Learning from life

New Year's Eve marked the end of a calendar year that, for me, was largely filled by my core clinical clerkships. For medical students, the first year of clinical rotations is a pivotal and transformative time—a transition from the tidy multiple-choice questions and lectures of first year to more nuanced complexity of the wards and clinics. It’s a time of excitement and of challenge.

The end of the year lends itself to reflection. This year, of my 25, has been more academically eventful than most. This was the year that I entered a locked psychiatric ward for the first time. This was the year that I learned to carefully scrub into a surgery. This is the year that someone confided in me that she had installed a deadbolt on her bedroom door as protection against an abusive partner and yet another told me of deferring filling critical medications to buy food for her children. This was the year that I auscultated, percussed, sutured, suctioned, lanced, interviewed and listened. This year was a compendium of experiences, each taking me a step closer towards the becoming a physician.

Attending and resident physicians, classmates and classroom professors all were crucial to the continued accumulation of knowledge throughout this year. However, just as important were the many patients who were willing to let their care be a part of my education.

The willingness of others to contribute to my education began before I entered my clinical rotations. The cadaver used in anatomy lab is often referred to as the “first patient”—the first chance that students have to connect their book learning with its more potent human corollary. Through a process that relies more on effort than on skill, the human form gives way to its component parts; bones, organs, tendons lay bare. The process provides an understanding that is far deeper that what could be achieved even after poring over Gray’s or Netter’s flashcards. Some discoveries were so shocking they become indelibly seared into my memory. While I had read about calcification of the aorta before, I was stunned to hear crunching under my fingers during the abdominal dissection.

I am frequently reminded of my anatomy cadaver. When I see a patient with heart disease, I remember the cadaver’s enlarged heart, the sutures from a previous bypass surgery still distinct. When I perform a musculoskeletal exam of the knee, I constantly reference the memory of the anatomy lab. I still wonder about his life. I am forever thankful to this individual and his family who prioritized my learning over the traditional process of bereavement.

For many patients, the downsides of medical student participation seem readily apparent. Particularly in outpatient clinics, where doctors and patients may have a relationship built on years of experience, the presence of a medical student may feel like an intrusion. Similarly, the repetition that must accompany the presence of a medical student further can be a deterrent, since a physical exam or history obtained by a student must always be verified by their supervisor. Likewise, a procedure conducted for the first time may be more uncomfortable and less efficient that when it is performed for the five hundredth time.

Yet despite all this, I found many patients who were willing to accept me as a member of the medical team. They let me suture their lacerations, draw their blood and attend the births of their infants. They freely shared their stories—of working to land a man on the moon and fighting in Europe during WWII, of sexual assault and caring for a severely disabled child. In many ways, medicine is a trade with skills that cannot be learned through books alone and must be crafted through muscle memory, personal experience and apprenticeship. From these patients I learned what a dilated cervix feels like as labor processes, how to approximate the edges of laceration and what can make a sick toddler laugh. I also learned how to navigate a language barrier, how to sit with despair, how to deal with anger, frustration and vitriol—which were sometimes directed against me.

Studies have examined the factors that predict patient participation in care provided by medical students. Altruism and a desire to contribute to a student’s education are both factors that predict participation. But on a more pragmatic level, other studies have shown that patients who receive care from medical students have high levels of satisfaction and that the participation of students does not seem to jeopardize care. On the hospital wards, students have a lighter clinical and administrative burden than other team members—providing them with additional time to perform repeat exams, answer questions and just talk with patients. Patients benefit as well, when a student is involved in their care.