In The Arena: Month of Wonders

baehrenBy David F.Baehren, M.D. 

Each month in my ED, we greet a group of fresh, smiling faces from the third-year medical school class.

Especially in the first 3 months of the academic year, these neophytes have a bit of the deer-in-the-headlights look about them the first few days of their rotation. They are visitors to a strange land (on a distant planet), and they are uncertain about what to do, how to do it, or even where to find the bathroom.

Throw in an unfamiliar computer program, and it makes for an uncomfortable transition.

They all eventually catch on and, for them, it becomes a month of wonders. They get first crack at patients who will eventually tell the story of their abdominal pain or ankle fracture multiple times.

By the time these patients make it to their inpatient bed, they want to charge admission for anyone else to hear their story. But for these medical students, they have an eager patient who will tell them everything they want to know.

And that, I suppose, is one of the biggest lessons.

These students must learn to separate the wheat from the chaff. They learn that if you want to see more than one patient per hour, you must get to the point quickly while allowing the patient to tell the pertinent aspects of the story.

Essentially, they learn that if a patient falls over while trying to put on their shoe, the shoe size is unimportant. This is a concept that many of our internal medicine colleagues seem to have missed.

When these students emerge from the room, they then must cull from 2 years of book learning a reasonable differential. It's interesting to watch the wheels spin while they try to put it all together.

"Schistosomiasis can be a reasonable thought in someone with abdominal pain and a rash--but really is quite unlikely if the patient has traveled no further than Detroit."

They nod at you and quickly learn that what you need to know to pass the boards and what you need to know to practice medicine in Ohio are not the same.

Next come the tests. If the student has rotated on a medicine or neurology service already, they will rattle off a bunch of expensive tests. After we weed out the serum plutonium level and the like, we talk about the utility of what we are going to order.

I love to talk about the lack of usefulness of the CBC. The student will get a very serious look on her face and try to take in the meaning of this. What do you mean a high white count does not prove infection and a low white count does not disprove it? It's like telling a kid there is no Santa. Very sad.

Treatment is a tough one. All those medications and interactions and adverse effects are daunting, even for a seasoned clinician. For these students, these meds are all stars in a wide galaxy.

After a month in the ED, they start to get a feel for what the common antibiotics, antiemetics, and analgesics can do for you and to you. They also learn that treatment regimens are a quickly moving target and that you never stop learning.

The transformation of these students is remarkable. They enter as wary medical travelers and emerge as more confident and competent clinicians.

The ED experience has a way of taking years of classroom experience and making sense of it. Students learn to think about patients in real time and formulate a plan for diagnosis and treatment.

We allow them to step out of the herd of students we see on surgery or neurology rounds and think as an individual. This is the way it will be in their own practice; so, the sooner they start to think this way, the better doctors they will be.

And the great thing about the ED is that when the student strays from the herd, we can keep an eye out for them so they don't get picked off by a lion or a cheetah.

Every student should have the opportunity to do a rotation in emergency medicine. I feel that their education would be incomplete without it.

Most academic departments are not able to have every student from their medical school spend time with them. This is why it is important for the community hospitals in the region of a medical school to offer rotations in emergency medicine.

If your hospital does not do this, consider talking to your administration about bringing in students.

There is benefit to all involved, especially the future patients of the students.

Dr. Baehren lives in Ottawa Hills, Ohio. He practices emergency medicine and is an assistant professor at the University of Toledo (Ohio) Medical Center.

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