The Transition from Pre-Clinical years to Clinical years
Tuesday, December 11, 2007
By Aishu, m4After passing (enduring, some might say) our preclinical years, entry into the clinical years was one fraught with excitement and eagerness to finally experience what ‘medicine’ is all about. Or so we thought. There we all were, making our instrument purchases with much zest, debating on which stethoscope to buy from the type to the colour. “I shouldn’t get green, it will be very hard to coordinate with my clothes” said a friend. “Its more worthwhile to buy a Littman, it can be used for paediatrics as well” said another. “I really can hear even the faintest murmurs with this Welch Allen” concluded another. And so we went on preparing for that entry into the wards. Names to be printed on nametags were carefully worded after much consideration for their ease of pronounciation & recognition (or difficulty for some, if you didn’t want to be called upon to answer!). And when the day finally arrived it was grand. I remember enjoying the feeling of transversing the hospital corridors in my white coat, complete with all the formal regalia – stethoscope occupying prime position around my neck, tendon tapper, pen torch and the all important pen & notebook all perched in my pockets. And then there was the not-too-rare instance of patients addressing you as ‘lokun’ and thanking you profusely. So we went about talking to patients, privy to their most private of symptoms and touching them everywhere in the name of ‘physical examination’. It was all very grand indeed.
Slowly as the first few weeks passed and the excuse of ‘only my 1st month in the wards’ began to become outdated, the responsibilities of that white coat began to dawn. The impending arrival of clinical exams created a sense of general panic as now it just wasn’t about chit-chatting with patients. In about 20 minutes (which really seems like 2 minutes when you are in the hot seat) we were expected to convey the patient’s current, past and expected problems all at one go together with our best opinion on what to do for him/her to a senior doctor (their annoyed/frowning/bored looks didn’t help at all). Oh well, this was still manageable – it was only e-clinics and no one would fail, we told ourselves.
And then it all began in earnest – serious general medicine posting, daunting logbooks with an amazingly endless list of conditions which were ‘must see/must know’ and the horror of a looming clinical exam to top it all off. You see, this was probably the first time we had to deal with an unknown enemy in an exam – gone were the days of theory exams with a set range of topics and comforting ten-year series. Now we had to face a patient; a human being who could be of any size, colour and disease profile. He/she may not want to talk to you or worse tell you misleading information and may pretty much have just about any known (or unknown) disease in the world. And not forgetting the examiner who may be kind or fierce, easily mollified or demanding postgraduate standards, have a motherly expression or one of ‘Im out to get you’...point made. It took us pretty much half the posting for all of this to sink in. And it was only then that the immense range of general medicine dawned on me – there were so many cases to study, physical examination skills to hone and management to learn. Amidst all this was the part about enjoying yourself in the wards and feeling like a doctor. Anyone can be forgiven for forgetting this last bit!
As they surged past, clinical years were turning out to be much more than finally experiencing ‘real’ medicine. Your seniors wisely advise you to strike the balance between spending time in the hospital and with your (much less enthusing) textbooks. They tell you clinical exams are all about the 1/3rd rule: the patient determines a third of the outcome, the examiner another third and you the last third – so just focus on getting your third right and don’t worry about the rest they preach. Any of us will tell you however that, that is easier said than done. My examiner, ‘Dr WPK is very fierce, I m doomed’; ‘What if I get a difficult patient” and so on we moan. It just is not possible to pretend that these are not (very) valid concerns. And so there you are the poor medical student trying to pass your posting exams.
Soon you realize that wearing that white-coat gives you a lot of responsibility and that you owe a lot to your patient. You start taking active interest in their conditions, checking their management and saying hello to them everyday. You start to feel that your presence might indeed make a difference to that lonely, old Mdm Tan. And then I got a glimpse into the nuances of dealing with patients – do you treat them just like new friends, share hand phone numbers and even emails or maintain a ‘doctor – patient’ kind of relationship. I had to grapple with responding to a patient’s queries through hand phone communication – whether I should have even given her my number and to what extent I can act as a ‘medical adviser’ and just how and when do I say no and draw the line? These were an important part of my clinical training. I believe all of us have learnt from such experiences – all while dealing with the perennial haunt of exams and assessments of course!
Amidst all this, subtle dilemmas begin to emerge. Drawing the fine line between simply asking patients to talk to you and persuading them to do so for example. You know that a patient has been examined countless times and is not very keen to talk to you. But he has massive splenomegaly. What if you never get to examine an enlarged spleen? Or worse what if you get a similar patient for your exams? And so there are some who will try to get the patient to be examined one last time. It takes definite courage to walk away from that patient wishing him well and tell yourself there’ll be another time. The first time I did that, it was difficult. Subsequently, it was the obviously natural thing to do. Add to that coming across classmates who dont quite have the same principles as you when it comes to proper ‘medical student conduct’. They might leave curtains open (even if its by just 2 cm) or discuss histories in the lift or act like a stone to a crying patient (it could really be their way of consoling but still..). So you are confronted with endless possibilities – do you just put up with them or confront them with how you feel? Or simply avoid them and co-exist in separate ‘zones’ in peace? These are just some of the ‘situations’ we have to deal with. And so we learn, pass postings and on retrospect, grow.
Yes, 1 year on, I have realized that these experiences do allow (possibly force) one to mature in terms of learning how to deal with patients’ expectations as well as your friends and enter new realms of tactfulness in communication. Thankfully and joyfully, I’ve realized that it’s not just about the various stressors and dilemmas. The exams are merely meant to prepare you for the future – where we will be facing ‘exams’ everyday when managing your patients. In fact, it can all be summed up in a single episode: I was walking blissfully after the end of a long day when a person fainted outside the hospital canteen. Next thing I knew, a man said ‘Doctor Doctor, over there quick’ pointing to the fallen lady. I rushed to her side, heart pounding, willing myself to find just as strong a pulse in the lady’s wrist. I couldn’t. Abandoning the radial pulse, I turned to the carotid, mentally rehearsing the sequence of CPR and everything else that my emergency medicine doctor had calmly said the day before. Much to my relief, the carotid pulse was there – not pounding or bounding but there. Almost simultaneously a nurse appeared and I heaved a sigh of relief. Taking my place beside the nurse it just struck me – the magnitude of what I could have done and was expected to do. It was the patient in front of you who mattered at the end of it all.
I say now that one can still enjoy ‘real’ medicine as a clinical year student – it is after all a potpourri of all the above! From the thrill of that white coat to patient’s expectations to professional dilemmas to dealing with fellow classmates and exams: that’s what ‘real’ medicine encompasses. And realizing this will just make it all much easier and loads more enjoyable!
