Monday, May 29, 2023

Medical Education Is A Patchy Thing


I've been asked a lot, first, why do you want to be a doctor, and then, why did you want to become a doctor. I've always been too concrete to say, “destiny,” which is a more positive word than “fate.” Nowadays, now that my doctoring is through – or is it? – I tend to think it was destiny, what with my father being a neurosurgeon, and with my temperament harboring kindness and with my being smart. But back then, when I was a medical student, it might have felt more like fate, although I never regretted it. Even when I felt I might not belong to the Harvard Medical School milieu, even when I was a malprepared and maladapted second year student appearing on the wards of the Beth Israel Hospital with a formal and unwelcoming Benjamin Banks as my first attending, even when the house staff were the insiders who hazed me and I was the outsider, I never thought that I didn't belong. I might not have known how to play their game yet, but it was I who belonged, because my father was a great and devoted doctor and I was a chosen and respected son, and if I perceived the BI crew as formidable and ingrown and somewhat bleak, it wasn't me who didn't fit in medicine, I figured, because one thing that I had been given by my family was self-respect, and that was never leaving me.

But that isn't to say I was ready, because I wasn't. I didn't picture myself saving anyone, or serving anyone, although being nice and essentially beneficent by nature, my brother and my sisters thought I was and family friends thought I was and I guess they mentally matched me up with their daughters, they all probably projected my being nice onto my role as a prospective doctor. But I was coddled, there is no better word for it, I guess. Not that I wasn't held to rigorous standards, I was, and I had internalized that, but it was all academics, although it was also sports. But classroom study was my thing, I excelled, my father said I could pass an exam in any subject, even if I hadn't studied it, as long as it was a multiple-choice test. Classrooms – let me at them. Tests – not a problem. Laboratories – well, not so much the hands on stuff, to tell you the truth, I was a theory guy, a words guy. Except for sports, there I was rock'em sock'em. But classroom studies, chess, my turf. My medical destiny? Maybe public health, my father drummed into me – they had a good deal going, he thought, practice was so high-tension, such a grind. Public health – all that time off, the academic postings in foreign lands, that was the greener grass to my father, and I accepted it faute de mieux.

And then, all of a sudden, there I was on the wards, real doctors and real patients and long hours. The patients were welcoming. In those days the BI had open wards, a big room with probably eight or ten beds arrayed around the periphery. When the sun came up we were there to take the daily blood tests, syringes, needles, tourniquets, test tubes in hand. One really nice black guy on the left as you came in had giant veins, and he knew he was the med student's gift. I came in and he said, “Hey, doc!” and beckoned me over and offered up his antecubital fossa – that is, the reverse side of the elbow – where giant veins stuck out like giant worms. He offered his veins as a return gift for all the care he was getting in these pre-Medicaid pre-Medicare days. Me - “doc.” Jesus, what a new world.

And then on the far wall was Mr. Marcuse, a spare and very thin little man who lived not far from the Mass General, but had wound up here at the BI. When he had appeared at Mass Eye and Ear, his chief complaint had been wax in the ears. Assigned to a medical student, a full history and physical had uncovered stomach pains in the review of systems. The doctors worked him up and determined he needed an operation for cancer of the stomach or intestines, or something, so they had operated and there had been post-op adhesions – fibrous bands had strangled his small intestines after the operation, probably performed by house staff, I guess – and he had lost pretty much all of his intestines and couldn't absorb anything and was wasting away on this ward of the BI, because he had sought help for excessive wax in the ears. No one said much about him, there was silent indications of a cautionary tale, but caution for what? Was the patient at fault for seeking care, the med student for doing a complete history, the decision to operate for what turned out to be non-cancer, the operation itself? Or a system that used human beings of the lower socioeconomic order to train doctors? No one said, but there was Mr. Marcuse stoically – or, rather, with anger suppressed – wasting away in his bed on the far wall, ready to give his history to one and all.

Looking back on it, maybe that was the shocking introduction. Or maybe it was the formal rounds where I was expected to know how to present a case, never have been taught to do so, just having seen an example or two, I guess, and only at the end adding to my succinct history, after Dr. Banks, with his little gray mustache and suit and tie bent over the patient with stethoscope in hand and in ears, only at the end did I add, Oh, and he is a diabetic. The look of disdain and offense and disgust that I was shot by Dr. Banks as he straightened himself up and snapped at me for only adding a crucial piece of “the case” as an afterthought. The look of glee from Lee Younger, one of my residents with a cruel streak, as he contemplated my dismemberment. I wasn't in Philadelphia anymore, I wasn't in a classroom anymore, I was no one in particular's son in the eyes of Dr. Benjamin Banks and Lee Younger, I was just an ill-prepared second year student at the med school that had just decided that waiting for the third year to send the students onto the wards was a waste of time, let's just send them in second year, ready or not here they come, and Dr. Benjamin Banks had probably been one of those in opposition and here was the proof of the pudding, ill-prepared me, fresh meat. Maybe thin-skinned me, entitled me, reluctant me, not ready for prime time me. I guess.

