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Notes of a Medical Student

2015; American Academy of Pediatrics; Volume: 5; Issue: 9 Linguagem: Inglês

10.1542/hpeds.2015-0096

2154-1663

Ann Fleming Beach,

Empathy and Medical Education

Years ago, when I was a medical student and resident, I kept a list of all the patients I saw. I wrote down the name, diagnoses, and 1 medical thing I learned (the science of medicine) and 1 nonmedical thing I learned (the art of medicine). I encourage the students and residents I teach now to do the same thing. I always say, “You’re learning at the speed of light. If you review this list, at the end of a day, at the end of a week, at the end of a year, you’ll be amazed to see how much you have learned.”I recently came upon the little notebook from my very first clinical rotation as a third-year medical student. It was a fascinating read. There, I found the young student I’d forgotten about: scared, naïve, full of false bravado, hopeful, excited to learn, unwilling to be belittled, amazed at the endless variations of the human condition, thrilled after years in the classroom to be actually seeing patients, trying to learn what it was to act professional.Here, unedited, are the “art of medicine” comments I wrote that summer long ago, as I was finding my way in clinical medicine.I learned a lot about Dr ______. He has an ego problem and takes it out on students, especially in the presence of others. I found out, much to my surprise, that I can keep very quiet and not talk back. I also didn’t like the fact that it was so easy for me to be subservient; I thought I had more spunk than that. I also rediscovered that I cry when I get mad. I need to work on how to react to being belittled and yelled at.I saw my first forceps delivery. I was amazed that it didn’t hurt the baby.Talk to the patient, even though they may appear out of it. They’re often more aware than you think.Interesting to see attitude of a teen mom regarding compliance with diet and medications for the welfare of the baby versus convenience and personal desires. After all, how disciplined was I at 15 years old?My first real delivery!!! The resident helped a little but I really did deliver the baby: a red-headed girl. Now I know how slippery they are, and that I really can hold onto them.I learned about working with Dr ______. It’s much better to act like a complete dummy and do nothing until she specifically tells you to, than to try to think 1 step ahead like you do for other doctors.I got to know Dr ______. He’s much more of a good guy than I thought. He’s also an excellent and patient teacher. He explains slowly, and knows how much responsibility to give you.For the first time, I felt like I was accepted in the position of a professional.Never, never rush anyone into making a big decision. I think this patient is very regretful and would have probably made a different (or at least a more clearly thought-out) decision.Dr ______ wasn’t the dragon I thought she’d be….This is the first time I’ve seen someone who got pregnant because she and her husband were having trouble and she thought it would bring them closer together.Dr______ always teaches the guys a LOT in the doctor’s changing room, when they are changing into or out of scrubs. I’m over in the nurse’s locker room, missing it all! Unfair!It’s difficult to convince someone their baby is OK; you just have to show them the baby.I CAN palpate and recognize enlarged lymph nodes! Even axillary ones!I presented a case at Case Conference. Dr ______ taught me the necessity of being very specific when presenting a patient. Even a “simple” case has a certain number of necessary details. NO case is “simple.”People’s lack of understanding of their anatomy and physiology is amazing. I guess I’ve been in science so long I’ve forgotten. This girl told me her boyfriend’s large penis had hit a nerve and caused her PID.You can’t worry too much about offending a patient; they have to know the truth.For everything there is a right way and a wrong way. Just because something looks easy, don’t be slack with it!Everybody doesn’t understand human function like I think they should. After she lost 1 ovary, she asked me if all her children would be the same sex since she only has one ovary now.I need to learn how to handle people with a totally positive review of systems, yet allow people who are nervous, apprehensive, lonely, etc. to talk and get a load off their minds.Now this was a good lesson! I asked about blood pressure and she mentioned it had been up on occasion. Since it wasn’t her main problem, I didn’t ask a lot more. My attending asked how she knew she had high blood pressure, how often it had been checked, if she had ever taken medication. Turns out she has a real problem with labile hypertension and her surgery had to be postponed until it was better controlled. It’s important to remember to ask enough questions so that you completely understand the patient’s problem, even if it isn’t the chief complaint.Think ahead when you see a patient. There are a certain number of things that need to be done, but they don’t always need to be done in a certain order. Think ahead so that the patient in pain has to be moved as little as possible during an exam.It doesn’t matter how personable or knowledgeable you are. There are some patients who cling to 1 doctor and if you’re not that doctor, forget it!When will I learn to be more assertive and trust my own judgment and feelings? My patient wasn’t really improving and I kept asking….Finally she went to surgery and had a big abscess drained.Don’t forget the security guards; they are there. You don’t have to handle everything yourself.There must be some trick to retracting the foreskin of a penis….Be more aggressive; sometimes you’ve just got to hurt babies and make them cry during an exam. No use looking if you don’t look hard enough to see.You need to be able to say “I don’t know.” It’s better to hesitate and check things than to plunge ahead blindly.So, as an attending now, what about that “learning at the speed of light” thing? Well, yes and no, it seems to me. It seems like daily, there are a million things to be learned. I remember the fear I had for so long, that I hadn’t learned enough and would hurt a patient (no, that fear hasn’t quite gone away after all these years). So, as a student, I felt like I was learning at the speed of light. Every single patient taught me so much. On the other hand, we learn and unlearn so slowly. We are so slow to discard old ways, and adopt new treatments. Steroids for bronchiolitis, croup tents, prolonged intravenous treatment of osteomyelitis…don’t get me started. Our collective memory as a profession holds on to old facts and absorbs new ones painfully slowly.As I read these random notes about the “art of medicine” from my enthusiastic, much younger, “can’t wait to be a doctor” self, I wonder. Did those attending physicians have any idea what they were teaching me? I suspect they thought they were teaching me about Pitocin, stages of labor, how to take a history, and how to present a patient. I learned those lessons, but the other ones, the ones this story is about, the ones that stuck with me, the ones they didn’t know they were teaching me, those are the lessons I really learned.Now that I sometimes spend the day with medical students and residents, I wonder what “art of medicine” lessons are they learning? I am sure the lessons they are learning aren’t the ones I think I’m teaching….