The academic realm
The social realm
The personal realm
The technological realm
Live in the now
Few realize how free one becomes by forgetting about The Next Step, just for a little while."
by Sneha Kannan
Sneha is a 2nd year medical student at the University of Pennsylvania. She currently writes for Making the Rounds, a blog from the Perelman School of Medicine at the University of Pennsylvania.
Success is a funny thing to us medical students. We’re trained to always think about The Next Step and how we get there. One can hear us routinely speak about 2019 as if it’s tomorrow. Until now, in our second year, at the end of our classes and right before we start rotations, “success” in achieving those goals was clear to me. I knew what I had to do to get where I wanted to go. There was a certain cut-off for my GPA to get into my dream college and for my MCAT to get into my dream medical school. I had to show leadership by being the President of some club and show initiative by shadowing doctors and volunteering in the community. This isn’t to trivialize my or my colleagues’ résumés, but simply to make the point that determinants of success were clear until now. The idealist could argue that this view is cynical. After all, if you just do the things you want in life, success should come. To an extent, that’s true in medicine. But there are certain things that everyone has to do to move on to the next step. Now, it’s just harder to know what those are. We don’t really have a GPA anymore. And our clinical grades do matter, but it’s unclear how much. Subjective recommendations become as important as objective numbers. But much more immediate than that, how would I gauge if I know medicine? Is it a good Step 1 Board score? Is it good clinical grades? Stellar preclinical grades? Meaningful interactions with patients? The determinants of success have become murky. But personally I went through a larger change. In the past few months, towards the end of my first year in medical school, I had a fundamental shift in what I inherently call success.
The academic realm
In college, I focused on understanding the principles and concepts taught in class. Our exams were so hard that I was proud of myself if I did well because I knew I really got it. Now, tests cover a fraction of the material we learn in a given month. And the information we learn in our preclinical curriculum doesn’t translate directly to the care of patients. The number of times we hear, “the boards love this, but I’ve yet to see this disease in my career,” is comical. So it behooves me to stop caring about my absolute score on exams and start developing an internal barometer for my understanding of basic principles in medicine. I’ve started to assess my knowledge less on retention of facts and more on an ability to systematically apply a method of analyzing medical problems. (This likely comes from the engineer in me). We and most other medical schools have a class called Differential Diagnosis, where in response to a patient’s history and physical exam we have to come up with a list of diagnoses that are most likely and prove our recommendations (perhaps the closest to ‘House, M.D.’ we ever get). This class phenomenally captures the method of thinking I mentioned previously. Finding facts is a job for UpToDate and Google, but our job is to know how to look for the right things. Going methodically by organ system and having a basic global understanding of physiology is a good start – the rest can be found on the Internet. Unsurprisingly, it’s been one of my favorite classes to date.
The social realm
College was the first time I really had to juggle my academic life, my friends, and personal responsibilities like sleep. More meaningfully, it marked the dawn of my frankly alarming dependence on Google Calendar. There was a certain self-importance that came with seeing how busy I could be and how many demands I had on my time. Especially at MIT, there was a social currency in the number of back-to-back meetings or colors on an iCal. Success was defined as the ability to fit everything in my life. But after 18 months in medical school, the idea of being busy is less a point of pride and more a necessity. What has been far harder for me is to ensure that whoever is on my calendar gets my full attention for the time that I have them. My idols at Penn have been champions at this. I’m constantly amazed when the Chief <insert title here> Officer takes a few minutes out of their day to meet with me (I email faculty asking for life advice far more often than I should probably admit), and they spend those few minutes, however small in number, completely focused on me and what I have to say. If they can do it, there’s no earthly reason I can’t do the same. When I go out with friends, I try hard to stay off my phone. If someone needs some emotional or moral support, I make sure I’m there and I’m there for as long as they need. It’s a particularly bad feeling to be vulnerable and simultaneously be conscious of a clock. Incidentally, I’ve found that anyone I’ve interacted with understands my schedule, and they’re already inherently conscious of the demands on my time; I’m almost never late. I hope to translate these habits directly to patient care in my career.
