The eStudent: Nothing About Me, Without Me?

I recently had the wonderful privilege of being accepted to present at a conference on medical education. I’m excited; this is a first for me!

It also came with a less-than-wonderful ‘first’: the privilege of paying a hefty conference registration fee.

Now, I can appreciate that organizing a conference is an expensive endeavor. Venues cost. Staffers cost. Esteemed keynote speakers cost. I get that.

What I don’t get is how a conference on medical education can accurately reflect interests and engage stakeholders in medical education by pricing out the main recipients of medical education: students.

Sure enough, looking over this conference’s speakers list, students are scarce. Plenty of deans, administrators, clinician-educators, and research scholars, though. It’s a conference about learners, but without learners.

To be fair, this isn’t a new phenomenon. Last year, I was elated to see the AAMC webcast its Medical Education conference. With great interest, I watched. I learned. I chimed in via Twitter when the dialogue called for (more often, presumed) a student’s perception or perspective.

And then I rolled my eyes when the post-conference survey, to the question, “Which of the following describes your role?” failed to include the option, “Student.” That moment spoke volumes, and it said everything about the student’s role in educational innovation and curricular design.

This is the essence of the problem. As students, there has to be a bigger role for us in medical education than taking post-intervention comprehension assessments or filling out satisfaction surveys. There has to be, to draw upon clinical analogies, a shared decision making model that invites students’ values, goals, and habits throughout the design process. Medical education without student engagement makes about as much sense as patient care without patient involvement.

To give credit where it’s due, I’m lucky to attend an institution where the student voice is present from the inception of an educational design process. But my experiences on the national scale imply these are outliers, not norms, and that’s a fundamental flaw.

ePatients, as advocates for access to their clinical records and active involvement in their own care, have in recent years coined the moving message, “Nothing about me, without me.”

That’s the attitude we need in medical education. That’s what we have to aspire to, and advocate for. To be eStudents: learners who don’t just participate in and function within an educational ecosystem, but actively shape it.

On Rounds | 4.26.2015

It’s the weekend after end of block exams, which means it’s time to dig through the 742 links in my Pocket queue. That also means it’s time for another edition of “On Rounds,” bringing you my favorite reads of the week.

On the new MCAT | Forbes
There’s a lot to like about the new Medical College Admission Test; with new content in psychology and sociology, MCAT 2015 acknowledges that there’s more to doctoring than biochemical pathways and physics equations. But are multiple-choice tests the best way to identify humanistic, socially aware aspiring doctors? What more we can do to foster diversity and holistic thinking among medical trainees? Allan Joseph and Karan Chhabra break down the good, the bad, and the path forward.

On quack science and journalistic ethicsVox
When it comes to pseudoscientists and their cults of personality, what’s a better-knowing journalist (or healthcare provider) to do? Speak out, and validate a quack? Or stay silent, and let faulty information rule the airwaves? Julia Belluz is on point with this one, and her insights and advice here ought to be required reading for every journalist, scientist, and clinician with a social media account.

On medical schools as laboratories of health transformationForbes
Esther Dyson once remarked that change in medicine happens one retirement at a time. She’s dead right. If we want our healthcare system to pivot from expensive care and late-stage interventions to systems-based practice, preventive care, and population health, the transition begins with how we train future doctors to think. At UT-Austin, the new Dell Medical School is bringing a ‘re-boot’ to a 100-year old model of medical education. David Shaywitz breaks down their educational approach, and what it could mean for medical schools nationwide.

On the value (or maybe not?) of health apps New York Times
There are two kinds of people. On one hand are those who own wearables and use health applications: the young, the affluent, the health-conscious. On the other hand are those who might often benefit from digital health but can rarely afford it: chronic disease patients, the elderly, and those with limited access to care. Today, the consumer market for health apps and devices is larger than ever. How do we connect tech fads to health outcomes? How do we balance rapid innovation with health equity? This NYT article doesn’t offer all the answers, but it raises many of the right questions.

