Playing Doctor

In most any discipline, the adage of “practice makes perfect” holds true and medicine is no exception. Doctors rely on their previous experiences with patients and disease to make decisions on a daily basis. Naturally, we all want the most experienced healthcare professionals looking after us as patients. Ideally, doctors would be fully trained and competent before ever coming in to contact with real patients. Realistically, however, we must acknowledge that novice doctors have to practice somewhere, and the best training is hands-on experience.

Thankfully, simulation training in medical schools has progressed significantly to provide students more experience before they are actively involved in the care of real patients. Simulation has transformed modern medical education and can be found throughout the curriculum. By the time we get to clerkship and join the teams treating real patients on the wards, medical students have extensive practice in the basics of patient interviewing, physical examination, and certain simple procedures. In one of my previous articles, I alluded to the schemas that medical students are taught as a way to approach clinical problems. Practicing these schemas to build thorough differential diagnoses based on a patient’s history and physical findings is what solidifies our learning, and simulating a realistic scenario where these schemas must be employed is the next best thing to having to do so in real life.

Early in medical school, we began learning clinical skills alongside our other foundational courses. We started by learning how to conduct a patient interview and taking full medical histories, and later progressed to performing the various forms of physical examination. After the first two years, the rest of medical school is focused on repeatedly refining our basic diagnostic and therapeutic skills through exposure to various diseases in real patients.

At my school, we have Standardized Patients (SPs) to help us practice while we are in the early stages of our education. SPs are essentially actors hired by the medical school to act out realistic patient scenarios that give students the opportunity to practice in a simulated environment. We have a Clinical Teaching Center that is fully equipped to simulate real clinical rooms. SPs provide feedback to students from a patient’s perspective. This gives us critical insight into a patient’s perception of us during clinical encounters, and is a key component in teaching us how to perform our role while tending to a patient’s comfort and modesty.

Breaking bad news to someone about a bad diagnosis or a failed outcome is an unfortunate task that doctors are charged with doing on a regular basis. In addition to clearly conveying important diagnostic and management details, you often need to manage an emotionally charged situation. I can’t imagine having to be the first person to tell someone that they have end-stage metastatic lung cancer without being trained on how to approach that conversation in a way that minimizes patient distress. Practice sessions with SPs allow us to practice this and other such scenarios, and provide us with a framework to work with. SPs can also provide comments on some of our physical examination skills that an observing tutor may not be able to notice. In fact, I credit an SP for the first time I palpated a liver during a physical exam. It was the SP who realized that I wasn’t pushing down into his abdomen at the correct angle to feel his liver. After he showed me how, I was able to feel the rim of his liver moving down as he breathed in.

As part of the curriculum, my school holds regular technical skills sessions where residents and attending physicians teach us how to perform some basic procedures. We recently had a session on endotracheal intubation, where we practiced intubating and ventilating a plastic simulation mannequin with exposed lungs and stomach. After a demonstration on how to correctly place the laryngoscope between the base of the tongue and epiglottis to properly visualize the larynx, we were given hospital-issued laryngoscopes and flexible tracheal tubes and told to practice.. In the first few attempts at intubation, sounds of fake mannequin teeth snapping were heard across the room as many of us angled the laryngoscope incorrectly. Getting the angle right avoids accidentally breaking the patient’s teeth, and after some guidance from our tutors, things quickly improved.

The mannequin’s exposed stomach and lungs allowed us to easily tell if we inadvertently placed the tube down the esophagus rather than the trachea — an important error to recognize and remedy early when intubating to avoid gastric distension. In real life, you would use your stethoscope to check that the breath sounds are coming from the lungs and not the stomach. On my first try, I was able to intubate my plastic patient pretty quickly, but as I began to ventilate I found that only the right lung was inflating. Noticing that I was depriving my patient of half of his tidal volume, the resident at my station suggested I try bringing the endotracheal tube back up a bit. It turns out I had pushed my tube too far down that it reached the right bronchus, rather than stopping just above the carina – the point above which the trachea splits into right and left main bronchi. Fixing that allowed air to reach both lungs, and my mannequin was saved from respiratory failure.

Another thing we got to practice that day was ventilating a real person using a bag-valve-mask (BVM). Due to the importance of rapidly providing adequate positive pressure ventilation to a patient who is not breathing, the staff anesthesiologist leading the session wanted to ensure that we all had proper technique using the BVM. Using herself as the patient, she had each student practice placing the breathing mask over her mouth and nose and ventilate her, giving us valuable feedback on how we’re gripping the mandible, the seal formed by the mask, and our ventilation pressure and rate.

While the process of manually ventilating a patient appears simple, getting the right pressure and avoiding hyperventilation is critical to avoid complications. Too much pressure (especially in a pediatric patient) can cause a lung to burst leading to a condition called pneumothorax. Too fast a respiratory rate, on the other hand, can make a patient feel dizzy and eventually pass out from decreased blood flow to the brain. Knowing all this, I was rather nervous when asked to essentially control my professor’s breathing for 30 seconds using a BVM. On my first try, the doctor’s feedback was that I wasn’t ventilating nearly hard enough to inflate adult lungs. She had me try again, so I cautiously squeezed the BVM harder for a few rhythmic breaths, and got a thumbs-up of approval from the doctor. Most patients in real life will not able to be correct my technique, so it was great to get such personalized advice from an expert in airway management portraying a patient’s perspective. This opportunity to train in a controlled environment gave me some confidence in my ability in performing a simple yet potentially life-saving maneuver.

Simulation has found its way into multiple aspects of the medical school curriculum. In addition to some of the clinical and technical skills examples I mentioned above, our core courses incorporate simulation through problem-based learning. On an almost daily basis, we are asked to solve realistic patient cases based on the lecture material we are learning at the time. As a student, I am grateful for being able to practice and hone my skills in a simulated, risk-free environment. These are skills I will be using to help treat real patients in a few months when I start my clerkship rotations. Although I am by no means an expert at this point, the early exposure and training I am receiving will undoubtedly better prepare me to provide the best outcomes for my patients in the near future.