I wrote this a few years ago after precasting my first medical student from University of Virginia.
“Like drinking from the fire hose” was how Scott, the second year medical student from UVa who was precepting with me last week, described life in the real world of my office at the end of the first day.
He was part of the program where, wet behind the ears medical students are sent out from their ivory tower to spend a week in primary care. My first glimpse of him, standing at the door with overgrown, tousled hair and open faced youthful look, reminded me of myself some 35 years ago. We shook hands, had a beer and I briefed him on the upcoming events. He didn’t flinch when I told him we had to leave the house at 6 am to round at the hospital before going to the office – though told me rather sheepishly that “I normally get up around nine thirty”.
With apologies for the perennial time pressure, we bustled through rounds – with me chivvying him with such questions as “what tests would you do to see if Mr. X has some predisposition to blood clots that’s caused this fifty something year old to have a stroke already?”. Or what social supports and medicines can we order to help the family cope with debilitated and wheezing eighty six year old Mr. Y – whose son was keen to get him home.
Interspersed was banter with the nurses (my kudos was definitely enhanced by having a cute student in tow). It was a bit like having an exotic pet that everyone wanted to, maybe not scratch his ears, but interact with by showing him whatever interesting pathology or “fascinoma” they were dealing with.
Before even hitting the madness of the office I had the impression he was probably seeing me as some eccentric old bugger* with an impossible schedule, but his composure – verging on nonchalance – never failed. Throughout the week he maintained, at least apparent, interest as we dashed from pillar to post and room to room. We marveled at the prevalence of overindulgence diseases, speculating whether “Mrs. So and So could get off both her blood pressure and diabetes medicine if she lost a hundred pounds?” or “would Mr. What-it’s liver recover if he stopped drinking?” We were impressed and intrigued by how many chest pains, abdominal pains, dyspeptics, hypertensives, migrainers, and many others, had a significant psychological element. (One career opportunity Scott is contemplating is psychiatry. I am the son of a psychiatrist, who was himself proof that mental disease is contagious, and have inherited those genes and interests. We had mental illness in common and I enjoyed his remarkably perceptive observations and insights into the psyches and foibles of the various patients.)
I reveled in showing him the massive array of diseases that we see in “the front line” of primary care: In being the dogmatic teacher - though myself seeing, with rekindled fascination, the myriad permutations of the human machine gone wrong (a fascination one might expect the student to have, though I remember only too well my own days in medical school being so anxious and overwhelmed it was hard to be fascinated). I pompously warned him how we “have to be on our toes” as any patient that walks in the door may have cancer causing their anemia ;their “indigestion” may be caused by a heart attack ; their headache may be caused by meningitis.
Come Saturday morning, when I was once again alone, and could zip along with no interruptions, I missed having my acolyte to bullshit** to when there was some particularly nasty tonsils or ripe boil to enthuse over.
The Practice of Medicine
The practice of medicine is just that I point out – very little certainty, just a lot of educated guess work. I felt a little on the defensive rationalizing the “quick and dirty” strategies that we often employ – prescribing what you’re pretty sure will work for Mrs. A’s urine infection. The ivory tower approach would be to culture and know what bugs you’re treating. I float the concept of “diagnosis by treatment”. If they get better you must have been right.
One interesting communication problem that is indicative of the ivory tower culture versus the real world is that, we jaded old doctors, who are of course the fop of those sexy drug company’s sales reps and advertising in general, refer to all medicines by their brand name. The unimpeachable bastion of purity and truth teaches its students only generic names Scott informs me – so there was a lot of consulting of the Palm pilot that we might be on the same page.
Incidentally, the medical school of Thomas Jefferson’s bastion of purity there in Charlottesville costs a cool $45,000 a year for out of state students. Thus you finish your four-year training with a debt equivalent to a moderate sized mortgage, and precious little chance of doing anything other than getting straight on the earnings treadmill to start the long slow process of getting out of debt.
It was the full Monty, as Scott stayed with me so that I could harass him with questions and observations as we drove together to and from work and at home – though there was precious little time at home as I dragged him along on Tuesday evening to the Pratt Medical Center board of directors meetings (where the CEO voiced no objections but said it might make him want to change careers) and on Thursday night to the Moss Clinic as part of his social education.
I fear he thought the whole thing a little overwhelming – but maybe it’s a good thing that up and coming doctors should see this, and all the insane busy work over and above straight patient care as we pre-certify medicines and tests as a requirement of the HMO’s; as we write copious and redundant notes for fear of law suits or to justify our charges to the insurance company.
But maybe I’m wrong, and he was happy with the “fire hose” intensity – and even appreciated being made to do pelvic and rectal exams (on patients game enough to make the ultimate sacrifice to learning).
He certainly left me with a gracious compliment that he had “learned more in one week than in two years a medical school”.