On restoring the ‘joy of medicine’Medstro
When it comes to physician lifestyle, we keep hearing the same stuff: provider burnout is at a high; satisfaction is at a low; most doctors today wouldn’t recommend the profession to their children. We know all that; now, what are we going to do about it? Medstro and Geneia’s “Joy of Medicine Challenge” invites your ideas to restore joy to the practice of medicine, and they’re offering $1,000 for your thoughts. Instead of talking about how our healthcare system is broken, let’s ideate on how to fix it.

On Rounds | 3.24.15

In recent months, as I’ve transitioned from senioritis to sleep deprivation, I’ve come to appreciate the value of brevity. Goodbye, RSS; hello, Twitter, Circa, and BriefMe.

It’s with this perspective that I’m launching ‘On Rounds,’ a (hopefully!) weekly curation of big ideas, reflections, and byte-sized foods for thought. If you’re finding it tough to keep up with the world beyond the lecture hall or clinic, outsource that task to me.

On sitting with patients | New York Times
We often discuss empathy decline in medical training, and why it occurs; in this insightful, incisive piece, Dhruv Khullar absolutely nails it. Pre-meds don’t aspire to treat medical records and lab values, but people. But in medical school, knowing the patient takes a back-seat to knowing the pathophysiology, creating a rift between expectation and reality.

On MOOCs and medical training | Slate
While the MOOC is no longer a novelty, it’s still an enigma: what’s the place of online education in the knowledge market of the 21st century? This month, Yale raised the stakes by announcing its new online physician’s assistant program. In light of an imminent physician shortage and the ever-rising costs of higher education, one has to wonder: is there a place for online, or hybrid, education in medical training?

On re-designing deathCalifornia Sunday
Ideo, the legendary design firm, has built its brand on challenging assumptions and breaking the barriers of, “Well, we’ve always done it this way.” What happens when the strategies that have driven the design of products are instead applied to processes—say, death? And more crucially, how do we inspire and train clinicians to apply the design framework to the act of doctoring, itself?

On UX designMedium
What are the skills and roles that effective design requires? Irene Au breaks it down here, and spoiler alert—the parallels to patient care are remarkable. If we envision the bedside encounter as a co-design collaboration between a patient and provider, the implications and applications in this piece for clinical medicine are fascinating.

On health tech and how bad it isNew York Times
In most fields, the technologies work for the people; in healthcare, the people work for the technologies. Here, Bob Wachter explains why the transition to electronic health records has been a rough one, then lays a roadmap to realizing the value and potential of digital medicine. It’s a daunting task, but an essential one if we eventually hope to treat patients, rather than “iPatients.”

Medicine, Live-Streamed?

MeerkatAs a health tech optimist, I’m constantly fascinated—and completely stumped—by the science of ‘viral’ ideas. What is it that makes some innovations emerge, ignite, and transform, while others stumble, sputter, and fade?

Take live-streaming, for example. The concept of broadcasting one’s first-person perspective in real-time isn’t a novel notion. It’s existed since the early 1990s, when tech pioneers like Steve Mann strapped on cameras and webcast their lives to the world. And, if you’re a millennial in medicine, it’s how you attended medical school.

So what makes Meerkat, the latest ‘app of the moment,’ matter? The short answer: simplicity.

Until now, live-streaming has been done by big institutions for big events: the State of the Union, Apple product reveals, March Madness games. Sure, casual users have YouTube or Vine, but the real-time element of a live-stream takes engagement a step further.

Meerkat now empowers you, the viewer, to become the broadcaster. Open the app, click ‘stream,’ and cast via a link that’s available on your Twitter feed. It’s intuitive, instant, and inexpensive—it’s Meerkat.

How might we leverage this real-time capacity to share our perspectives to enrich medicine?

To transfer knowledge. Take it from a medical student: conferences cost. A lot. An academic conference is a buffet of food for thought, but learners and patients are often left to catch the leftovers through tweets and news releases. Now imagine a future where every presentation, pitch, and panel is immediately available. Imagine a future where your audience isn’t just a room of conference-goers, but the global Twitterati. And imagine the impact that will have on the time to translate insights from bench to bedside.