Weeks later in the rotation we made rounds on the semi-private rooms at the BI. Little groups of housestaff, short white coats, “Boys In White” was the title of a sociological study of medical school, senior residents and junior residents and interns and students on what seemed like a traveling team huddled together going from room to room, like a platoon. We visited patients, reviewed their tests and studies and vital signs and reviewed the chart notes and performed for one another. We were there most of the day while the attending physicians came and went. One lady was in her late 40's, I guess, petite and dark haired and wiry and very yellow and very concerned about something as she approached us to find out when something was going to happen or something, but almost frantic. The head of our team, maybe it was Bruce Chabner who went on to excel at the NIH, dealt with her formally but not unkindly, she scurried back to her bed, somewhat unsatisfied, and we moved on. That afternoon I guess we were going to go back to see her but we heard that she had died. She had been so alive. No one said anything.

I was sent by a chortling Lee Younger to evacuate manually the bowels of Mrs. Naruscewicz, who suffered from some apparently terminal illness, was bed-ridden, who couldn't speak English, and who objected to this necessary but invasive assault on her body with groans and grunts. I said, there there, I have to do this, and she resisted but I was finally successful. It was quite unpleasant, which pleased Younger no end.

Of all the Harvard hospitals I had chosen BI for my internal medicine because I had heard they were the most humanistic in their approach, a hospital with a heart. Maybe so. But it must have been there that I was introduced to the gallows humor of house staff, a psychological defense against the trials of dealing with people with serious diseases. Most memorable were the series of signs of the dying patient – the O Sign when the mouth of the patient formed that perfectly round letter, the Q Sign when the tongue protruded out of the edge of the mouth, and the Fly Sign when an actual fly buzzed round and round the patient's face awaiting death. I guess we laughed when we first heard it. It was there that I heard the expressed intellectual fascination with the pathophysiology of the patient, the distancing from the individual in anguish and distress, those feelings that went unremarked, or frowned upon as unseemly and uncontrolled. This was the foreign territory of clinical medicine I hadn't experienced at home, where my father suffered along with his patients, usually nonverbally. He never made fun of a patient, he never discussed a patient's physiology with relish, although he did manage to publish over 130 papers, even though he was not in a university hospital. He most relished the two bottles of wine he received each year from a patient who never forgot, and he would have relished the short speech of a person I didn't know, who came to his memorial service at The Quadrangle, his last home, when this man stood up at the front and told the story of how my Dad had made a diagnosis of his own dad that no one else could make, and operated on him, and gave him decades more of life. No one talked about things like that at the BI.

But of course my Dad had his own defenses. His telephone number was BA6-5050, which he said was appropriate, since when you came to him, that was about your odds, 50-50.

I also did my obstetrics rotation at the BI. I “delivered,” that is, I sat at the foot of the delivery table when a Catholic mother pushed out her eighth baby. I guess someone congratulated me at my first delivery. I don't even remember clamping the cord, but I certainly remember the other-worldly feeling of a newly formed baby, a little human being, coming out of another human being and landing in my lap. No one said much.

Finally, I did my pediatrics rotation at Children's Hospital. Since it was my last rotation I got the most out of it, I had been acculturated, I knew about coming in early, I knew how to present a case, I sat quietly and cooperatively with the neonatology team helping them do a double volume exchange transfusion of babies with Rh factor incompatibility, erythroblastosis fetalis, all that. One day I was taken into the neurology ward. All the little kids were on the floor playing with toys, little toy cars to pedal around, in their hospital clothes. And they all had football helmets on their heads. I wondered what that was all about, and either I figured it out or someone told me it was because on neurology, kids had seizures, and their heads had to be protected as they fell. It was shocking to me, these poor kids, the parents. But no one said anything.

There was one very nice attending there, an active, extroverted somewhat pudgy, bouncy, and kindly man, and I posed a question for him. Why are the internists such stuffed shirts, and pediatricians are so nice? He said, it's very hard to be a stuffed shirt when your patient is peeing on your leg. Question asked and answered. I went into pediatrics.

We were taught and questioned and quizzed and tested and coached and examined and rated on all our scientific and clinical knowledge and skills and performance. Our emotional reaction to all that we were exposed to and experienced remained, throughout my training as a medical student and later as house staff and as clinician treating thousands of patients through decades, as patients experienced severe illnesses and deaths, as well as wonderful cures, unexamined and unexplored, private territory to work out on our own.

Budd Shenkin

Saturday, May 27, 2023

Medical Student Medical Event Debriefing Service - A Proposal


Medical Student Medical Event Debriefing Service


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