Opinion
A PIECE OF MY MIND Artaza Gilani, BSc University College London, London, United Kingdom.
Corresponding Author: Artaza Gilani, BSc (artaza.gilani@ucl .ac.uk). Section Editor: Roxanne K. Young, Associate Senior Editor. jama.com
Unintended Consequences Every medical doctor reading this essay shares something in common: you were once a medical student. You entered medical school fresh-faced and wide-eyed, enthusiastic and eager. You spent days on a ward and nights inside a library. You felt a strange mixture of embarrassment, unease, and pride when a patient first mistook you for a doctor, and you dreaded ward rounds with the consultant (the UK equivalent of an attending physician) who, let’s just say, had developed a reputation for being firm with students. Eventually you began not to mind the demoralising remarks, or at least you minded less. You started to take them on the chin and were reminded by friends that it was all part of the parcel; it was character building. At the end of a long day you no longer seemed to mind as much as before because at least, after all, you were given some attention. At least your presence was acknowledged, and you left with something you did not have before, be it an extra bit of knowledge, be it the experience of seeing a clinical sign, or be it the realisation that you needed to hit the books. There remained something, however, that you struggled to get used to. In fact, while you let your first experience of it pass by, years later the same experience saddened you like never before. It is hard working in medicine. As an attending physician you face constant pressures from the government, the media, your department, patients, colleagues, family, and, of course, medical students. In a busy hospital environment when patients outnumber the beds available, when your clinic is running behind schedule, and when there are more medical students around than there are doctors, you feel that something has to give way. As the cortisol levels rise and your to-do list lengthens, stress plants its feet firmly on your shoulders. Under such circumstances, one of the first things to be “sacrificed” is the medical student. Consequently, as you sit down documenting your management plan in a patient’s notes and you notice a student approaching you out of the corner of your eye, you—metaphorically, but perhaps sometimes also literally—let out a sigh of frustration. He always begins with the same phrase: “I am sorry to bother you”; words that have become so heavy on you that it is almost as if they are enough to cause an ulcer. They are heavy because you know what is going to follow: from his point of view, a small request for help; from your point of view, another thing to add to your to-do list and another few moments that have been squeezed out of your day. Sometimes you smile and let him speak, but other times, unbeknownst to you as you have become engrossed in your countless other responsibilities, your abrupt response and body language are enough to hurt him so much so that next time he avoids you and decides to approach the doctor sitting beside you. The trouble is, from his point of view, not yours, that
the other doctor also has a lot to do, and he tells the student in no uncertain terms that he does not have time for him. It is this that you struggled to get used to as a medical student: being ignored. Your friends would tell you that this is “just the way it is,” seniors would comment that “we have all been through it,” but you found such tradition difficult to stomach. You spent hours on the ward, you were keen, you were polite, you were enthusiastic, and if people gave you a chance, they would have seen that you could have been of use to them, but time and time again, you came across so many clinicians who were uninterested in your learning needs. You could not help but notice that people would not even look at you as you passed by; there was no smile, no nod of acknowledgment, nothing. As you stood around the ward, sheepishly wondering who to ask how to send off the blood sample you had just taken, no one batted an eyelash. You would turn up every day despite your previous experiences and dart from one end of the emergency department to the other trying to figure out where your presence would be least ignored. On the bright side, the moments you spent wandering allowed you to reflect on what was going on around you and permitted you to open your eyes. You understood that busy and stressful circumstances sometimes forced such reactions, but it baffled you why these incidents occurred when there were less than a handful of patients in the department. It bemused you that this could happen in a teaching hospital. And so you would tell yourself that “I am not going to allow myself to become like this when I qualify,” but somewhere down the line, something changed. Whatever it was, maybe it made you forget how things used to be for yourself. You became desensitised to the very needs that you yourself once had. Without realising, you became the very person who had caused you so much frustration just a few years, or even months, previously. Fortunately, not everyone you came across was like this. As you stood despondently hovering around the doctors’ and nurses’ work area, you would hear the words “Are you OK?” directed toward you. Here he was: the doctor whom all the other students spoke so highly of. The doctor who, despite having just as many things, if not more, to do as everybody else, did not mind spending a few moments listening to you present the patient you were told to see. Instead of cutting your story short and handing you a list of differentials and a management plan, or even just deciding to go and see the patient without sharing any of the above, he would spend a few seconds with you. He would ask you what you thought was going on and what you would do if you were looking after the patient. He would not sigh in front of you when you JAMA December 4, 2013 Volume 310, Number 21
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/01/2015
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Opinion A Piece of My Mind