To foster empathy. Too often, the communication gaps and patient-provider tensions in healthcare are rooted in a failure to understand the other’s experience. Live-streamers invite their audience to watch the world through their eyes, to witness the challenges they face daily, and to respond accordingly. What if providers could observe the barriers that prevent their patients from adhering to treatments? What if patients could see why their doctor seems distracted, or doesn’t have an answer to every question? With Meerkat, it’s possible, quite literally, to walk a mile in someone’s shoes.

To promote accountability. When the world’s watching, we sit up straight and put on our best behavior. The ability to (broad)cast public scrutiny on any individual is powerful—perhaps, too powerful. Whether or not we should put others under this spotlight, the indisputable truth is that we can. That alone should make hospitals and providers pay attention.

Let’s be realistic: Meerkat isn’t likely to be the next Twitter or Facebook; it’s too ephemeral, too public, and too inconspicuous to replace more established forms of public dialogue. But it does open opportunities to communicate visually and to communicate live. And in a discipline where many of our biggest problems are communication problems, that’s worth thinking about.

White Coats for Black Lives? Prove It.

When it comes to advocacy on matters of race and social justice, medicine’s C.V. is, at best, mediocre. 19th century medical students learned their craft by dissecting the grave-robbed cadavers of African Americans, immigrants, and the poor—the bodies that wouldn’t be missed or spark protest. Decades of translational research relies on an immortal cell line extracted, without consent, from African-American Henrietta Lacks in the 1950s. And, of course, there was that clinical experiment for “bad blood.”

Which makes it all the more fascinating, then, how medical students nationwide responded to the recent controversies surrounding the deaths of Michael Brown and Eric Garner:

On one level, it’s incredible to see medical students taking a stand, making ripples nationwide, and letting all our patients know that we stand with them. The white coat—even a short one—lends reputation and gravitas, and #WhiteCoats4BlackLives proves that if we stand (or die-in) together, people listen. As tomorrow’s doctors, we should be inspired from these events to capture that attention and guide public discourse on society’s leading issues: access to care, women’s health, medical errors, gun control … the opportunities are immense.

And yet, on another level, it feels somewhat hollow to die-in together, to call our campuses to attention with powerful gestures, to feel the pride of a national movement … only to return to clinic or class an hour later, ready to resume our usual routines. We have the public’s attention, but now I’m tempted to follow up with a question I encountered too often as an Indian-American liberal arts major: “What are you going to do with that?” If social media is any indication, we grabbed the microphone for a moment, dropped it, and walked off the stage. That’s not social advocacy; it’s feel-good activism.

Screen Shot 2014-12-18 at 09.41.38

In the days to come, we have to remember that raising awareness is a means to an end, but not an end in itself. It’s imperative that our objective is continuity, not complacency. We’re entering a discipline where our black and white patients’ life expectancies differ by five years. Where blacks have the highest rates of cancer, but the lowest rates of clinical trial enrollment. Where six percent of our colleagues are black. Where 70% of the applicants for NIH funding are white, and 1.4% are black. If we want to take action—to not just “raise awareness” of problems, but solve them—the social agenda practically writes itself.

As medical students, we chose this profession to help others—to make a difference. So let’s challenge ourselves to go beyond the “social activism” of fighting a disease by wearing pink, pouring ice water on ourselves, or sprawling out on a sidewalk. Let’s challenge ourselves to identify matters of race and social inequality within our communities, in our medical institutions, and at the bedside of each patient we meet. Let’s challenge ourselves to not simply “raise awareness” of the issues that are already trending in the media, but to take real, directly measurable actions to make these social inequalities artifacts of history.

A Digital Native’s Open Letter to the Academic Journal

Many of my grayer-haired relatives have recently made the leap to digital. The transition isn’t always smooth. There are the charming, all-CAPS lock emails; the Facebook posts to me … on their own wall; and even the occasional phone call about which app to use for playing a video with a .pdf extension. After the laughs and the face-palms, I remind myself that these fumbles are understandable. To transition from an analog lifestyle to a connected one is no easy task, and on some level, it’s important to respect and appreciate the effort itself.

