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Unofficial Prognosis

Unofficial Prognosis


Perceptions and prescriptions of a medical student
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Reflections of a fourth year medical student

The views expressed are those of the author and are not necessarily those of Scientific American.


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“We pass through the present with our eyes blindfolded. We are permitted merely to sense and guess at what we are actually experiencing. Only later when the cloth is untied can we glance at the past and find out what we have experienced and what meaning it has.” – Milan Kundera

Two weeks ago, I finished my third year of medical school. This is the year that you leave the classrooms and spend your time in hospitals and clinics, as an apprentice of sorts. After cramming medical information through books and national exams for two years, you finally make it to the hospital wards. You rotate through a range of specialties: internal medicine, surgery, pediatrics, obstetrics and gynecology, radiology, psychiatry, and neurology. You spend a few weeks on each, meeting a new team and discovering your role, and then once you start to get the hang of it you are shipped into a whole new medical world with a new language and a new culture. In the meantime, you finally get to do what you came to do: you get to take care of patients.

It’s almost astounding how many transitions there are in medicine. How many firsts. How many have occurred, and how many still remain. There are moments you will never forget, that make their way into your emotional psyche and set up permanent shop. That show their faces when you least expect them: maybe on the backs of your eyelids as you try to sleep, or perhaps in a stranger’s voice. The unfortunate outcomes that haunt you, but you try not to let oppress you. The first time I saw a fellow human being die. The first time I had to deliver bad news. There’s good, too, and beautiful. The first time I delivered a baby. The first time I helped someone through successfully quitting an addiction. And the personal growths: the first time I came up with my own plan from scratch to treat someone. The first time I stitched closed an open wound. The first diagnostic catch. And there is still so much more to come: the first time I will run a code; the first time I will be alone in the ICU; the first time I will have to make calls with no one watching over my every move. So much remains unknown, even at times unimaginable.

There has been every emotion on the spectrum, and sometimes they have occurred over the course of a single day. This past year has been wonderful and terrible. I’ve been thanked profusely and I’ve been disparaged. I’ve formed meaningful relationships with patients, and I’ve struggled with building rapport. I’ve felt incompetent and I’ve felt proud. I’ve been impressed by nurses, doctors, physical therapists, social workers, and many others so incredibly skilled at what they do. I’ve been ashamed by inefficiency and waste. I’ve imitated and I’ve developed my own style. I’ve been comforted. I’ve been able to comfort. I’ve laughed. I’ve been moved, scared, confident, anxious, overwhelmed, overjoyed, insecure, humbled, sad.

The hospital is a world in itself, with many moving pieces and emotional overload. And then there’s you, the third year medical student, trying to navigate it – sometimes playing an active role and sometimes being a shadow, sometimes making mistakes and sometimes doing well. By end of the year, you develop more and more independence; you evaluate patients yourself, and you are surprised when colleagues trust you. By the end of the year, you formulate assessments and plans, and you run those by seasoned physicians, and you are amazed and nervous by the number of times those plans go unchanged. Your white coat has developed stains – usually metaphorical, and sometimes literal – and you carry them with you and let them shape you.

There were two major themes I could focus on to think about third year: there was efficiency, and then there was poetry. Yes, one thing I was struck by was the burden of what can only be described as logistics, and the stark reality of how encompassing it can become. You hear residents complain about “scutwork,” and you finally get it. There is a lot of paperwork. There is a lot of time spent hunched over a computer, writing daily progress notes, cranking out discharge summaries, documenting everything, on hold with outpatient providers and insurance companies. There is tedium and there is waste. You use a fax machine more than you ever thought possible in 2014. We carry around small slips of paper in our scrub pockets with checkboxes of tasks to do, and we cross things off as the day goes by. Yes, I put in morning lab orders. Yes, I ordered the evening hematocrit check on Ms R. Yes, I filed the notes in the charts. Yes, I updated the sign-out for the night team. This is the reality of the majority of each day, every day, and it can soak up so much of your time and your mental energy – if you let it.

And then there’s poetry. It’s a main reason many of us, I presume, went into medicine in the first place, and it stays with you, moves you, and changes you. I must have written hundreds of notes this year – my fingers skilled at tracing the pattern of the phrases “heart regular rate and rhythm, lungs clear to auscultation bilaterally” over the keyboard. But none of it made a dent. No, what I remember is the patients; the emotionally salient encounters remain crisp. The early ones carve a deep imprint, and I wonder if they all will – if their impact is a function of our being green, or if it’s a more indelible feature of this profession. These individuals have taught me in every possible way. About this business we call doctoring. About life. You remember and forget and remember again why you chose this career in the first place. There is poetry all around, if you open your eyes to it. You can lose the forest for the trees, or you can rebuff the forces that threaten to jade you and remain clear, appreciative of what is around you, grateful and humbled by the role you are in. It’s easier said than done.

Now, as I begin my last year of medical school, my goals are humble. From wanting to learn everything possible to the one goal riding above it all: to do good. I want to do right by my patients. There is so much you can pour into patient care. At times there will be puzzles, but I will try to make sense of them. I will make mistakes, but I will learn from them. I will work hard. There will be inevitably be countless moments where I will not know the best course of action, tiny decisions peppering the day with each having potentially dire consequences. I will do right.

And that, somehow, is the force that has propelled me through this year and I hope will sustain me throughout residency and beyond. It has been there through it all: through the long days on call; through the late night literature searches; through the times of indecision; through the petty grievances. I will do right by my patients. Inspiring me and grounding me. And so you make sure that sandwich arrives for the patient who came in after the cafeteria closed for the night. And so you make that MRI happen. And so you sit by bedsides and explain and re-explain, because it’s information overload, and so you demonstrate patience and compassion. You can’t do it all, and you are bound to experience many times you are unsure. But there is a meaning behind all of what we do, and it is this: I will do right by my patients.

In the 2012 commencement speech to the Harvard Medical School graduating class, Don Berwick invoked an image that resonated with me deeply:

There is a way to get our bearings. When you’re in a fog, get a compass. I have one—and you do too. We got our compass the day we decided to be healers. Our compass is a question, and it will point us true north: How will it help the patient?

To every patient I’ve had the privilege of meeting over the past year: thank you for letting me be involved in your care. Thank you for your teaching, for your lessons on humanity. In return, I will spend my career trying to do right by you.

Now, as I stand at the interface of my last year of medical school and think about my upcoming applications to residency, how soon this is all coming, and the gaps and weaknesses I want to focus on before I must answer to Doctor, I take a mental pulse. Am I scared? Absolutely. Worried? Without a doubt. But ready?

I have to say yes. Because we have a guide, and it is our patients. I need to trust it. Because really, what else is there? If not that as a guide, then what?

That, simply and invariably, is all I need.

Ilana Yurkiewicz About the Author: Ilana Yurkiewicz is a fourth-year student at Harvard Medical School who graduated from Yale University with a B.S. in biology. She was an AAAS Mass Media Fellow, and her work has appeared in the New England Journal of Medicine, Aeon Magazine, Science Progress, The News & Observer, and The Best Science Writing Online 2013. She has an academic interest in bioethics, currently conducting ethics research at Harvard after previously interning at the Presidential Commission for the Study of Bioethical Issues. She is also interested in general internal medicine and quality and systems improvement. Follow on Twitter @ilanayurkiewicz.

The views expressed are those of the author and are not necessarily those of Scientific American.



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