Oct. 12, 2007

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Staying the Clinical Course, Patient to Patient

Rachel Eastwood Jason Sanders

The long journey to board-certified clinical practice starts broadly but becomes much more focused from the end of third year through residency; think funnel. Outside observations about inflexible physician careers are not wholly unfounded when considering the residency lengths of medical and surgical subspecialties.

Yet while future psychiatrists and orthopedic surgeons often have a hunch about their direction at the opening White Coat Ceremony, many of their peers wrestle with multiple options through the waning months of core clerkships and even beyond. A quiet momentum builds toward residency selection, though many students take on what amounts to an extra career pursuing an “extracurricular” interest. Over the entire span of the HMS curriculum, nearly 50 percent of the class deviates at some point from the four-year straight and narrow. And though there are many benefits to these pursuits, questions arise about the challenges of clinical re-integration.

New Generation of Multitaskers
Research is a relatively time-tested companion to patient care, especially in fields like oncology, where patients are eager to know about the most cutting-edge drug trials. Taking sabbatical for more than a year or two, however, raises concerns about clinical proficiency, especially in technically oriented areas. And yet the 21st century mix of adjunct endeavors will continue to grow beyond research—from journalism, to public policymaking, to health care financing. The resiliency of clinical acumen will need to withstand an even greater test with these forays.

My first trial by fire took place after spending the past year in the MBA program at Harvard Business School. I re-entered the wards by completing a subinternship in medicine along with a few other students who also had taken a year “off”: doing research, exploring the medical humanities, or just traveling.

No More Flashcards
The farther you go from the USMLE Step I, the more your immediate recall of underlying mechanisms begins to slip. Needless to say, this is frustrating; think sieve. As many a house officer has said to a buoyant HMS III, “You’re probably closer to that than we are.” Hence the useful role that an HMS III can play on a team by giving a concise, five-minute, one-page presentation on a patient’s illness at the end of a week or clerkship.

Time to read is inversely proportional to greater patient responsibility, i.e., interns have even less time to check UpToDate than subinterns. Yet knowledge needs to flow at the rate of a drip, not a bolus, as can be seen by the spotty track record of continuing medical education programs (especially the type involving sitting in a dark room for two days amid mind-numbing PowerPoint slides).

Patients, As Always, the Best Teachers
The silver lining to ephemeral minutiae is the clinical instinct you develop with cumulative experience. Yes, preclinical courses provide a necessary foundation; yes, I will always remember how certain things work (whether the Frank–Starling mechanism or the renal H+/K+ pump) because of gifted lecturers and tutors. But it’s patients who really synthesize a constellation of facts and figures and theories into a coherent gestalt.

To recall management of an acute coronary syndrome, just think back to your first code blue in the middle of the night or the patient on the Bigelow who had an MI during morning rounds. My image of a patient in liver failure dates back to Patient–Doctor II days at the West Roxbury VA and the completely rational explanation of an exasperating disease, myasthenia gravis, goes back even further to my Mentored Clinical Casebook patient as a first-year. Such frameworks helped me perform a focused H&P (history and physical) and develop a prioritized A&P (assessment and plan). And, of course, these were neither static models nor biased anchors; rather, they shifted with new insights from senior teachers and literature reviews. The refinements become smaller and smaller as you progress, however, and your old cases become trusted advisors for the next patient.

—Jason Sanders is a fifth-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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Copyright 2007 by the President and Fellows of Harvard College