It’s a similar philosophy that we should apply to the academic medical journal’s search for its place in an information economy centered on social media. In a distant era before I was born, medical journals produced content that was aggregated, validated, and current. Now, content aggregation is as affordable and simple as a well-curated Twitter feed or Flipboard Journal. Validation comes in the forms of shares, RTs, and up-votes by the trusted voices of one’s network. And as for current … don’t even ask me how many blog entries, Facebook posts, and tweets I penned in the nine months that this paper was under review, revision, re-review, final edits, and scheduling for publication. These factors all converge upon the question: how do medical journals ‘do digital’ and stay relevant in the time of social media?

If this week’s “Intention to Tweet” study in Circulation is any indication, the jury’s still out on that one. From Dr. John Gordon Harold at the “ACC in Touch” blog:

The trial, “Intention-to-Tweet,” randomized 243 articles published in Circulation to either receive social media or not and found no difference in median 30-day page views (409 [social media] versus 392 [control], P=0.80). There were also no differences observed by article type (clinical, population, or basic science; P=0.19), whether an article had an editorial (P=0.87), or whether the corresponding author was from the U.S. (P=0.73).

The trial authors noted that these findings suggest “a social media intervention in a traditional cardiovascular journal setting may not increase the number of times that an article is accessed and viewed in the first 30-days after publication.”

In brief: “We’re posting links to our articles, but readers aren’t clicking.” Despite the journal’s efforts, social media did little to boost article traffic. . What’s a journal to conclude—and how is it to respond—after that? If I’m the social media editor for a medical publication (oh wait!) here’s what’s on my mind:

Right message? If there was an antithesis to Buzzfeed or Upworthy’s trademark brand of clickbait, it’s something like this:

I’ve spent the last five weeks of my life living, breathing, and dreaming the cardiovascular system (which is a less hyperbolic system than I’m proud to admit), and I understand about 25% of this tweet. Understandably, the academic’s journal’s charge isn’t to make headlines, but to faithfully report the science. But if I’m allowed to be naive for a second and idealize research as an enterprise that creates knowledge, informs public opinion, and affects institutional decision-making … isn’t step 1 to make sure that research is seen? And isn’t a pre-requisite to being seen to be interesting, or curious, or evocative? When communication happens 140 characters at a time, even the best content may fall flat without a compelling ‘hook.’

Right medium? 75% of Twitter’s users are primarily mobile; for Facebook, it’s 78%. Let’s put the Circulation study’s findings into perspective, for a moment. Realistically, how often do you read any article—much less a full-length academic publication—from start to finish on a mobile interface? Also realistically, how often do you actually get back to the articles saved to Pocket, Readability, Instapaper, etc.? Now think about the last time you struggled with reading a PDF on a smart-phone (as if academic journals use large, easily-readable fonts to begin with …) and it’s entirely logical why social media hasn’t translated to page views for Circulation.

As mobile becomes the new default in how we access and interact with content, academic journals should reimagine how they present content to a society on the move. Podcasts? Short-form news updates? Info-graphics or tweet-embedded media? Perhaps it’s time to repackage the academic paper into formats that fit daily function.

Right audience? Beyond the Circulation study, here’s a real question for journals’ social media editors … who’s the [intended] audience? For most journals, it seems platforms like Facebook and Twitter are another channel for dialogue with providers [Exhibit A: the language of the above tweet]. That’s undeniably valuable; amid busy workflows, clinicians need filters to locate and organize the latest data, and social media is integral to that process.

Still, there’s a deeper conversation here about how academic medical journals can use their social media presence to connect with the real stakeholders: the patients. Patients are not only the key backers of research (read: taxpayers), but its core beneficiaries. A public presence offers an opportunity, perhaps even the obligation, to bring research findings out of the ivory tower and into a broader, community-wide dialogue.

In closing, I’m not too optimistic that social media will disrupt the academic journal enterprise anytime soon. Hands down, a well-curated Twitter feed offers more agile and accessible (not to mention affordable) content, any day. But for now, peer review outweighs social network curation; impact factor supersedes RTs or up-votes; and publication volume, not blog traffic, drives tenure decisions. In the meantime, academic journals would be well-served to think more deeply about how to craft their message and hone their medium for an ever-evolving, digitally-focused audience.

