ER, PIMPING and Medical Education

At Brown, we have a class called "Doctoring." It's how Brown has figured out how to teach us to be doctors (the more personal, less factual stuff we'll all need to know before we hit the real world--the world of Turk and JD on Scrubs aka intern year or residency--and beyond). The way they do it is they teach us through checklists. I had no idea before I started learning all this stuff that there's actually a secret system to the way doctors talk to their patients. Thinking back, I'm trying to figure out if I would be upset as a patient knowing that my doctor was trying to "warm me up" with small talk before getting to the meat of the interview. I guess even when you know that a doc's trying to do that, it still works and you still feel more at ease. So how does one become a doctor / get initiated into this secret society that is medicine?

Medicine, like all sports teams, has a certain rite of passage that one must go through before being accepted as a part of the "team." Learning the medical interview is the first step of initiation. The basic History and Physical (H&P) has been used by physicians for centuries. It's a systematic way of figuring out what's going on. It's a way to listen to the patient's side of the story (the subjective) and then test your hypothesis for what the patient might have with the physical. Every doctor learns the order of this interview along with all the abbreviations. CC, HPI, PMH, FH, SH, Nutrition / Sexual history (they don't have an abbreviation because oftentimes they're omitted because they're not as pertinent to the case), ROS, PE. In our first year, we learned how to take a history. We could do it in our sleep. Now, we're learning how to put it all together with the physical exam.

An integral part of the doctoring class is the 1st and 2nd year mentors. Us students go to a doctors office or hospital and shadow practicing physicians and see real patients. We put our memorized checklists to use and ask all the questions. The challenge this year, is to learn what questions to ask and when. More than that, it's to know what parts of the physical exam to perform based on the patient's presenting complaint. This year, we're supposed to put it all together--all the stuff we learned last year, the history and the physical exam. It's a daunting task, but we'll be on the wards in May, so I speak for myself when I say that I'm feelin' the pressure.

My mentor, an ER physician in Massachusetts, is helping me realize all the things I have yet to learn by constantly "pimping" me. Pimping, is something that will happen to us for the rest of our careers. It's how your superiors tell if you're smart, and how well you're understanding what's going on. I feel like it's also a way of them showing off how much they know and how little you know. The way it goes is they'll ask you questions, usually until you get one wrong. For me, it's making me realize how little I know even though we've taken so many courses, and how much I have yet to learn. It's a great way to learn, but again, it's putting the pressure on.

One thing I've had to get over is the very concept of a medical student or a resident. Medicine is something you learn over a long period of time. It takes time to store and be able to recall all that information. There's always going to be a first time for medical students and residents--whether that's performing a procedure or asking a question or giving bad news. Before, I thought about what I might do if someone in my family got sick. Would I let a medical student or a resident make decisions / do procedures for/on him/her? Now that I'm a part of the system, I've encountered so many kind and generous patients who have graciously let me poke around, listen to their hearts and lungs (at first in the wrong and then in the right places and positions), push on their bellies, shine lights into their eyes etc. As a patient myself, or a family member, I might get annoyed by a medical student doing all sorts of things to me / my loved on.

A nice elderly couple last week in the ER made me think about my own biases. The woman was in for stomach pain, and the husband was there by her side. I asked her if I could take her history, and then my mentor came in and watched me perform a belly exam (after he had taught me last week how to do it on another patient) and then present my findings to him. The woman was so kind. She let me proceed and the whole interview and PE took longer than it would have had my mentor done it all. Afterwards, the couple asked me where I was in school, how I was liking it, and if I knew what kind of doctor I wanted to be. They told me about their daughter who was in her 4th year at another medical school (I forgot what kind of doc she wants to be). We had a brief conversation and as I was leaving I thanked the woman for letting me take her history and examine her. She replied, "You've all got to learn on someone. My daughter learned from all sorts of patients, and I'm happy to contribute to your medical education as a way of giving back to the medical community."

The encounter made me think about my own biases and practices. I'm going to the doctor tomorrow for a regular check up, and like the woman from last week, I'd be happy to help contribute to someone's education. If there's a medical student / resident there, I'll be happy to let them interview me / do a physical. We all have to learn somehow.

-Ed Cheung