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Third Year Learning Curve

Hsrobeythomas1Thomas Robey -- Four months into my medical clerkships, I’ve only recently grown comfortable with the unique tension inherent in being the team’s medical student. In my experience there are several characteristics of being a medical student that can play against one another. The three I’ve been thinking about recently are:

1. Medical students tend to know the least general information.

2. Of the inpatient physician team, students spend the most time with their patients.

3. It’s difficult for patients in the hospital to differentiate between attending, resident and student.

Whether it’s getting pimped on rounds or being stumped by a lab result or watching my intern crossing out order after order, it is clear that I know less than everyone else on the team. There’s a reason we’re called medical students: we’re still in school! It’s a wonder that patients let us touch them!

But maybe there is a benefit to the hospital patient in being cared for by a student. You will hear again and again that it’s the medical student’s job to collect a complete set of information. At first, this takes forever. Most of us laugh when we recall how much time we spent collecting our first medical histories. The third year introduces med students to reporting, diagnosing and managing, but most importantly helps students to refine their data collecting skills. It still takes me much longer to do the physical exam than my residents, simply because I need to be comprehensive in order to assure that I collect all of the data. Furthermore, we care for 2-4 patients in the hospital, while the resident is in charge of 5-7 and the senior as many as 18! The upshot of all this is that medical students have the privilege to form intimate relationships with patients. That extra time in the room, a complete fundascopic exam, deciphering the patient’s social situation, even performing a rectal exam, all tell the patient that this medical student cares about her health.

We care providers can take advantage of the codes that help identify students and doctors. As Ben, Anna and Ben have previously pointed out on The Differential, the white coat is loaded with significance –- to co-workers, patients and the public in general. Where I attend school in the Pacific Northwest, the coat is de-emphasized, if worn at all. On my current rotation, however, the coat is as good as my ID badge. But this only applies to nurses (“I need to call his resident to verify that order”) and consultants (“this guy is going to ask me about cryoglobulins”). A short white coat looks more like a white coat than anything else.

To a sick patient, coat length may not even register.

My standard clarification is the introduction, “I’m the medical student on your care team.” After all, it’s not fair to the patient for you to impersonate a physician. Medicolegal issues aside, the patient needs to know why you cannot immediately answer all of her questions. This is also the honest way to prevent yourself from over-extending your authority. Some may view “I’m a medical student” as a crutch; I see it as a polite way to say, “I’m sorry I do not know that answer right now, but I will go read about it, ask my teachers, and come back to talk about it.” (It wouldn’t hurt to say it that way sometimes, too!)

Someday, I will look back and laugh about how long it took me to do an initial history and physical exam for a patient. I hope I do not have to look back with regret about the time I was able to spend with them.

January 26, 2008 in Thomas Robey | Permalink

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