The personal realm
We’ve had classes in medical school dedicated to teaching us to be kind and compassionate towards our patients. Accordingly, my classmates are the most compassionate group of people I’ve met. I want to go a step further – success as a doctor involves compassion towards patients. Success as a person, though, means being compassionate towards myself and towards my friends and family. For the former, I’ve attempted a slew of personal improvement goals over the past several months. From taking care to eat well and exercise to giving myself the occasional mental cheat day where I do nothing but read a good book or watch some TV, I have had to slowly reprioritize health and wellness over academic achievement-- no easy task for me! For the latter—compassion towards my friends—these past few months have been a sobering lesson in how to be a good friend and how not to be a bad one. The experiences are far too many, but the lesson I’ve learned is this: knowledge will come (and go), but the impact we have on those around us lasts far longer than a solitary bad grade or a negative evaluation from an attending physician. By getting into medical school, especially a strong academic one like Penn, my classmates and I have shown that we are dedicated to the idea of achievement. In my observations, I’ve seen that school always gets prioritized but interpersonal considerations tend to fall by the wayside. For example, when exams come around, my classmates and I understandably become a little more stressed. But more often than not the anxiety levels become so high that we stop eating well and sleeping and being cognizant of how our stress is being displaced onto the people around us. We all get our studying done, but there isn’t as much of a premium placed on being considerate people during exam week. This wouldn’t be an issue if we went into exam mode once a semester like undergrads do, but in our preclinical years we had exams once a month and as we move into the hospitals, our stress level is constant, only to increase as interns, residents, and fellows. Forcing myself to spend a tiny bit of energy not taking my life out on the people around me has gone such a long way, even in the 2-3 months I’ve been trying.
The technological realm
And as a last and somewhat fun personal goal, I’m trying to be mobile-technology backwards. Today’s world of apps and large screens and The Next Big Thing is Here (credit to Samsung) makes it remarkably hard to disconnect. Technology comes with huge perks, but I was recently on a commuter train to New York and 80% of people were staring at their phones. I was shopping yesterday and the minute the line got longer, one by one people started pulling out their mobiles. I noticed one day that my environment resembles this far more than I’m comfortable. My personal attention span has dropped so low that even if I’m waiting for someone for five minutes, I have to start browsing (something that’s made listening to lectures hard). So I’ve made a conscious effort to put my phone down and away. I’m the awkward person now that stares straight in an elevator when everyone else is on their phone. I walk looking up when I’m on the street. This particular goal has involved eliminating mindless browsing. As a fun exercise, I challenge you to count the number of times a day when you’re staring at a screen and you unconsciously type “www.facebook.com” or a time-wasting site of your choice. To be clear, this isn’t deciding to be unreachable, just more mindful of what I use technology for. Doing so would allow me to put a premium on human interactions over digital ones. Furthermore, it will hopefully allow my dependence on technology to stop negatively affecting those around me, whether it’s a patient who’s feeling slighted because I’m typing away notes on a computer without looking at them or whether it’s a friend who’s trying to speak to me while I’m busy texting someone else.
Live in the now
As an undergrad I always had medical school in the back of mind. Now I could have residency in the back of my mind all the time-- it’s easy to miss the present in worrying about the future. I’m no longer waiting to start my career – it’s begun. The perspectives and habits I develop now will stay with me throughout my career. All of my above measures of success have one theme in mind – live in the now. Cliché as it is, the past 18 months have been one long exercise in enjoying the ride instead of fretting about the destination. Better to change how I think through medical issues rather than worrying about how my grades seem on a transcript. Better to be engaged in a given interaction than worry about the next thing on my calendar. I carry around a fortune in my wallet: “Hardly anyone knows what is to be gained by ignoring the future.” Note that there are two meanings. As medical students, we tend to live by the one that says ignoring the future is terrible. As for me, I try to live the interpretation less traveled: few realize how free one becomes by forgetting about The Next Step, just for a little while.
Few realize how free one becomes by forgetting about The Next Step, just for a little while."
by Lauren Miller
Hi! My name is Lauren and I am a second year medical student at the University of Pennsylvania. I’m involved with Elizabeth Blackwell Society (EBS), which is the most inspiring name for a group because Elizabeth Blackwell was a champ (the first woman to receive a medical degree in 1849, driven by her desire to give females a better reputation). Our main goal this year for EBS has been to help empower and connect women in medicine. Through this club, I have realized how important it is for us – women AND men – to support women in their endeavors. Women in medicine make up half of the workforce, so equal pay, equal promotion opportunities, and equal social rights are of benefit to everyone. Discussions with medical faculty have highlighted that many women in medicine care deeply about this issue-- even if they are not vocal about it.
Remember when I said one of our main goals for EBS was to connect women in medicine? I think that in some ways, we didn’t fully meet this goal. We did a great job of connecting female medical students with female physicians. But looking back, I realized that we made no attempt to connect women across all of healthcare, which made me wonder if this is actually a much larger problem. So I met up with a friend of mine, Kate, who is currently a nurse working in an ICU and also studying to become a nurse practitioner. We chatted about the relationship between nurses and doctors that Kate has experienced, as well as the differences in respect granted to female and male physicians.
We started the conversation by discussing what relationship Kate holds with female physicians and if it differs at all with her relationship with male physicians. Kate immediately responded that it totally varies with the physician. There are, in her mind, two distinct types of relationships that she has with physicians. “The first relationship is with those physicians who are incredibly passionate about patient care and education, including the education of nurses. Some nurses won’t admit this, but a large proportion of the time they don’t know why they are doing the things they are doing – they are just doing it. And that is a really frustrating thing! Doing something blindly because someone else told you to do it makes it really hard to grow, to learn, or to provide the best care. So when physicians take the time to explain why they are ordering this test or why the nurse needs to check a vital sign on the patient every twenty minutes is incredibly helpful.”