Searching Under the Streetlights

Walking home the other night, I walked upon a man knelt on the ground, searching for something under the streetlight. He told me he was searching for his wallet, and I, too, got on all fours to help.

After some time, I asked, “Are you sure you dropped it here?” The man laughed, “No, of course not! I lost it a few blocks over that way, but the lighting is much better here.”

As a child, I found this often-recited parable silly; what sort of nut does that? In these first months of medical school, I found my answer: we do.

Despite medicine’s obsession with data, evidence, and validity, when it comes to education and assessment, we search under the streetlights. Time and time again, we look not for the metrics that are important, or the outcomes that matter most, but those that are easiest to obtain.

Exhibit A: the way medical students are evaluated. Some time ago, Ashish Jha asked Twitter, “What makes a good doctor?” The results don’t have NEJM- or JAMA-caliber rigor, but they’re telling; ‘Competent/effective’ ranks fifth, after ’empathetic,’ ‘good listener,’ ‘compassionate,’ and ‘humble’ … even ‘intelligence’ is eighth. And yet, I’d challenge any medical student to tell me, with confidence and candor, that their medical curriculum values those traits above clinical knowledge. I don’t blame my school, but the system; there’s a reason that, of the 759 pages in my First Aid for the USMLE Step 1 book, the social sciences are a succinct 13.

The conversation about post-Flexnerian medicine, competency-based assessment, and holistic evaluation is refreshing. But there are buzzwords thrown around at conferences, and then there are the day-to-day realities—where a clean divide exists between the things that really matter, and the things that are easy to measure. In medical school, clinical knowledge comes before empathy, listening, or compassion, because clinical knowledge is a number. A discrete, objective data point that fits nicely on a bell curve.

Even as I complain about the system, I absolutely understand it. Last block, I scored a 91% in the Medical Knowledge competency. A good, clean, objectively quantifiable 91%. Meanwhile, my peer reviews ranged from ‘sub-optimal’ to ‘above average’ in Integration of Knowledge, and ‘entry-level’ to ‘aspirational’ in Professionalism. The result: I passed Microbes & Immunity, even though I might be terrible (or wonderful) at putting ideas together and working with others.

Perhaps the reality of medical education today is that we simply don’t yet have the tools and evidence to align what matters in learning to what matters in clinical practice. Maybe the informatics platforms aren’t refined enough to reliably identify the ‘well-rounded physician.’ But if that’s the case, then let’s take a moment to erase the buzzwords, look past the illusion, and admit to ourselves what’s really going on: that we’re searching under the streetlights.

Remember Me?

Man … it’s been a while.

When you’re in school enough hours per week to call it a full time job, other things fall by the wayside. Like the cups and plates stacked in my sink. Like the girlfriend I see those one or two times a day I look up from my textbook. And certainly, the blog where I’d naively hoped to chronicle the daily experience of it all.

If anything, the silence on this page in recent months speaks to where life is at right now. Every day, there are new lectures to learn, new cases to cover. And every night, as the clock hits 1:00am and I’ve downed my third cup of coffee, I count the hours till my alarm clock is set to ring and tell myself that I’ll put thoughts to paper another day. It’s always another day, every day.

I’m reminded often of a post I penned a few months ago, wondering why healthcare providers don’t often enough translate their frustrations in clinical practice into innovative solutions:

It’s attention – or more specifically, the scarcity of it. Nobody recognizes the opportunities for creative destruction in healthcare better than the people who spend each day in the trenches of clinical medicine. But after patient care, administrative hurdles, research responsibilities, teaching duties, continuing education, and something that might resemble a personal life, providers have neither the interest nor the capacity to cultivate an innovative spirit.

And that’s exactly it. Make no mistake, I absolutely love medical school. I love drawing out concept maps that tell a story of disease from the etiology to the pathophysiology and clinical manifestations. I love when I’m able to sit with a patient, elicit the right narrative threads, and connect them with what I’ve learned in class to weave an initial diagnosis. I love working with experts across the spectrum of health and wellness as part of a patient care team.

