, full of injustice and oppression. I find myself an imperfect man perfectly given the ability to alleviate suffering, on a personal level with a smile or a hug, and on a larger scale by fighting injustice and refusing to stand idly in the face of oppression. Poverty belongs in a history museum. And hunger…we have enough food in the world for every member of the human family to eat a balanced 3000 calorie meal. When we eliminate poverty and hunger, there will be many other injustices for us to face. I want to make facing these injustices my mission. My mission is to be ‘human’ as best I can; to work to establish justice in any capacity that I can, from a generously given smile to an honest political campaign.

Photo Credit: Robot Brainz

Categories
Empathy

Properly Unprepared

It was late afternoon, and the current nursing shift would be relieved in less than ninety minutes. The feeling of impending Friday freedom was palpable on the floor of the intensive care unit. I was on my way to meet with my last patient of the week, who had been brought in for an unintentional drug overdose. My goal was to determine whether the overdose was truly accidental, and if she was a candidate for compulsory psychiatric hospitalization. I passed by a large bank of computers without stopping, and knocked on the patient’s door. When I walked in that room, all I knew was the patient’s name, her age, and the reason for her hospitalization. Other than those preliminary facts, she was a complete mystery to me. I spent fifty minutes with the patient, and had a relatively pleasant conversation. When I walked out of her room, I opened her medical chart for the first time.

Unfortunately, that day, the story that I received from the patient and the information that I got from her chart told two different stories. Numerous providers had noted that she was irresponsible with medications, and I got the sense from the chart that she only sought medical care to gain access to controlled substances. Now that I had established a good relationship with my patient, I would have to re-interview her in an attempt to reconcile the information I had seen in her chart with the picture she had painted for me in the moments prior. My Friday freedom would just have to wait.

I would not be surprised to find out that the ICU staff was laughing at me that day. After all, I ended up spending more than two hours with this patient when I could have conducted only one brief interview. Even though the majority of my first hour with the patient was pure confabulation, I viewed it as a valuable component of my assessment. That first hour represented my sole opportunity to get to know my patient without any bias. Had I looked at her chart before walking into the room, I unquestionably would have written her off as an irresponsible, drug-seeking troublemaker. I would have asked her pointed, perhaps accusatory questions about her behaviors, and worse, I would have known exactly when she was lying to me, further eroding any respect I may have had for this patient.

Electronic medical record systems help to facilitate the sequestration of large amounts of information about our patients with minimal effort, and it’s largely considered taboo to meet with patients without first researching their medical record.  The information physicians can learn from the medical record can be undoubtedly beneficial in many situations, but extensive chart reviews can also lure us into a false sense of security, allowing us to preconceive an identity for our patients before ever having met them.

Had I read my patient’s chart that afternoon, I am certain that I would have made judgments about her that would have influenced my interview. Instead, I learned about my patient by allowing her to tell her own story. I thought about the information she shared with me, and, perhaps more importantly, what she failed to tell me. Because the patient never discussed her well-documented mishandling and possible dependence on prescription medications, I felt confident in making an assessment that this patient had relatively poor insight about her problems.

Featured image:
hGraph: patient + clinician looking together by Juhan Sonin

Categories
General

The Chasm Between Pre-Clinical and Clinical Medical Education

Depending upon which school you attend, the first one to two years of medical school are predominantly classroom-based learning. As medical students, we spend countless hours memorizing facts about disorders and diseases. We pore over diagnostic criteria, look for the minutiae in radiographs, and stress about the side effects of antibiotics and other medications.  While all of this information is useful and important, the reality of medical education soon changes when students start spending time in the hospital and in various clinics.

In transitioning from pre-clinical to clinical education, it soon becomes clear to medical students that what you learn in class and what you actually see in patients is quite different. Furthermore, even when presentations are clear it is still not trivial to determine what an actual patient’s diagnosis may be.

One poignant example, which I remember well, occurred while I was shadowing a local pain management Physician as part of the early clinical exposure course at our school. The patient whom we saw had a textbook case of C-7 radiculopathy with associated shoulder pain and loss of sensation. We had learned about radiculopathy in medical school, and I had a working knowledge of the diagnosis.  After I had spent some time interviewing the patient, my preceptor asks me what I thought the diagnosis was. I had some idea that the patient had a radiculopathy, but in my nervousness and uncertainty all I could muster up were a few whispers and murmurs.  My preceptor turns to me and basically says that this was a very clear case of C-7 radiculopathy.  After hearing the diagnosis, I distinctly remember thinking that I had known the disorder and had seen the symptoms in the patient, but had been unable to connect the dots.

The ability to connect the dots and turn pre-clinical knowledge into data that is useful in a clinical setting is a difficult skill to acquire.  You have to deal with patients that have varying presentations and many associated comorbidities, both situations that are not emphasized in much of the book and lecture-based learning of the pre-clinical years.  The only real method to attain proficiency in a clinical setting is hands-on experience.

Noting this need for hands-on experience, medical school curricula has changed substantially over the last decade. More medical schools now offer early clinical skills and patient experiences in their curricula, hoping to bridge the chasm between pre-clinical and clinical education. At the school that I attend, we start to see real patients in the second week of our first year. In the second semester of our first year, we embark on a year-long experience in local clinics where we work with practitioners to learn the ins-and-outs of clinical medicine and practice. Most other schools have implemented similar programs. Furthermore, the trend towards shortening pre-clinical education to one to two years is a direct response to student need for early clinical experience.

While early clinical exposure is important in medical education, it must occur with a solid foundation of preclinical knowledge.  Balancing knowledge acquisition with practicing clinical skills is a juggling match every medical student must deal with. Luckily, we don’t have to learn all of it during medical school, as medicine is a lifelong learning experience.

Featured image:
stethoscope by Dr.Farouk

Categories
General Lifestyle

Medical Humanities

Evaluating me, my attending writes,

Sometimes our strengths can also be
our weaknesses
and in OB-GYN, confidence can be taken as
arrogance.

I eat 32 chips ahoy cookies I find
six months after I first opened them
in the back corner of my kitchen cabinet,
behind cans of beans and tuna.
That same day, my neighbor’s daughter texts me
a photo of red bumps under her pubic hairs.
A bag of trash is the only thing in my refrigerator;
no time to take it out and it would have made
my apartment smell like dead people.

The people who die in hospitals—you see it
in their skin—grey and dry—two days before
it happens. My chief tells me to notify the family
but there was no one who cared, so I write it up.
A new patient sleeps in the dead patient’s old bed.
Just as soon as the morgue people leave
the nurse’s assistant changes the sheets and
mops the floors in bleach.

Doctors skip lunch. I do too
to put off the depression that smacks me
when I stop propelling patients from bed,
to diagnostic test, to operating room and
start propelling white bread and meat-mush
from esophagus to anus.

Featured image:
Bed by Alex