Calling all Penguins

Last night was the first time in a long time that I had a smile on my face that was not due to a great glass of wine. As I drove home from school with my friend Adam, I felt real happiness flood my body, and a lightness that I have not experienced in awhile. So what happened yesterday that would bring about such a wonderful sensation in my body?
Yesterday was the first exam of the year in our clinical class PCM, also known as Principles of Clinical Medicine. You may remember me writing about this class last year. It's the one afternoon every week that we talk about the non-scientific aspects of becoming physicians. You know, the touchy feely stuff that I so love. This term was full of learning about the psychosocial aspects of treating patients; we had panels of patients that came in to talk to us about living with chronic illness, or eating disorders, or living with disabilities, and what we as future physicians need to know about treating these different patient populations. We also learned more specifically about how to evaluate patients with circulation issues - heart, lung, and kidney diseases. I have a better idea of how to read a chest x-ray, and I know far too much about how to read an EKG (that's the electrical study done on your heart). Will I remember all this for clinical rotations next year? Probably not, but I'm sure that I can call back those penguins when I need to.
Penguins? We had this great lecturer who used the metaphor of our brains being like a giant iceberg, and each new piece of information that we learn in medical school is like a penguin on the iceberg. As we go through school, the iceberg gets way too crowded and we have to kick some penguins off the iceberg. Hopefully though they don't swim too far away, or as one of my classmates voiced in lecture, they don't get eaten by the nearby Orca whale.
So my relief yesterday came not only from the fact that I was able to call back some penguins to my iceberg during the exam.....but also because I realized that my iceberg is growing, or at least is able to hold more and more penguins as I continue through medical school. They may not be too comfortable on my iceberg, getting stacked up on top of one another, but they are there, and with some effort of recall I can remember their names.
This is apparent to me today, not after taking the 70 question written exam yesterday that included information from last year's PCM class, (penguins that are definitely OFF the iceberg), but more apparent due to the apparent ease of the testing with patient/actors. Yesterday I had two different patients, one a woman coming in for a checkup after an episode of fainting while in the grocery store, and another a blind patient wanting to establish care with me as her primary care physician.
Unlike the stress experienced in the written exam, there is no nervousness anymore with these patients/actors. I am not worried about asking all the right questions, nor about the physician in the room checking off all these little boxes when I do ask all the "right" questions. There is a flow that occurs that I can't say happens due to any conscious effort on my part. Yes, I do remember to ask pertinent medical history questions, and yes I do forget some of them, and yet, I don't really care that much about my "grade". What I do care about is how I treat the patient and how I establish rapport with the patient, as I know that the knowledge will come with more time and experience.
I received the greatest compliment yesterday from the blind woman (who wasn't acting - she was really blind!). When she gave me my feedback at the end of the exam, she told me that she really LIKED me, and further, that she felt that I really liked her. I realized she was right. I did like her, and I really wanted to get to know her and her health habits, so that I could take good care of her. And I wasn't pretending! I really wished I could have been her doctor! Moments like that make all the stress of medical school, taking exams, and the constant pressure to study and learn, just melt right away. Aha....that's why I am in medical school. Not to stuff my iceberg with all these penguins, but to reach out to patients and invite them onto my iceberg.

Right on the Money

These aren't my words, but they so succinctly express what I am currently experiencing, and it is stated so eloquently, that I had to pass this article on. It's written by a physician, Dr. Pauline Chen, and it's entitled, Medical Student Burnout and the Challenge to Patient Care:

"Not too long ago, I read a paper titled 'Burnout and Suicidal Ideation Among U.S. Medical Students' in The Annals of Internal Medicine. It brought back a flood of memories.
Medical school was not easy for me. I knew that I wanted to become a doctor to help people, but I had given little thought to the process. I was poorly prepared for many things: the pressure to excel in ways that seemed so far from caring for people; rapidly mounting debts I signed off on every semester; a roller coaster existence from chronic lack of sleep; hazing from the more experienced students and residents; and the realities of patient suffering despite my best efforts.

