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Student Scene December 16, 2002 Tarayn Grizzard Photo by Jeff Cleary Re-centering the Patient in Clinical Education In 17 months, I could be a doctor. This is scary for me (not to mention those who know me) for many reasons. My relative youth, lack of practical medical training, and inability to scrawl a properly illegible prescription all point to my not being quite ready to leave medical school for the world of internship, residency, and the day-to-day world of medicine. Filing a plan for a fifth-year of med school seems imminent. I'm not alone in this. Over the past few months, I have personally heard increasingly loud murmurs of fifth-year plans--"educational" travel, research in sunny climes, etc.--over the din of complaining that goes on in student conversation on the wards, at Patient-Doctor courses, and around town. Most of us have similar reasons. We're not ready to leave or cannot decide on a specialty and need more elective or reflective time to decide. As students we know that we will become more disconnected from patients as we progress through our training. Others are having a crisis of a different sort, that of disenchantment with the actual world of medical practice that we as students have long-anticipated and planned eagerly to enter. Since the transition to clinical life began last July, I have heard many complaints about work hours, team dynamics, and other typical issues but, most disturbingly, I have heard with increasing frequency discontentment with the actual practice of medicine in the hospitals. Students complain that hospital life is boring, that they spend no time with patients who stay so briefly sometimes that any continuity is impossible. Most students spend a vast portion of their educational experience in the hospital "managing" patients via telephone, fax, computer, or mounds of paperwork alongside the beleaguered house staff. Great Clinical Expectations As disturbing as I find the complaints about how tedious clinical practice is in the hospitals, it's tough to blame the critics. As students and American TV-viewers, we have been conditioned to expect medical practice to be fast-paced, colorful, and tinged with meaning--a veritable kaleidoscope of human experience, replete with a romantic subplot. Hospital life is a far cry from Scrubs or ER or even Marcus Welby, MD, and thankfully so. At the very least, any hospital with that many layers of conflict would have been shut down by the accrediting agency a long time ago. But what rings true about these shows--and proves addictive for many of us apart from the unrealistically attractive cast members--is the human drama, the sturm und drang of the physician-patient encounter as it is portrayed. Perhaps the boredom and disenchantment that many students feel is fundamentally a sense of loss, an unfulfilled expectation that they, too, would have connected with patients and their families at something approaching that dramatic level--or at least would have begun to learn how. The most distressing part of this is that as students we know that we will become more disconnected from patients as we progress through our training; residents are notoriously busier than students, spending most of the day dealing with paperwork, money, and hospital hierarchy. No wonder patients complain that physicians don't listen, miss important details, and seem detached from their care. In an environment where there is little impetus to be a caring, connected, in-touch physician, such skills may go unappreciated and unused. Reconfiguring the Patient-Doctor Dynamic Given the general state of upheaval that exists in health care and its effect on hospital practice, solutions for the physician-in-training who has little time or impetus to "connect" and truly care for patients emotionally and physically seem few and far between. It seems logical that until reforms adjust the current imbalance in health care, residency and early practice will be tough and potentially alienating experiences for physicians looking to engage fully in the care of patients. The real issue, it seems, is not what might be lost or underutilized in residency and early practice, but instead what bedside skills the students bring with them from medical school. The reasoning is that it is easier to build on a solid foundation than build anew. The question of whether or not students have enough experience interacting with patients to benefit their residency and build on in the future is a major concern facing medical schools today. The misgiving that students may not be learning the right skills to care for their future patients is one of the driving forces behind the newest HMS educational initiative, announced in an e-mail from the dean and covered in the Dec. 8 Boston Globe. The HMS Task Force for a New Curriculum is planning to overhaul the course of medical study to connect students with critical clinical issues more effectively and appropriately, given the current medical environment. In many ways, this may be the first ray of hope for the future of clinical medical education--and for future generations of physicians. Until then, students will continue to learn how to adjust, acclimatize, and prioritize their clinical skills to the rapid turnover, intense bureaucracy, and interpersonal isolation that characterizes modern hospital practice. --Tarayn Grizzard, a third-year medical student at HMS The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

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