said you were not sure how to carry out a particular practical procedure. Rather than turn away from you and ask somebody else to do it, he would talk you through the process. He, and all the others like him, did this because they had the foresight to understand that this was in everyone’s best interests, even if it came at the expense of losing a few minutes of the day. Such doctors keep in mind that the students of today are the doctors of tomorrow. Those medical students who you try to avoid are the very ones who will be working for you—or rather, alongside you—on the ward in just a few months’ time. As students they should recognise that they have an individual responsibility to ensure that they are developing their clinical acumen, but the doctors of today should also try and find it in their hearts to remember that they have a collective responsibility to help students along their way. Hence, when a newly qualified doctor falls short of your expectations, before talking about “that junior” in his absence, keep in mind that the very thing you are unimpressed with was what he was going to ask for your help with when he was a student. As you sat writing your notes and you noticed him approaching, it was this very thing that he was unsure of, but you were too busy and did not want to know. Had you taken a few moments to share some of your knowledge and experience with him, maybe you would have been more satisfied with his performance today. With the pressures clinicians are under, sometimes they do indeed become immersed in a never-ending list of things to do. Nonetheless, there is a way of telling someone that you currently do not have time. Even still, it is not often that you cannot spare 15 seconds, but if you really, really cannot, then with the correct etiquette and by being tactful with your choice of words, even the eager medical student will not be disheartened when you turn him or her away. Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the
2252
We all learn from each other directly and indirectly. From your perspective, you may feel as if you have done little to help a student, but what you are forgetting is that everyone else has not even looked at him. Everyone else has tried to avoid meeting his gaze while you decided to smile at him as you crossed paths. Little did you know that this small gesture made his day. All you did was ask if he was OK when he was invisible to everyone else, and from his point of view, your concern made up for all the negative experiences he had earlier that day. You spent two minutes discussing differential diagnoses and a management plan with him, and because of you his diagnostic and decision-making skills have matured. From you he learned that even the smallest gesture with a sincere intention can have a significant impact on an individual. It is because of you that he feels inspired to give students a helping hand when he is in your position; it is because of you that he will try to cope with the stresses of the job in such a way that they are not unknowingly taken out on students, and it is to you, whether you realise it or not, that he is thankful. Yes, we may have all “been there” and “done that,” but we must ask ourselves if such a tradition and culture is enough to justify continuing this negative trend of ignoring students. Medical students should be clear in knowing that they must take responsibility for their learning. They should be prepared to try their best. Being spoonfed is not what most students expect, nor is it what they want. Most do, however, want to become good clinicians, and doctors should work in partnership with them to help them achieve their goals. All it takes is a few minutes. Perhaps your influence will be such that your students will want to take something positive from the example you have set. Maybe then we will be able to cut the roots of this long-growing negative trend so that a new positive trend can be allowed to blossom.
Disclosure of Potential Conflicts of Interest and none were reported.
JAMA December 4, 2013 Volume 310, Number 21
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/01/2015
jama.com
A PIECE OF MY MIND Artaza Gilani, BSc University College London, London, United Kingdom.
Corresponding Author: Artaza Gilani, BSc (artaza.gilani@ucl .ac.uk). Section Editor: Roxanne K. Young, Associate Senior Editor. jama.com
Unintended Consequences Every medical doctor reading this essay shares something in common: you were once a medical student. You entered medical school fresh-faced and wide-eyed, enthusiastic and eager. You spent days on a ward and nights inside a library. You felt a strange mixture of embarrassment, unease, and pride when a patient first mistook you for a doctor, and you dreaded ward rounds with the consultant (the UK equivalent of an attending physician) who, let’s just say, had developed a reputation for being firm with students. Eventually you began not to mind the demoralising remarks, or at least you minded less. You started to take them on the chin and were reminded by friends that it was all part of the parcel; it was character building. At the end of a long day you no longer seemed to mind as much as before because at least, after all, you were given some attention. At least your presence was acknowledged, and you left with something you did not have before, be it an extra bit of knowledge, be it the experience of seeing a clinical sign, or be it the realisation that you needed to hit the books. There remained something, however, that you struggled to get used to. In fact, while you let your first experience of it pass by, years later the same experience saddened you like never before. It is hard working in medicine. As an attending physician you face constant pressures from the government, the media, your department, patients, colleagues, family, and, of course, medical students. In a busy hospital environment when patients outnumber the beds available, when your clinic is running behind schedule, and when there are more medical students around than there are doctors, you feel that something has to give way. As the cortisol levels rise and your to-do list lengthens, stress plants its feet firmly on your shoulders. Under such circumstances, one of the first things to be “sacrificed” is the medical student. Consequently, as you sit down documenting your management plan in a patient’s notes and you notice a student approaching you out of the corner of your eye, you—metaphorically, but perhaps sometimes also literally—let out a sigh of frustration. He always begins with the same phrase: “I am sorry to bother you”; words that have become so heavy on you that it is almost as if they are enough to cause an ulcer. They are heavy because you know what is going to follow: from his point of view, a small request for help; from your point of view, another thing to add to your to-do list and another few moments that have been squeezed out of your day. Sometimes you smile and let him speak, but other times, unbeknownst to you as you have become engrossed in your countless other responsibilities, your abrupt response and body language are enough to hurt him so much so that next time he avoids you and decides to approach the doctor sitting beside you. The trouble is, from his point of view, not yours, that
