New-found Freedom to Think in Medical School

Last week I had a conversation with one of my attending physicians. His critique of my presentation was the only thing I would ever be praised for before: exhaustiveness. “What lab data do you want? What do you think is relevant?”

It’s a question I haven’t really had to answer before. I’m used to being asked, “What’s the bilirubin?” Or listing off all the values in the complete metabolic panel. But which to I think are presently relevant? Well, I’m not really sure. I’d have to think about it.

To think about it

That’s exactly what is finally being asked of me. Not “Memorize this” or “Learn this physiology” but finally, “Figure out this clinical problem.” Of course, all the memorizing and learning is necessary for there to be any problem solving. But there has been an abrupt change in the focus.

In our Practice of Medicine course, we would sometimes take 4 hours to go through a single case. Many of the exercises involved creating comically exhaustive differential diagnoses or similar tasks. Criticism would be mainly for being not exhaustive enough. Of course this exercise in recall is useful in helping us learn the common conditions associated with symptoms, but it’s still just recall. Now I have been asked to vet the list myself.

I have been waiting for two years to hear someone say “Think!” I’m no longer evaluated purely on conformity to a rubric, on my ability to list off everything that might possibly cause jaundice ever. It’s objective, to be sure. But it’s not all that doctors actually do. Doctors think. And when they tell other doctors what they’re thinking, they do not behave like patients with head trauma, with comatose brains, vomiting up (and possibly aspirating) undigested information.

For medical training, the beating heart of the medical student, with its passions and emotions, was put into arrest so that we could be “objective.” The medical student reports the information without passion or emotion (for these, of course, would “cloud” judgment). As a result, his verbal presentation is given in a monotone voice with exactly as much life as his heart has that is as flat as his EKG. But to become a real doctor, the student’s heart must be shocked back to life. He must take on bias, bias for his patient and for truth). He must start to care about what the diagnosis is. He must care enough to argue for his patient, to defend his view on the diagnosis, and to persuade others that he is right. No longer are patients presented as a list of facts; they are presented in a story.

And only human beings, alert and oriented with beating hearts, can tell stories. And they do tell stories. Doctors tell stories. And medical students should pay attention, for this will help them to emerge from the stasis that their first two years have put them into.

It’s never pleasant receiving criticism. But the criticism I got last week shocked me back to life. It was liberating! I could and I should behave like a real doctor now, not just a mindless, heartless medical student. I hope that my mind remains alert and my heart stays beating.