Doctoring

April 15, 2016

This week marks the end of my first-year “Doctoring” clinical skills course at The Warren Alpert Medical School of Brown University. As part of the course, we were assigned to community clinical sites and paired with mentors with whom we worked to practice skills like vital signs, patient interviewing, physical exam, and oral presentations.

Last September when I first walked into the emergency department (ED) at my assigned site and shook my new mentor’s hand I was trembling and my heart was beating into my ears. It occurs to me now that on an EKG I would have been diagnosable with sinus tachycardia. But the ED went easy on me that day—there was no blood, no massive trauma, no deaths. That was good, because initially everything else was hard enough. I’ll never forget the first time I walked into a patient’s room, closed the flimsy curtain behind me, and shakily introduced myself. Even after all the practice with standardized patients, this was different. This was real, and I was terrified.

There were so many moments that taught me little by little. There was the first patient I interviewed with a psychological chief complaint. My HPI (History of Presenting Illness) checklist didn’t cover that, and so I learned that day that a history is not the answers to a set of questions, but the patient’s story. Another day, a resident took the time to talk me through reading a chest X-ray. Now I know to count the ribs as an indicator of hyperinflation, to trace the curve of the diaphragm, to recognize a thin line extending up the trachea as an endotracheal tube. I’ll never forget watching a code blue come in, how the staff worked like it had all been rehearsed, how calmly my mentor walked over to run the code. And then how it felt to see all the effort was in vain, to hear a human being pronounced dead.

But the most valuable learning opportunity of all was the one that was always there, the one that followed me into every interview and looked over my shoulder during every physical exam. It was the simple fact that these were real patients, this was a real clinical setting, that I had the great privilege to be let into actual people’s lives. Each day, as my notebooks filled with quickly scrawled histories and exam findings, my once halting oral presentation became smoother, and my comfort with the skills that once seemed so foreign and impossible began to settle. Behind all of that lies the patience, kindness and bravery of the patients I met.

I was also very lucky to be paired with an outstanding mentor, the head of the ED. To me, his mentorship was most often in the form of allowing me to learn: he let me see patients even when their chief complaints were beyond my abilities, and he always pushed me to present their cases completely even when we were pressed for time. Because of this, I learned and saw a lot.

Having all of those learning opportunities was important, because though the ED started off easy on me, it didn’t finish that way. One recent case in particular will always be engraved sharply in my mind. The site where I worked is not primarily a trauma center, but on this day the nurses came running in wheeling a girl drenched in blood, a trail of crimson behind her. Over the next half hour most of the ED staff crammed into her tiny room, first attempting to stop the massive bleeding from a huge laceration, then pushing fluids into her to increase her blood pressure. In the end they stabilized then transferred her to a larger hospital for immediate surgery. Since then I’ve seen that case a hundred times in my mind. Mostly I’ve asked myself again and again whether she inflicted that wound on herself—because it wasn’t just her body that was in danger: as she lay there, 18 years old and bleeding, she was also two months pregnant.

My experiences at this site have taken me from the simplest encounters to the most deeply jarring, and along the way every one of them has been affecting and moving. I’ve become more proficient and at ease with talking to patients, learning their stories and examining them to uncover symptoms. Perhaps most of all, though, I’ve gone from feeling like an intruder in the hospital to, even if just for fleeting moments, believing that I belong there.