“These types of physicians are also the type that regularly seek feedback. They will ask the nurses whether the action performed on the patient made any impact, or if it was comfortable for the patient. Nurses have practical, real time feedback about the basic function of the patient. And these moments of feedback and different perspectives lead to huge opportunities for growth from all sides. As a result, these physicians’ opinions are highly valued because they actually care about the patient, so when they ask for something I will do it immediately. I never worry that the patient’s care is being compromised in any way with these physicians. And this definitely isn’t a gender matter, but a personality difference.”
...these moments of feedback and different perspectives lead to huge opportunities for growth from all sides."
I then asked her about the second type of relationship (the physicians not quite as concerned with patient care). “The second type is with those who basically don’t do any of those things. They are competent, but they don’t have that same passion of caring for their patients. My relationship with these physicians is challenging. I end up calling him or her way more over any complication the patient may have because I worry. That same level of reassurance and trust is not there. And if the patient gets hurt, we all lose. So this is where the nagging-nurse-calling-all-the-time idea arises, which leads to a tense cycle.”
I wondered if this mentality resonated across her team, or if she was the exception. While there is always a spread of personalities and approaches, she said that generally, those physicians that care the most get the greatest respect and are easiest to work with. She acknowledges that some nurses get along better with male physicians if there is any sort of physical attraction, but sexual tension between doctors and nurses is really over-hyped in the media. She mentions that rather, the bigger problem that arises too often is the inability to set egos aside. “There are too many physicians and nurses who cannot do this and assume that he or she knows best at all times. However, I have learned that (patiently) taking the time to explain my perspective has helped me more than anything. Because ultimately, these people are still on your team and working with them is actually your only choice.”
On the topic of physical appearance and respect as a physician….
“It’s interesting, I think it is pretty well known that the more attractive the male physician is, the more he is liked on a unit (but I should preface this by saying that this comes AFTER it is determined that he is a competent, compassionate guy. Refer to types of physicians from above. If you are attractive but incompetent you get the “pretty boy” label, which is equally undesirable). However, I think it actually hurts the female physician if she is particularly attractive. I feel like they come in against the stereotypes of ‘you are pretty, you are a physician, you must not understand how the real world works. Your father is probably a physician too and he paid for your medical school.’ I know this seems harsh but this is definitely a thing that happens on my unit. The attractive female physicians render very little respect from their male physicians or from the nurses. They also get some unfair rumors spread about them – if you page one of these physicians and she doesn’t call back right away, multiple people on multiple occasions have responded to this by saying that she is probably hooking up with “____________” in the call room. But this would never be said about the attractive male physicians. The worst thing is there are about 5 female physicians that work on our unit that undergo these accusations– and frankly, all five of them are incredible physicians. I can’t speak for other units or other institutions, and it is possible that my unit is still backwards – but it definitely happens.”
On the topic of medical and nursing education…
“I think it would be really interesting to incorporate more joint medical and nursing education. I know how busy you guys are in med school, but my nursing school did a ton of team-based learning with other health care students. We did mock codes and simulations with PT students, OT students, PA students, respiratory technicians… but never with any med students, which is pretty unpractical. I personally loved these mock trials as they helped you figure out how you would operate in an intense situation. The best part is the ‘debrief’ that happens at the end. Everyone has to provide feedback and we brainstorm on how to optimize the results of scenario. Lots of unknown biases are always revealed and I think this would be so beneficial for nursing and med students to do together.”
Final last words…
“We [nurses] are here to help you. We are here to carry out your orders and to be your eyes and ears when you can’t be. To communicate and to show that we can trust each other really goes a long way, and to just take that extra minute at the morning of rounds, just ONE MINUTE to explain to the nurses what the plan of care is for the day – you have no idea how much that helps us. And the patient can see this too – the patient always senses how well (or even if) the nurse and physician is communicating. Also, spend some time at the nurse’s station. It’s not hard to ask a nurse how their shift is going, what they are doing that evening, or just if they need anything from you. Last thing, remember: people don’t care how much you know until they know how much you care.”
I have always known that the dynamics of the Doctor-Nurse relationship has been dissatisfying for many. While I can’t say whether or not other nurses would completely resonate with Kate’s perspective, I think all would agree that striving for transparent communication and doing what is best for the patient is the most crucial objective. Looking forward (to the beginning of my clerkship year in January), I have tweaked my approach to the clinics since speaking with Kate. In this next year, one of my goals is to learn how to think from a physician’s perspective. However, Kate reminded me that I will never be able to achieve this goal alone; thinking like a doctor requires me to think like a good team player.