clinical

Back In The (Teaching) Saddle

 I’ve signed on to help teach firstyear medical students how to interview patients. It’s been few years since I was involved in any teaching; five, to be exact. As soon as I found out I was pregnant with Babyboy, I decided not to re-up my involvement in a course teaching empathy to thirdyear med students. I loved the course, and I enjoy teaching, but it was one of the many things I dialed back when I had my babies.

And good thing I did. We’ve only been reliably sleeping through the night within the past year. I would have ended up in the loony bin if I’d tried to keep teaching on my list of responsibilities, with little little kids at home. I often have patients who come in with grave concerns about their memory and concentration abilities. In many cases, these are thirty- and forty-something working mothers of young children. My first question- “How much are you sleeping?” often yields the diagnosis. Hello, chronic sleep deprivation. It is a form of torture, after all.

Anyhow, now that my brain is reasonably functional, I decided to look for an opportunity to get back into teaching. The same week that I was thinking about it, an email went out to all the faculty, asking if anyone would be interested in joining the first year interviewing course. Hello, coincidence. I blocked out my Wednesday mornings and jumped in.

So here I am, into Week 2. I have to say, I am duly impressed. It’s a four month course, approximately two live hours per week devoted to practical skills building, on top of a load of readings, write-ups, and reflections. These first sessions are all about building rapport and using basic techniques (open-ended questions, continuers, silence) to obtain a good patient history.

These students don’t know any actual medicine yet, but the whole point of this course is, they don’t need to. They don’t need to be clinicians at all to efficiently yet empathically elicit a coherent story from a fellow human being. As a matter of fact, it may be better that they don’t know any medicine, so we can drill in the basics of bedside manner before these kids hit the floors for real.

I really can’t recall receiving any formal instruction in the clinical interview during my med school years. (Anyone from our alma mater reading this? Am I just blocking something out?) I can’t recall much formal instruction on this in residency either. (Of course, I don’t recall much from residency, in general. Hello, sleep deprivation… And unhealthy coping mechanisms… Didn’t make for nurturing the brain cells.) I did voluntarily participate in a course like this one as a clinical research fellow. I found the course exceedingly helpful, revelatory, even. But that was in my eighth or ninth year of training, and it was a choice.

And so I marvel that these newbies get this course. My job is to find them patients to interview on the floors, prepare them a bit, observe the interview, and then provide constructive criticism on their interaction as well as their write-ups. There’s some other stuff thrown in there as well, but that’s the gist of it.

Last week, it was with a bit of a shock that I realized these patient encounters are their very first. They have never, ever before in their entire, gunner, straight-A premed lives sat face to face with an actual live patient before this. Of course, it makes complete sense. They just moved here and started classes this month. Duh. But it struck me how special it was to be a small part of that first, precious, innocent encounter.

*And let me clarify- Yes, I was shocked to realize that these were their very first patient encounters, because they did so well. Far, far better than I would have at that stage, myself. I continue to be duly impressed.

I’ve also noticed how much I’m taking from the course. In my own clinic, I’ve become hyper-aware of when I jump in to the patient’s history. Do I tend to cut people off before they’ve finished? The research show that it takes attendings about 23 seconds before they interrupt the patient. Is that me? Lately I’ve been trying hard to keep my trap shut and let the patient talk. Silence.

And, I’ve realized that I’m not actually very good at using open-ended questions, continuers, and summary statements (like, “Let me make sure I’m understanding what you’ve told me. The pain started three days ago after you lifted that fifty-pound bag of birdseed, and then you went to the local urgent care center?”) I know I can benefit from these lessons as much as my students, and, I venture to say, I think many of my colleagues could, as well.

As far as these first encounters being special, innocent, and precious: The research is very clear that as we march through our medical training, our empathy drains away. We tend to become jaded, cynical, and insensitive. There’s been a huge push for med schools and residencies to teach empathy, which really means, to help trainees hold onto that empathy they had in the beginning. But, it’s incredibly difficult to do this given the structure of training being what it is, i.e., hellish. Many residents become bona-fide burned-out, after only a few years on the job!  I’ve lived this, and I know: these first encounters are special, innocent, and precious.

Ah, nostalgia… 'Actually, you're my second patient if you count that cadaver in med school.'

*These last few paragraphs were added in response to a medical student’s critique. See below commentary.

4 replies »

  1. I’m an MS4 and I have to say, while I know this was not the intention, this post strikes me as frustratingly condescending. I have intermittently encountered similar views of med students as “innocent,” “precious,” “kids,” etc, to use your words, from residents and attendings throughout medical school. As a non-traditional student, I am actually frequently older than my residents. My class contains many non-traditional students who have had varied and successful careers (environmentalist, opera singer, lawyer, …) before returning to school. Additionally, some of my fellow classmates have worked in healthcare previously, for instance as EMTs, nurses, and ED techs. These students often have a good amount of experience interviewing patients- sometimes more than the residents. It is true that the art of interviewing patients as a physician is difficult and even intimidating to learn, and we (med students) might look silly doing it for the first time. But think of how you would look to us trying to sing opera or craft a legal defense. You would probably still want to be respected and taken seriously, if you were trying to launch a career in one of those fields. Finally, even students who come “straight through” after undergrad deserve to be treated as adults. Not treating students as adults is part of the problem with our medical culture, and part of what can make training toxic to the trainees.

    Like

    • Thanks for reading me, Be, and for taking the time to thoughtfully comment! I was surprised to hear this perspective, as I had read and re-read the piece to make sure I didn’t mention any potentially identifying information about these students, nor inadvertantly include any negative commentary or criticism. I understand that my referring to adult students as “kids” was construed as derogatory. My take on this, as I was also a nontraditional med student and have been an adult learner time and again, is that I don’t personally mind this use of the term- it’s a common use of the word when referring to students at any level, in my mind- so I didn’t read it as potentially insulting. And, I’m trying to see where what I wrote could be interpreted as criticim or, worse, ridicule of the actual interviews- because actually, they’ve been very, very good, far advanced from where I was at this stage. I think it’s at the end where I mention that I was “shocked to realize” that these were their first patient encounters. Yes, I was shocked- because they did so well. I will clarify this, and also add how excited I am to be participating in this course- not only as a teacher, but as a student. After all, we are lifelong learners, and as I pointed out, I was never formally taught interviewing skills. I am learning from this course as well, and I freely admit that.

      Like

      • Thanks for responding to my comment and for providing some clarification. I agree that you did not say anything negative about the interviews. My comment was more a response to the overall tone of your essay. Honestly, it was also a response to those of my supervising physicians who have treated me and my fellow classmates with derision or condescention over the years, in ways that go beyond the tone of your post. I feel that I cannot speak to them directly, instead I bite my tongue and wonder how this became the norm in medical training.

        Like

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s