But when I step back for a moment, I realize that the reason I’ve felt a persistent, nagging frustration these last few weeks is that I’ve been so focused on the present, so concentrated on the lecture notes, the flash cards, and the mnemonic devices, so fixed upon what is, that I’ve completely stopped reflecting upon what could be. In the interest of comprehending the things I’ve been taught, I’ve deferred my curiosity about the things I haven’t.

I came to medical school to be a life-long learner—at least, that’s the buzzword they threw around at the interview, and at revisit weekend, and at orientation. But I don’t feel like one, at least not in these last three months. Still, the one piece of advice I do remember from those days of orientation is to stick with the habits and hobbies that make us who we are.  And, by getting back to writing and reflecting, I plan to do just that.

 

Beyond Protcols

EMTs learn, train, and practice by protocols. But some situations challenge us to operate beyond the guidelines.

Technicians, not diagnosticians.

Here’s a fact that, despite my best efforts, eluded the students who knocked on my dorm room door at 2:00 A.M. asking me to diagnose their stomach-ache or to differentiate a possible sprain from a potential fracture: emergency medical technicians are not diagnosticians.

It’s a fact that’s drilled into us during our training. We do not paint portraits of diagnostic clarity, but form foggy sketches of clinical approximations. Indeed, every emergency medical provider is well-trained in the art of cookbook medicine. We identify plausible signs and note visible symptoms, determine which protocol best fits the patient’s condition, then systematically implement a recipe of mandates and instructions.

There’s a protocol for chest pain. Check the ABCs—airway, breathing, and circulation. Start high-flow oxygen. Administer aspirin, 320mg. Check vital signs. Blood pressure over 110 mm Hg? Start an IV, run fluid, and give nitroglycerin, 0.4mg. Repeat dose if … …

There’s a protocol—quite a few, to be precise, for difficulty breathing. Sudden onset shortness of breath? Urticaria? Swelling? B/P depression? Treat for allergic reaction. Noisy, wheezy breathing? Accessory muscle use on inspiration? Peripheral edema? See the checklist for COPD exacerbation.

While all these protocols truly underscore the ‘technician’ in ’emergency medical technician,’ where EMTs define themselves is not in these cycles of recognition and execution, but in the moments beyond the lines—those aberrations and anomalies for which no protocol exists.

Call it in; patient DOS.

“Medic 86, you are responding to an unresponsive patient. 916 River Falls Drive,” the dispatch tones blared, the lackluster monotone of the programmed voice an ironic contrast from the emotional tragedies and urgent crises it often signaled.

I stumbled out of bed and into my medic boots, groggy and irked. 5:17 A.M. … Yechhh. We moved with a requisite urgency, but our optimism muted; at this hour, it was almost invariably a panicked caller who’d awoken to find a rigid, lifeless relative in the bed across from them. To hope for more was, as I’d come to learn, to invite frustration and failure.

On scene, our skepticism was soon enough confirmed. The patient—or what had until recently been one—lay eerily still as stone in bed, her eyes locked in an inhumanly blank gaze, mouth locked grotesquely open as if to convey horror and shock, limbs woven into the unmistakable contortions of rigor mortis and imbued with the hues of lividity.

“Call it in: patient DOS,” the supervising paramedic instructed matter-of-factly.

Our anxious pulses eased, our breaths calmed, our emotions sank; there would be no opportunity to resuscitate a life here. The darkened tints of my goggles masked fresh tears. Experience and exposure aside, even the most seasoned EMTs are rarely up to the task of remaining stoic in the face of death. Sensing the mounting tensions between my external restraint and my internal distress, I withdrew to the kitchen to collect myself. EMTs, after all, are collected.

There is no protocol for human compassion and empathy.

As I stood over the kitchen sink, the warm water reinstating a sense of calm and cohesion, I heard a nearby sniffling that was not my own. I turned to see, tucked away in the shadows of a recliner chair in the living room, the patient’s son. Unlike mine, his face showed little emotion or pain; instead, his solemn countenance and still expression inspired in me both admiration and wonder.

“I’m sorry for your loss,” I whispered to the man. The words felt stale even as I said them; they were the trite recitations of someone who didn’t know how to properly express compassion or consolation. “Is there anything I can do for you?”

