On Becoming a Doctor: Excellent Medical Student, Terrible Clinician
There is a saying that you enter medical school wanting to help people, but exit it wanting to help yourself. It may be a cynical view, but a realistic one. The criteria to being a good medical student are far different from being a good doctor. Medical education may be breeding a legion of self-serving, grade-grubbing, SOAP-note spewing machines rather than the “empathetic”, “compassionate” and “caring” physicians of admission essays yore.
I was no different. My first two years of medical school, I was largely a disinterested student; I didn’t care for basic sciences, research or pathology. Like many others, my knowledge waxed and waned with the test schedule, and after Step 1, I entered my clinical years an acceptably successful medical student.
Excellent student, terrible clinician
Third year (MS3) begins a reign of terror led by the constant gauntlet of heavily-weighted rotation grades, standardized exams (NBME Shelfs) and the looming threat of residency applications and ‘Match’, when, after 20 years of schooling, some pie-in-the-sky computer would tell me if I was good enough or not to be a doctor, and subsequently determine my life for the next three to seven years.
Grades were a priori to make myself the most competitive residency candidate possible. I studied and worked hard. Each patient became an opportunity for me to impress on notes, rapid-fire oral presentations and predict nuanced ‘pimp’ questions. I learned to charm patients just enough that they’d acknowledge my “care” to the attending during rounds; I interrogated my patients just enough to write the excellent notes I knew I’d be evaluated on; I “learned” about my patients by memorizing their daily lab values to proudly recite on rounds.
Patients weren’t people with problems but stepping stones to rack up points with the attending. Once rounds were over, patients became time-sucks from shelf studying time, an exam worth 30% of every rotation grade. Real humans do not follow textbook presentations, but exams do; the warm body in front of me only detracted from my evaluation by cold scantron. By my attendings’ clinical comments, I was an “excellent medical student”, but I knew I was a terrible clinician, rehearsed only in the games of academia, not medicine.
How I learned to stop worrying about the ‘Match’ and love patient care
My shift in paradigm came with a shift in career path. My worst fear as a fledgling surgeon was not ‘matching’ for a residency spot. My worst fear as a fledgling emergency physician was killing a patient. Suddenly playing doctor became very real, and in the middle of my OBGyn rotation, I started to care not about textbook presentations but real-world ones. I didn’t care for OBGyn and volunteered to cover the peripartum critical care unit, a similar environment to emergency medicine (EM).
My first day on the unit, I saw a patient roll in as I was in the middle of practice questions on the computer. I glanced up but returned to my test preparation, justifying my delay in evaluating the patient because the resident was still in surgery. Half an hour later, the resident came to evaluate the patient and I followed - the patient was obtunded, hypotensive and sitting in a growing pool of her own blood. It would not have taken a MD to realize that this patient required immediate medical attention, and I kicked myself for not evaluating her sooner. I may have been a pretend doctor, but it finally struck me that I was a pretend doctor on very real patients.
For the rest of my time in the unit, I made it a point to personally round every hour, on the hour, on every patient. I didn’t always write notes for these hourly rounds – getting credit was no longer important to me – patient care was. While they initially questioned my obsessive rounding, the residents quickly came to trust my dedication and leave me to my own in the unit, knowing I’d alert them if necessary.
At my institution, hell hath no fury like an OBGyn resident unnecessarily interrupted, so I spent my time reading on appropriate treatment courses for the different conditions I saw in the unit. After I rounded, I’d give the resident a list of orders to put in; the nurses began to treat me as the main provider in the unit. I got to be the first person to make critical medical decisions, sending patients to the OR STAT, activating mass transfusion protocols, calling codes, and truly impacting patients’ treatment courses. I pulled long hours and hardly studied in the traditional sense with prep books and practice questions, but I was constantly reading on my patients. I aced that Shelf exam and got the best evaluations of the year, from some of the notoriously toughest residents in the hospital. I had learned to stop worrying about the ‘Match’ and love patient care.
Not “just” a student
After that revelation, I fought to earn more responsibility and trust on each rotation; I learned more, gained competence and became more satisfied in my chosen career in medicine. On emergency medicine, the specialty that started it all for me, I learned more medicine in one month than I did in my entire third year. It was a pass/fail course with no motivation by grading, but I was terrified I would be the first person to evaluate a patient and not recognize a critical condition. That hemorrhaging patient from day one on the peripartum critical care unit still haunted me.
People can decompensate quickly and unpredictably – at any moment, you may go from being “just” a student, to being the only medical provider in the room. At the end of that rotation, I aced Step 2. Behind each question I’d see faces of patients with that exact presentation; behind each answer choice, I’d see the clinical consequence of making the wrong decision. Finally, I understood what it meant to be both an excellent medical student, and (at my level of training) an excellent clinician.
The academics of medicine often makes us forget the “59 yo AA M with pmh CHF dx 2010 (EF 20% by TTE 8/2013) p/w SOB x 2d” is a real person, with real vulnerabilities and real fears. We are not “just” students, but trainees and members of the medical profession. Grades and exams do not define us, but are simply checks on clinical competence. Trite as it may be, remember what you wrote about in your admissions essay – why you embarked on this journey in the first place. We came to medical school not to become excellent medical students, but to become excellent doctors; all else, the grades, the ‘Match’, the exams, will follow.
Amy Ho is a fourth year medical student at UTSW going to University of Chicago for emergency medicine residency. Healthcare policy and patient advocacy was what drew her to medicine in the first place and actually being part of the 'house of medicine' showed her that medicine as a culture is not at all what the rest of the world would expect it to be. In part, she thinks this contributes to some of the problems pervasive in healthcare today – physicians aren't necessarily the most active in looking for and implementing change. She writes on issues that she thinks are important for the medical community to consider as a way to gradually shift us towards progress.