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.


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.