“She’s gone, right?” the son asked, his composure again taking me by surprise.

“ … Uhm, well … Uhh, yes. Yes, I’m sorry to say so. Sometimes, we can try to start their heart again, but here, it doesn’t seem like there’s anything we can do. I’m sorry.”

“Actually, I don’t think that’s true,” he responded, motioning to the foot stool beside him. “If you could spare a moment, would you sit down?”

Now as confused as I was curious, I obliged. The son paused for a moment, taking a pronounced gulp and wiping his eyes for the first time.  “Please,” he said, “Would you pray with me?”

I drew back, stunned by this request. Religion, to me, was going to the temple once a year because my grandparents said so. Religion was when we would skip prayers at Diwali to swap brightly-wrapped gifts and eat rich sweets. It had no bearing on my moral compass, much less my practice as a healthcare provider. I was an EMT, not a priest or chaplain. What place did I have to engage in prayer?

For the first time in my medical career, I was at a loss for words or actions. In my EMS training, I could triage a mass-casualty incident. I could intubate a patient and breathe for her. I could stabilize a fracture of any size, location, or orientation. But I could not respond when asked to share in a gesture of faith and spirituality.

There was no protocol for human compassion and empathy.

There, caught at the intersection of reason and emotion, challenged by intuition and expression, I deferred thought to instinct. I met the son’s gaze, sat down, and put my palm in his. At that moment, there was no sense of protocols or directions, rules or expectations; there was only the circumstance before me, and what felt like the right thing to do. The man closed his eyes and wept in silence. After several minutes, he cleared his throat, loosened his grip, and nodded to me with a brief, “Thank you.”

A reflection.

When I’m asked what my most memorable call in EMS has been, people expect the multi-vehicle collision or the successful resuscitation. But there’s more to EMS than running lights and sirens, and there’s more that we can do than fulfilling checklists. That night, I wasn’t confronted by a matter of faith, but a matter of understanding and responding to a person’s needs as he navigated one of the most difficult chapters of his life. In that moment, the best care that I could offer that patient was to be emotionally present for her son.

In a discipline where it’s easy to feel the frustrations of merely checking off boxes or meeting the medical-legal obligations of cover-your-ass medicine, it’s important we remind ourselves that our most profound abilities lie not in our procedural dexterity or acute observations. As EMTs, we instead define ourselves by the moments when we go beyond the guidelines or transcend the limitations of protocol-based medicine to provide for our patients’ needs—biomedical and beyond.

In this patient encounter, names, events, and details have been altered and fictionalized to protect patient anonymity.

Do No Harm: The Student’s Paradox

This is my first post for ‘Com(med)ore,’ my new blog. Here, I hope to chronicle my experiences as a medical student at Vanderbilt University over the next four years, from White Coat Ceremony to Match Day. In the lead-up to medical school, I’d like to share some of my essays reflecting on my time as an emergency medical technician during my undergraduate years. Thanks for reading; any feedback and comments are welcome!

What happens when medicine’s cardinal dictum meets its steep learning curve?

Primum, non nocere. First, do no harm. This is medicine’s golden rule, every health professions student’s North Star of guidance. For in medicine, there is much that appears futile, much that weakens our foundational preconceptions of ‘right’ and ‘wrong,’ much that offers some distant, plausible benefit beyond the horizon. All this, we justify with the understanding that, if nothing else, we leave our patients no worse off than as we found them.

Except, that is, when the task requires it.

To the novice EMT student, the teaching hospital is a daunting place. Everyone—except you—seems to have a defined task and purpose. The attendings review charts, the residents conduct physical examinations and obtain histories, and the nurses administer procedures and monitor patients. Amidst the structured chaos of the emergency department, it’s hard for a learner to not feel like a weed in the grass, an inessential intrusion lacking roles or responsibilities. In the overcrowded county ED, where beds of agonized patients spill out the exam rooms into the hallways, even observing from a corner means being in the way.

I was only too happy, then, when a voice barked, “You, student, get over here.” I looked up clumsily and, seeing a nurse across the room gesturing in my direction, hastily obliged. Without even a glance away from the computer screen, she thrust a plastic bag of supplies into my hands. “Here, make yourself useful. Bed 23 needs an IV.”