the other doctor also has a lot to do, and he tells the student in no uncertain terms that he does not have time for him. It is this that you struggled to get used to as a medical student: being ignored. Your friends would tell you that this is “just the way it is,” seniors would comment that “we have all been through it,” but you found such tradition difficult to stomach. You spent hours on the ward, you were keen, you were polite, you were enthusiastic, and if people gave you a chance, they would have seen that you could have been of use to them, but time and time again, you came across so many clinicians who were uninterested in your learning needs. You could not help but notice that people would not even look at you as you passed by; there was no smile, no nod of acknowledgment, nothing. As you stood around the ward, sheepishly wondering who to ask how to send off the blood sample you had just taken, no one batted an eyelash. You would turn up every day despite your previous experiences and dart from one end of the emergency department to the other trying to figure out where your presence would be least ignored. On the bright side, the moments you spent wandering allowed you to reflect on what was going on around you and permitted you to open your eyes. You understood that busy and stressful circumstances sometimes forced such reactions, but it baffled you why these incidents occurred when there were less than a handful of patients in the department. It bemused you that this could happen in a teaching hospital. And so you would tell yourself that “I am not going to allow myself to become like this when I qualify,” but somewhere down the line, something changed. Whatever it was, maybe it made you forget how things used to be for yourself. You became desensitised to the very needs that you yourself once had. Without realising, you became the very person who had caused you so much frustration just a few years, or even months, previously. Fortunately, not everyone you came across was like this. As you stood despondently hovering around the doctors’ and nurses’ work area, you would hear the words “Are you OK?” directed toward you. Here he was: the doctor whom all the other students spoke so highly of. The doctor who, despite having just as many things, if not more, to do as everybody else, did not mind spending a few moments listening to you present the patient you were told to see. Instead of cutting your story short and handing you a list of differentials and a management plan, or even just deciding to go and see the patient without sharing any of the above, he would spend a few seconds with you. He would ask you what you thought was going on and what you would do if you were looking after the patient. He would not sigh in front of you when you JAMA December 4, 2013 Volume 310, Number 21
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/01/2015
2251
Opinion A Piece of My Mind
said you were not sure how to carry out a particular practical procedure. Rather than turn away from you and ask somebody else to do it, he would talk you through the process. He, and all the others like him, did this because they had the foresight to understand that this was in everyone’s best interests, even if it came at the expense of losing a few minutes of the day. Such doctors keep in mind that the students of today are the doctors of tomorrow. Those medical students who you try to avoid are the very ones who will be working for you—or rather, alongside you—on the ward in just a few months’ time. As students they should recognise that they have an individual responsibility to ensure that they are developing their clinical acumen, but the doctors of today should also try and find it in their hearts to remember that they have a collective responsibility to help students along their way. Hence, when a newly qualified doctor falls short of your expectations, before talking about “that junior” in his absence, keep in mind that the very thing you are unimpressed with was what he was going to ask for your help with when he was a student. As you sat writing your notes and you noticed him approaching, it was this very thing that he was unsure of, but you were too busy and did not want to know. Had you taken a few moments to share some of your knowledge and experience with him, maybe you would have been more satisfied with his performance today. With the pressures clinicians are under, sometimes they do indeed become immersed in a never-ending list of things to do. Nonetheless, there is a way of telling someone that you currently do not have time. Even still, it is not often that you cannot spare 15 seconds, but if you really, really cannot, then with the correct etiquette and by being tactful with your choice of words, even the eager medical student will not be disheartened when you turn him or her away. Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the
2252
We all learn from each other directly and indirectly. From your perspective, you may feel as if you have done little to help a student, but what you are forgetting is that everyone else has not even looked at him. Everyone else has tried to avoid meeting his gaze while you decided to smile at him as you crossed paths. Little did you know that this small gesture made his day. All you did was ask if he was OK when he was invisible to everyone else, and from his point of view, your concern made up for all the negative experiences he had earlier that day. You spent two minutes discussing differential diagnoses and a management plan with him, and because of you his diagnostic and decision-making skills have matured. From you he learned that even the smallest gesture with a sincere intention can have a significant impact on an individual. It is because of you that he feels inspired to give students a helping hand when he is in your position; it is because of you that he will try to cope with the stresses of the job in such a way that they are not unknowingly taken out on students, and it is to you, whether you realise it or not, that he is thankful. Yes, we may have all “been there” and “done that,” but we must ask ourselves if such a tradition and culture is enough to justify continuing this negative trend of ignoring students. Medical students should be clear in knowing that they must take responsibility for their learning. They should be prepared to try their best. Being spoonfed is not what most students expect, nor is it what they want. Most do, however, want to become good clinicians, and doctors should work in partnership with them to help them achieve their goals. All it takes is a few minutes. Perhaps your influence will be such that your students will want to take something positive from the example you have set. Maybe then we will be able to cut the roots of this long-growing negative trend so that a new positive trend can be allowed to blossom.
Disclosure of Potential Conflicts of Interest and none were reported.
JAMA December 4, 2013 Volume 310, Number 21
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/01/2015
jama.com
