As a medical student, I remember a consultant saying to me, “Watch what I do, take away what you like, forget what you don’t. Do that throughout your career and you’ll end up emulating the best of your trainers.” I found this strange, as it encouraged me to scrutinise the way senior doctors behaved. Now, as a consultant, I recognise that whatever I say or do is considered and judged by those I train.
This creates a pressure, to put across the best of myself. And that requires energy. So, if I walk into a clinic room and am told by the nurse that there is a student waiting for me, I may experience a brief “Oh…really?” Many students will have witnessed a slight deflation in the faces of doctors to whom they have been attached for the morning or afternoon – as though to say, “What a pain!” Their presence will change the way I conduct myself. I will have to be mindful of their need to understand and be involved with the consultations (otherwise they will become completely bored). And it will complicate my interaction with patients, should they appear hesitant or show signs of annoyance when I introduce the observer. What would have been a series of two-way interactions turns into into a three way, dual purpse conversation. All of this requires an investment of concentration and effort.
This apparent downside has advantages. Having accepted the fact that I have a student, I will move into a different gear. I become teacher and doctor. My behaviour tends to improve. If I find myself behaving less than perfectly, I will remind myself that the impression I am making is contributing to the development of that young student or doctor. They will either accept or reject my approach, not formally, not such that their impression will be fed back to me, but cumulatively. I do not want them to look back, fours years hence, and say, “Yes I remember seeing a consultant do such and such, and I told myself there and then that I never wanted to be like that with patients.” (We all have examples we can think of, I’m sure!) We only have to look back on our own evolution as students, junior doctors and middle grades, to recognise that the way we behave now is due to an accumulation of different experiences and different judgments. None of us want to display behviours that end up on the discarded pile.
What else does the student bring to the clinic or ward? He or she brings the need for clarity. Their questions have a habit of cutting through any pretence to omniscience that we may have maintained while trying to understand a complicated concept or disease. Just as a fallible maths teacher may crumble in the face of an apparently naive question about geometry from a 10 year old, so a medical student’s simple enquiry about auto-antibodies or cardiac murmurs can reveal the true depth of one’s true understanding. To avoid such discomfiture in the future, you may even go and look it up for first time in ten years. Sometimes, you find yourself explaining a complex situation to the patient and the student simultaneously. This generates a true sense of engagement, and can result in a successful scientific or technical interpretation, understood by both in plain language.
They can also work, quietly, to preserve our humanity, and perhaps such a simple quality as politeness. If I’m running late, it is easy to fall into a pattern of hasty turnarounds and compressed consultations. Any temptation to hurry the patient along will be countered by the knowledge that efficiency tricks and verbal ticks are being observed. I may know the patient has unanswered questions, which I ‘just do not have time’ to address. One look at the student’s face will tell me if I’ve been too hasty. Caught up in the ever-present temptation to hurry, the outsider’s expression serves as a barometer of decency.
Perhaps some doctors, supremely confident in the way they behave, are not influenced by the presence of students. Others may put on a performance, energised by the showmanship that expertise and hierarchy can encourage..although this can result in the patient being excluded from the interaction. It has to be remembered that the axis of primary importance in the room is that between patient and doctor, not doctor and student.
So having students around can be a good thing, for patients. And for senior doctors they are valuable too, as moving mirrors, passing influencers, potent in their ability to reflect back the best and worst of our ingrained medical habits. Saying that, I would not want to be followed by students all hours, all days. Because they require attention, they will necessarily slow down whatever medical process they happen to be observing. Sometimes it is nice just to get on with your own thing, in your own way, even if that does involve falling back into your own bad habits (or catching up on emails). But now and again it does no harm at all for someone to put a mirror in the corner. Sometimes that mirror will speak, and, venturing outside the comfort zone of silence, say ‘I thought you did that really well.’