Being a medical student

Students, you make us better doctors!

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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.’

 

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Fade to green

Faint2

I fainted half a dozen times during my training. It’s a problem that worries quite a few people, so here are some of my fainting tales. They may make you feel better.

I should have known it would be a problem because during GCSE biology I was asked to dissect a cow’s eye. It slipped and rolled under my scalpel, glancing at me as it turned. My teacher asked me if I was alright. Apparently I had gone green. As soon as he said that I began to feel green. I lay my head down on the cool workbench and soon recovered. It was close one.

Then, before applying to med school, I spent a night in the local Casualty department. I watched a junior doctor try to prise a splinter from the hand of a young lady. It was hurting her, and she kept yelping. The doctor got irritated and said the anaesthetic ‘should be working’. He kept digging into her hand, she started to cry, I felt lightheaded, moved my legs to keep the blood flowing…and I was out. It wasn’t the gore, it was the negative emotion – I think. Anyway, they put me on a trolley, checked my blood glucose, and the same doctor told me the only explanation for such low levels was an insulinoma. I got home, looked it up, and for some months assumed there was something unpleasant growing within me.

So to med school, and the post-mortem. I had been really looking forward to this. The Professor of pathology lifted out a series of pre-mobilised organs and held them up for those of us in the viewing gallery to see. I glanced past his gloved hands at the cadaver, glimpsed the head, saw the juices drip off the liver…and down I went. As usual I came around immediately, to be told that when the Professor heard the thump he looked up and called out, ‘Will someone see if she’s alright?’

Then came venesection practise. My partner shakily inserted a needle into one side of my elbow vein and out the other, causing a ‘sixer’ sized haematoma. As it swelled I began to sweat, the edges of my visual field closed in and I immediately sat on the floor with my head between my knees. Another close one. However, come the first day of my third year as a medical student, entering the wards at last after two years of lectures, I did less well. We met the house officer (she seemed so grown up) and were told that it was our job to do the phlebotomy rounds each morning. She assembled a vacutainer set and asked me to roll my sleeve up. Pretending to take blood, she held the needle a centimetre from my skin. My brain said NO WAY, the sweat came on and clunk, I was down. The clunk was the sound of my forehead connecting with the edge of a sink. The rest of the day went fine, but the bruise took a week to settle.

I entered the operating theatre as a student on a vascular surgical firm with great trepidation. For some reason the blood and gore did not affect me as it did some others. I watched a consultant repair a ruptured abdominal aneurysm, observed the blood as it pour off the table into his white rubber boots, saw him curse as he nicked the spleen and was forced to remove it…but the fascination allowed no room for vasovagal syncope.

But I was not cured. For my elective I travelled to Nepal via Delhi.  In a busy Indian market square I asked a cobbler to repair the soles of my shoes. He stuck strips of orange rubber onto them with stringy glue that he applied with a stick. His friend tried to clean out my ears with a cotton bud while I waited, but I pushed him away. I was pleased with the job on the shoes though. Anyway, come the first day on the wards in Kathmandu I was feeling a bit rough, having accidentally swallowed some tap water while shaving two days before. I stood in the breeze of an inadequate fan, watched a cat slink between the legs of a hospital bed and lick some organic fluid from the edge of bucket containing sharps…and there we go! I came to on a bed with ECG stickers on my chest. The Professor, a very serious man, asked me if I had a heart problem. I said no. What really upset me was the group of students and doctors at the foot of the bed peering at the soles of my shoes.

After that there were no more uncontrolled total faints. I came close during a stressful central line insertion as a senior house officer, but I think a hangover predisposed me to it. I slipped to the floor, put my cheek to the plastic tiles, sweating, the wire still sticking out of the patient’s neck, and fought it until a nurse brought a cup of ice cold water. Within minutes I was back on my feet, hands clean, fresh gloves on, ready to finish the job. I don’t think the patient ever knew what was going on.

Since then I have found myself in many faint-prone situations, but I am glad to report that it is no longer a problem. Blood, stress, chaos, suffering…none of it hits my pulse rate or blood pressure. Rest assured, if you are a fainter, it gets better.

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