I walked over to ‘Bed 23,’ whose name was Ms. Suarez, an elderly Latino woman whose grandmotherly, pleasant demeanor belied the throbbing pains and swelling in her leg. Recalling our classroom instruction, I recited the didactics in my head. Position the arm. Apply the tourniquet. Arrange your equipment. Flush the extension set. Sure enough, there it was: a bouncy, blue-green line right in the crease of her elbow. I swabbed the site, unsheathed the catheter and mumbled, in a hesitant tone that surely betrayed my naivete, “A little poke; un poco dolor!”

Tensing to subdue the quiver in my hand and heart, I readied myself for the plunge. Just like class. This is just another manikin … except, one with nerves, emotions, and probably, a temper if you don’t get this right. With a deft motion, I pulled back the wrinkled skin and inserted the beveled tip into Ms. Suarez’s arm. Anxiously, I fixed my gaze upon the catheter, hoping desperately for the flash of scarlet that meant a job well done. Nothing—damn. I looked up to Ms. Suarez, her pained, yet forgiving, gray eyes meeting mine as if to say, “There, there.”

And here, I thought it was the healthcare provider’s role to do the caring and comforting.

A band-aid later, I again prepared myself, determined not to let down this frail grandmother who reminded me so much of my own. Place tourniquet. Flush tubing. Palpate vein. Cleanse site. Unpackage catheter. Insert stylette. Bevel down. Aim shallow—not too shallow. Once more, I searched in anguish for a flash in the catheter, but found nothing.

“Dig around in there,” a resident at the next bed advised, “Sometimes, you’ve got to explore nearby to nail it.” My eyes darted from the catheter, to Ms. Suarez, and back. With every additional failed attempt, with each futile dig, I saw her flinch in agony, her lip steadfastly bitten in attempt to mute her expressions of pain.

Finally, head down and tail between my legs, I sheepishly returned to the nurse’s station and admitted that I hadn’t been able to perform the most elementary of tasks. I watched as she, almost effortlessly, placed the IV, my eyes too ashamed to confront Ms. Suarez’s once more. “Don’t sweat it,” the nurse casually remarked, “Some people just have bad veins.” As if the responsibility for my errors wasn’t mine, but the fault of Ms. Suarez and her ‘bad veins.’

We always default to ‘do no harm’; it’s as much a staple of medicine as the white coat, pager, or stethoscope draped over the collar. Yet in the natural learning curve of patient care, to err, to fail, and to hurt are almost inevitable. That first blown IV, the first failed intubation attempt, the first perceptual error by the novice diagnostician—these are the unavoidable costs of developing mastery. If we don’t try and fail on the first patient, it’ll be on the next person, or the one after that; the climb to competency must start somewhere. As reluctant as I was to make further attempts after my struggles with Ms. Suarez, I acknowledged that continually trying—even if it sometimes meant failing—was the only way to eventually emerge a proficient provider.

When doing harm is likely, or probable, or seemingly inevitable, how can we, as students, respond?

First, we can find mentors that don’t berate failure, but comfortably acknowledge and constructively address it. The pressure to perform and the stigma against failure that pervade cultures of healthcare often don’t prevent mistakes, but perpetuate them. As Clayton Christensen said, an organizational philosophy of ‘failure is not an option’ is really an unwillingness to discuss or improve upon failure.

Second, we can ‘bend’ the learning curve through practice. No manikin, drill, or application can truly replicate the bedside experience, but they can approximate it. After my first unsuccessful intubation attempt, my preceptor challenged me to practice the task until I could do it correctly and under time for 100 repetitions. The next attempt, then, was simply my 101st consecutive success; muscle memory and the comfort of experience made the difference.

Finally, and most critically, we can offer our patients the gratitude, humility, and candor they deserve for being our most important educators. Despite our best efforts, harm happens. The best we can do for our patients is to thank them for walking with us up that steep learning curve, so that we can someday provide for our future patients and community the highest standards of care.

In this patient encounter, names, events, and details have been altered and fictionalized to protect patient anonymity.