After all the years of education, both academic and clinical, the end point arrives when its time to be on your own with patients. Now, it’s just you, the doctor, and this person, who may be a total stranger, with a problem you need to solve. No longer do you have an attending physician to ask an opinion. No longer do you have a back-up source to help you decide what to do. You are the person in charge. You have to confront this person, talk to them, examine them, reach a conclusion that they accept, and formulate a plan that will solve their problem. What did medical school do to prepare you for this situation? What happened during those nine years that produced a person capable of correct diagnosis and treatment?
Anything that takes 9 years to create is a complex entity. It has been initiated, formed, molded, modified, tested, re-tested, and validated over and over until it runs perfectly and does its job without error. Medical school, internship, and residency are tools that take an inexperienced person and turns him into a confident professional. The success of that process depends on the commitment of the individual, and their ability to maintain humility and balance.
It starts with learning the basics. A thorough knowledge of anatomy, physiology, biochemistry, microbiology, and pharmacology not only provides information, but starts to point your career in a specific direction. Pathology further defines that direction by providing a look at the wide variety of diseases. Clinical rotations on surgery, internal medicine, pediatrics, OB-GYN, and multiple subspecialties eventually narrow the career focus even more.
These are all tests, not just of your didactic knowledge, but also of your emotional and psychological strength. They test your commitment, your resolve, your stamina, and your stability. They train you to think on your feet, have quick recall of facts and data, and make accurate decisions. At 3 AM can you answer the phone, be alert, and respond to an emergency? If not, you better not consider obstetrics.
Internship and residency are times of exposure and re-exposure to hundreds of diseases and scenarios that require action. Repetition is a good teaching method; at least it is in medicine and was for me. The more patients you see with heart attacks, the better-prepared you are to anticipate and treat the numerous complications which can occur. The more IV’s you start, Foley catheters you insert, lacerations you suture, chest x-rays you read, and cases of Pityriasis rosea you see the better you are at those things. With each exposure, comfort and confidence increase, but they must not transform into arrogance.
An important concept learned and tested repeatedly is deductive reasoning. When presented with a set of facts and data, are you able to make a diagnosis and form a treatment plan. The only way you achieve success at this is by doing it on every patient. A patient’s history, physical exam, lab results, and imaging (x-ray, CT, MRI, etc.) studies are used to define the person’s problem. The more often you use this method the easier it becomes. In case presentations with your attending physician, this process is employed every time. Presenting a case and answering colleagues’ tough questions is another emotional test that prepares you for a family’s tough questions.
Medical training/education stresses a specific process a doctor uses on every patient encounter. If you follow this organizational template, you will have asked the right questions, done the right exam, and come more easily to the right conclusion. On every patient you do the following:
CHIEF COMPLAINT—Why have they come to see you
HISTORY OF PRESENT ILLNESS: What symptoms, when, where, how did this happen.
Other questions for detail
PAST MEDICAL HISTORY:
Allergies to meds
Medications currently taken
Surgeries—in the past
Hospitalizations—past
Other Illnesses—other illnesses the patient has or has had
SOCIAL HISTORY: Do they smoke-how much? Alcohol-how much? Drug use?
FAMILY HISTORY: Any familial diseases
REVIEW OF SYSTEMS: A complete questioning of symptoms related to each body system
PHYSICAL EXAMINATION: Head, eyes, ears, nose, throat, neck, heart, lungs, abdomen,
genital, rectal, extremities, nervous system, skin.
IMPRESSION: Initial diagnostic thought
PLAN: How do you plan to diagnose and treat the patient.
This method is used for every patient. It is learned in physical diagnosis class and repeated for most patients. Admittedly, if an adult has classic shingles, it’s easily recognizable. Still however, the doctor will need to ask some questions, perform an exam, and prescribe treatment. The template is still employed, just not 100% of it. Other, more complicated patients will challenge the doctor, and he will need to use the whole process to come to a conclusion.
The characteristics I emphasize are discipline, commitment, compassion, patience, humility, and selflessness. In nine years of training you gain knowledge, learn procedures, and employ processes, but learning these 6 traits is essential, too. Medical education stresses these attributes, encourages them, and some professors display them in their interactions with patients. But if they are not inbred, the process will not produce a physician who displays these characteristics with every patient. Medical school, et al. is the time these traits are refined with the goal of becoming second nature in practice. Some times it’s successful, but we all know arrogant doctors who missed the lecture on humility. Intellect is essential, but respect and courtesy are just as important if not more so.
Medical education is a marathon with a lot of sprints. It takes a long time, but along the way you’re asked to do more, work longer hours, make sacrifices, and endure embarrassment all for the purpose of being ready to respond to emergencies, deal with tragedy and death, make decisions quickly, and have answers for anxious families. You “toughen up” and do what’s expected of you. Julius Caesar is credited with saying “Experience is the best teacher” and medical educators in my era agreed completely.
Wisdom and knowledge were principles that were stressed every day, but resisting one’s personal biases and judgemental behavior were under emphasized. One rare instance was when neurologist, Dr. William DeMeyer, before he presented a severely ill patient, warned classmates not to react emotionally to any comments the gentleman made. He stressed remaining expressionless and stoic. I don’t think I ever learned to be that way. It wasn’t my nature to seem uncaring and indifferent, my interpretation of his reaction. I couldn’t and didn’t treat patients like that.
Over time, you discard your judgements and biases and just do your job the best you can. I had very few patients I disliked, but I treated those with whom I had disagreements exactly the same as those who were “friends.” That had to be. A physician must develop a non-judgemental temperament or his relationship with patients will be strained. Success in the profession depends upon it. Being friendly, yet professional, was a fine balance I tried very hard to maintain. I hope I accomplished that goal.