Even surgical residency, despite the relentlessly long hours, seemed so much closer to what I wanted to do. Some of my professors tried to 'humanize' the process. They invited us to dinner in their homes, supported our extracurricular efforts to set up health screening clinics in low-income neighborhoods, and tried to make our basic science courses more relevant to working with patients. But sitting where I am now, as someone who teaches medical students and who loves helping others as a doctor, I can understand the challenge they faced. Given the fire hose of information medical students must learn in just four years, how does one ever gently take a sip?
Despite my teachers’ efforts, I was about as miserable in medical school as I had ever been. I felt alone. Neither I nor my classmates could admit to failure, and the last thing I wanted to do was to let anyone but my closest friends know just how unhappy I was. Success in medical school was the first step to a future of helping others, and I was not about to jeopardize that.

Last week I had dinner with two former classmates from that time. We had not seen each other in over a decade, and after catching up on personal news and reminiscing about gross anatomy lab and our first nights on call, one of them said quietly, 'I hated med school. I wanted to quit.' The elephant in our collective memories had broken free. With that elephant now running loose, and the three of us more comfortable with our own professional accomplishments, the conversation grew more honest. 'If you look over my entire lifetime,' my other friend said, 'those four years were the lowest point in terms of self esteem.' He held his hand out in the air, plotting an imaginary line that dropped precipitously to his knees. It took nearly 20 years for the three of us to learn that we had each been miserable as medical students. It has taken even longer for researchers to discover the extent to which such feelings exist among American medical students.

In 2006, Dr. Liselotte N. Dyrbye and her colleagues at the Mayo Clinic found that nearly half of the 545 medical students they surveyed suffered from burnout, which they defined as professional distress in three domains: emotional exhaustion, depersonalization and low sense of personal accomplishment. Moreover, the researchers found that each successive year of schooling increased the chances students would experience burnout, despite the fact that they had entered medical school with mental health profiles similar to those of their peers who chose other career paths. More recently, in the paper on burnout that had first caught my eye, Dr. Dyrbye and her colleagues widened the scope of their research, analyzing survey responses from 2,248 medical students at seven medical schools across the country. Again, nearly half of the students surveyed met the criteria for burnout. But the investigators discovered an even more ominous finding: 11 percent of all the students surveyed also reported having suicidal thoughts in the past year.

Dr. Dyrbye notes that we are just starting to learn about the high levels of distress in medical students. 'It’s incredibly disconcerting,' she said. 'What are the causes? And what can we do as educators to facilitate their well-being? We need a better understanding of the causes of stress to design interventions that will help improve student wellness. Students, just like doctors, need to take care of themselves in order to take care of their patients.'
Medical schools have more recently recognized the importance of this issue. For example, the Liaison Committee on Medical Education, the accrediting authority for medical schools in the United States, now mandates that all schools have a program for student wellness in place that includes 'an effective system of personal counseling for its students.' But beyond the personal implications, what are the ramifications of medical student burnout for patients?

In a third study, Dr. Dyrbye found that when tested for empathy, medical students at baseline generally scored higher than their nonmedical peers. But, as medical students experienced more burnout, there was a corresponding drop in the level of empathy toward patients.
'What do they really need to know before graduating from medical school, and how could they most efficiently learn?' Dr. Drybye asked, reflecting on one of the central challenges of medical education. 'All the information we want to share with them is not necessarily what they really need to learn.'

By the time my dinner with my former classmates last week had ended, we had made plans to stay in touch and to do something I had never been sure I would ever do: return to my medical school in two years’ time to celebrate our 20th reunion. Over the course of our dinner conversation I felt strangely connected and nostalgic about medical school; I was deeply moved by what my two classmates had chosen to do with their education. One is a well-loved community obstetrician/gynecologist; the other is a psychiatrist devoted to teaching, working in a county medical clinic and caring for severely traumatized Hmong refugees. And both love their work as doctors. As I listened to them talk about their work, I was reminded of one other thing Dr. Dyrbye had told me. 'We need to change things,' she had said, 'because maybe the students who are most vulnerable are the ones who are most empathic.'"