Medical Student Medical Event Debriefing Service - A Proposal

 

Medical Student Medical Event Debriefing Service

MSMEDS

Inevitably, in the course of medical school training, medical events will occur which are striking. Sometimes they are destabilizing – being present at a death, seeing a patient happy one minute and dead the next, seeing a patient raving crazy, seeing a patient and family receiving a dire diagnosis, seeing the controlled chaos around a code blue, tending to a severely ill patient day after day with no end in sight, seeing children suffer and families coming apart. Sometimes, happily, there are uplifting events – an amazing life-saving, life-changing event, a great diagnosis and treatment, an operation that seems magical, a recovery to health, seeing the devotion of a spouse, a birth. Whether positive or negative, seeing the human condition unfold before you, where you are a participant, where the context is medical, is a deeply emotional experience.

How do medical students deal with these experiences? Variably. All students are different, the circumstances in which they find themselves with each event are different, the input they get from those around them are different. Usually, most of what happens to students is internal, often solitary. They absorb it. Sometimes there is the counsel of a wise and experienced clinician, someone who handles it in their own way, who can give advice, someone who can offer concern and solace. Occasionally, such a person can elicit the students feelings and reactions in a way that not only consoles, but deepens their appreciation. But in most medical schools, I think, this is usually a matter of chance, of who is available when, of who has time and inclination, of who is equipped.

Sometimes, unfortunately, the surrounding atmosphere is not so positive, and reactions are psychological defenses. The gallows humor that develops in medical trainees has been well documented, as senior students and house staff ironically make light of a dying patient. Iconic sarcasm on medical lingo is typified by evocation of the progression from the O sign to the Q sign, and to the Fly sign. The O sign is when the dying patient's mouth forms a circle; the Q sign occurs when the tongue protrudes in the corner of the mouth, and finally the Fly sign is when a fly hovers circling the patient and awaits his or her death. House staff observes the process of dying by asking, how far along is he, and reference made to O, Q, and Fly. Sometimes there is just a flip comment, “That's the way it goes, on to the next.” House staff laugh as they assign the student to evacuating the bowels manually of a terminal patient. Often there is intellectualization as in, “What a fascinoma! Wasn't that an amazing EKG?” It's not so different from soldiers, or police, as they gird themselves against the rigors of their profession and life itself. Defenses against the stark realities of life, disease, and death abound.

You would think that medicine, with its history of beneficence, would have evolved ways of passing on wisdom in the face of these events, and in many ways it certainly has. But in many ways it hasn't. When airline pilots have traumatic events, accidents or near-misses, guidelines call for them to be grounded and counseled for a period of time. When that happens to a surgeon, he or she is expected to proceed to the next case as though nothing had happened, schedule comes first, tough it out. And students and trainees, when faced with these events, are often left to fend on their own. Scientific knowledge is presented and judged and tested constantly, but humanistic knowledge almost never.

If students are to be taught humanistic medicine, it would make sense to recognize the impact of these events, and to view them all as opportunities to deepen the humanity of the student, whatever the student's ultimate career objective. Students could profit enormously by discussing the events, and most importantly their reactions and their feelings and their reflections on the events, with someone wise and understanding and experienced. Doctors have a lot to give in their roles as physicians, but what they can give is predicated on what they have absorbed.

While departments and divisions throughout the university will have resources to provide this reflective counseling, and while there is something to be gained by having a variety of approaches that different disciplines might offer, some centralization would have advantages. A separate service would ensure that effort would not be diluted and derided by those who view humanization as somehow namby-pamby. A centralized service would allow faculty to best learn from each other, and to identify strengths. A centralized service could arrange for constant availability for processing events. A centralized service would bring more attention to the effort to all the students, perhaps even by conferences, classes, and publications. A centralized service would enable tracking of the student body to take place, papers to be written about the experience, statistics to be kept, and progress made in an organized fashion. If it's important, put it in one place, and staff it with those who are wedded to the task.

We propose, then that a MSMEDS be established. There are many ways that one can imagine that this service would be organized and operated. Wherever it is centered, the department of psychiatry should be involved. Senior clinicians noted for their humanity should be involved. Departments notoriously resistant to such considerations – one can think of orthopedics and urology, perhaps – should be involved. Students should be empowered to participate in the shaping of the efforts.

To support this important service, funding should be assured, and yearly reports should be made available on the efforts of MSMEDS. If it's important, give it money, give it personnel, and write about it.

Budd Shenkin