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Resident physicians, as learners

August 18, 2009

I already explained what a Resident Physician is. So now, I’ll tell you what it’s like to be trying to learn while in this role.

I have been fortunate to be working at a training program that is relatively new, and relatively small. It makes it a comfortable place to learn, a place where we can focus on developing as clinicians and members of the community, instead of working all hours to make sure the hospital keeps ticking along. Sometimes it is difficult to convince the attending physicians that we are capable of seeing patients on our own and of managing their care to a certain extent. Sometimes, we might even do an exceptional job of it. Although many of the specialist and some of the family practice programs in this province are service-based, we are privileged to not carry that burden where my placement is. There are advantages to both systems, but for me, the balance of life and work where I am seems to be just right.

It can still be a bit wonky, like that long-weekend I was on call and didn’t get to stop for a bathroom or a meal break. Or the time I was a fool and carried TWO pagers on my belt, having signed up for both regular house call and Internal Medicine call on the same night. I lucked out, and the house call was light. I even got to discover a new area in the bowels of the hospital, where they stick patients who are undergoing rehabilitation, often after complex orthopedic surgery. I must say, I did not look very fashionable with my Batman utility belt’s worth of pagers and cell phone. I didn’t have time to learn much, and the circles under my eyes the next morning didn’t look so great either.

Sometimes, exhaustion at the end of the day means it’s hard to eat right, exercise, study, stay in touch with friends and family, and do all that other stuff we are supposed to do to keep well. There are no unit-based tests, only a few big exams that are quite “off in the distance,” so the drive to read and memorize is not quite as strong as it used to be. Shame-based learning is still in effect. This is the kind of learning that is undertaken when one is tired of looking like a fool, of saying “I don’t know,” or of getting scolded for being an idiot. Fortunately, the kind of doctors I’ve been working with in this community are keen on teaching and not so keen on belittling. Still, it doesn’t feel great when one of their questions can’t be answered, so there is a clear incentive to stay reading. (I am still planning on writing a full article about “getting pimped” in medicine, don’t worry!)

Medical students / interns/ and residents ask a lot of questions too. Sometimes it’s because we are genuinely curious and trying to figure out why something was done a certain way. Occasionally, it might be to show off the fact that we FINALLY, ACTUALLY, KNOW SOMETHING!! And after we share this thought in the form of an innocuous question – our ego is smacked right down again by our attending physician poking holes in our superficial understanding of the topic. I fell into this trap early in the month; stupidly, I asked “what do you think of the link between Lantus and cancer?” noticing a physician ordering this fancy kind of insulin for a patient, and thinking I might seem like I knew my up from my down. “Oh? Lantus and cancer? Tell me about it?” Yah, I had only read the little blurb in the newspaper and wasn’t prepared to describe the pathophysiology of the thing. Fizzle!

Since the diseases don’t read the textbooks, sometimes I feel pretty silly reading too. That, and I’m tired of pushing my eyes across a page and not having any more room in my brain to collect the information. All the facts are meaningless until a patient walks in the door, then it all has meaning. Wwe do need to answer patient questions thoroughly and accurately, and generally know what we are doing and why.

We can be naive and not know how to answer when questioned by a preceptor. Sometimes attending physicians ask “tell me what I’m thinking” questions – which are impossible by definition – but usually they are reasonable and ask us about our approach to diagnosis or treatment of an illness.

While making his rounds, a doctor points out an x-ray to a group of medical students.

“As you can see,” he says, “the patient limps because his left fibula and tibia are radically arched.”

The doctor turns to one of the students and asks, “What would you do in a case like this?”

“Well,” ponders the student, “I suppose I’d limp, too.”

That’s not an unreasonable answer, if you think about it. It’s just not what they want to hear. Sometimes we know exactly what  kind of answer should be given, and we know we learned about it in the cardiology block of 1st year med school, and that UpToDate has a great article on it, and that it’s on page 139 of Cecil’s Essentials, but we cannot for the life of us recall the name of that physical finding or quaint disease you want us to shout out. “Osler’s nodes! Grey-Turner’s sign, damnit! Oh, it’s the Duke Criteria and that thing in his mouth is Oral Hairy Leukoplakia! Arg!!!” If we don’t know the answer, we do know where to find it. For many of us, the answer is in our second brain. The brain that is, like a large sauropod’s or ornithischian’s, present at our hip*. In my case, it’s an iPhone, either in my pocket or on my belt. It’s got a lot of what I need, except for common sense, logical reasoning, critical thinking, and empathy. Okay, it has some of what I need, like drug doses and differentials for even the most peculiar of presentations.

All the residents I know are ‘good folk.’ We help each other out with the learning end of things, swapping battle stories and sharing interesting findings. But there is a reputation – on TV mostly – that interns are a frisky bunch, whose main concern is, well, not the awesome murmur on Mrs. S in room 503.

Walking down the hospital corridor, the Nursing Supervisor found it shocking to see one of her nurses walking toward her in total disarray. Her uniform was wrinkled, her hair was a mess and if that wasn’t enough, one of her breasts was hanging out of her open top.
Yelling at her, the supervisor said, “Miss Thomas, how do you account for your appearance. Not only do you resemble a derelict, but your breast is exposed!”
Quickly stuffing her breast back into her uniform, the nurse replied, “Those damn interns. They never put anything back when they’re finished using it!”

The part about not putting stuff back where it came from is true. We also don’t usually know where to find it, and have to ask several nurses, clinical co-ordinators, cleaning personnel, and patients in order to find the vital signs or bedpan we seek. Good thing the staff and patients are usually pretty nice. I’m definitely going to have to keep counting on them, for many years to come. Thank heck for teamwork and people far smarter than me!

I guess I had better practice what I preach and go learn something now.

—–

* The “second brain” of the Brachiosaurus/Apatosaurus and Stegosaurus was actually more like a nervous relay station, perhaps a ganglion or enlargment of the spinal cord, at the level of the rear hips in order to better control the rear legs and tail.

4 Comments leave one →
  1. Nico permalink
    August 18, 2009 10:43 pm

    That’s I think the hardest part of my education, is the “smackdown” learning moment. It’s the adult version of getting smacked on the snout with a newspaper.

    I’ve learned to just take it, vent later, and try to avoid it. But then, I wouldn’t be In School if I knew everything.

    • August 23, 2009 6:50 pm

      Absolutely that kind of learning can happen in any field. It’s just a tradition in medicine, passed on from one generation to the next. Once a person has the realization that they are no longer the smartest duck in the pond, the blows are not as harsh. I’m not saying I’ve accepted mediocrity, but I know I lack a steel-trap mind and try to make up for it by being a human. Sometimes I even fail at that. But, I’m learning.

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