Patients: just a tool for medical learning?

Comments: 4

Katie Groom is studying medicine at a London university. She is currently coming to the end of her first clinical year, based in a London hospital. Here she describes the tension she feels between respecting patients as people to be cared for and seeing them as 'subjects' to learn from as part of her clinical training. This is one in a series of stories that the Point of Care programme is presenting on the issues that staff face in trying to ensure a positive patient experience. The views given in this article are those of the author and do not necessarily represent the views of The King's Fund.

It was just another normal bedside teaching session with one of the notoriously scary professors on the acute admissions unit – or so it seemed. It turned out to be an experience that neither the patient nor I would ever forget.

The patient was in her 30s and worked in a clinical position in a London hospital. Her husband, a 'non-medic', was accompanying her. The patient did not have a firm diagnosis as  yet; more tests were being done. We started by asking the patient what brought her into hospital?

As she was telling us her symptoms I became acutely aware, as did the other students, that she had what looked like a classic presentation of the first signs of multiple sclerosis. I felt my temperature rise as I realised the patient, a practising clinician, was thinking exactly the same as us. The session became an awkward game of dodging what we all knew.

The consultant stepped in, asking another student to give him the diagnosis. At last multiple sclerosis was mentioned. I vividly remember the blood draining from the patient's face. My heart raced. I didn't think that such events really happened. I was receiving the information that was in my head as if I were the patient.

It was at this point, in my first clinical year, that I began to question our role in relation to the patients. Up until now we had learnt about physiology and pathology. Now we actually became part of real people's lives.

Bearing in mind that this patient was in acute admissions and hadn't had time to prepare for her diagnosis, I felt uncomfortable being part of what was simultaneously a consultation and a teaching session. The primary focus of the session was our learning, not her well being. Of course medical students need to 'play doctor' and experience giving diagnoses first hand as part of the training. But it seemed to me to go a bit too far at the expense of this patient.

Now that I have just started my surgical rotation, I am even more aware of these problems. Our learning is our top priority, not the patient.

Surely the patient's well being should be at the top of a doctor's priorities, with the teaching of their students taking second place? That is doubtless what patients would prefer. In our introduction to the module, I asked the doctor whether we should ask patients whether they'd be happy for us to take part in their operations. The doctor replied: 'they are asleep', as if their opinions and consent did not matter.

Our days as medical students have become focused around which patient has the best clinical signs, who has the most severe pathology, and what’s the most exciting surgery we can scrub in on (exciting being the most life-threatening for the patient). Our time is consumed with meeting deadlines, completing an endless number of assessments and preparing for exams; we rarely sit back and reflect on patients as individuals.

Should we be thinking more about whether a patient who has been recently diagnosed with cancer would really want an army of medical students asking endless questions? I know I certainly wouldn't want to talk to a whole host of people after receiving a life-changing diagnosis myself. What stops us from putting ourselves in our patients' position? Surely that's what empathy is, something we all defined in our entrance interviews for medical school. How is it that we have become so consumed with our own learning that we forget those initial reasons why we went into medicine?

When I defined empathy at my interview I wasn't just ticking a box, it was something I genuinely felt; medicine was a career where I would be able to practise it every day. How have I forgotten this? Looking back at the personal statement I wrote during my A-levels, I remember my enthusiasm and the experiences I had already had with patients. Back then, I worked as a carer in a residential home, where I focused completely on the residents and their needs. I took part in GP visits, when all I did was talk to patients and listen.

This all seems so far away from where I am now. As exam season is well under way, putting our patients first really does take a back seat. We are furiously trying to examine patients with diseases we haven’t seen before – anything that's going to help get us a better mark in our exams. Taking time to think about patient care first surely just wastes time?

All these questions have been buzzing around my head, alongside all the other information I'm desperately trying to cling onto. Maybe it is time to realise that in less than a couple of years we actually will be doctors. These patients we overlooked and pestered while abusing their time will now be  our main priority. Of course we need to put our own academic work first – after all, good patient-centred care relies on competent doctors. But it also depends on doctors who put their patient first.

Perhaps, as medical students, we need to strike a balance. We need to take the time to remember our experiences, reflect on our patients and how we make the next patient feel that bit more comfortable. Maybe we should even go back to those experiences we had before medical school, those that prompted us to take the path that led us to where we are today. Taking a step back from our checklists and deadlines would enable us to listen to our patients and get to know them. Maybe it would make the whole process much more efficient and enjoyable for patients and clinicians alike.

Comments

#889 Esther Goosey
Independent social worker/ locum deputy ream manager

It is extremely refreshing to read these comments from a doctor of the future. My experience as a social worker has confirmed that the majority of doctors based within a hospital have not left behind this focus on symptoms, diagnosis and treatment once they are 'let loose' on the general population. Patients are not seen as people but a collection of maladies that need to be cured. As can be seen in the emphasis on whether the patient is medically fit when considering discharge, despite indications (social, environmental or emotional) to the contrary.
I have seen a significant deterioration in patient care with my father's admission to hospital. He's in his early 80's with a number of health issues, one of which was C. Diff ( he contracted this on his last admission to hospital). The C. Diff has been focussed on to the exclusion of all other serious conditions such as heart failure, thrombosis and epilepsy. My attempts to speak to the consultant has not been successful and almost a week later he is still thinking about whether he "can" speak to me. The SHOs and registrars on the ward do not appear to have a clear picture of my father's medical history as no-one reads the medical notes and handover appears to be like 'chinese whispers' where vital information is lost every time it is passed onto yet another health professional. My questions in relation to how my father's care is being managed and who is taking a holistic view of his treatment is regarded as an inconvenience. For example no-one seems to be able to explain why a decision was made that my father should have 'nil by mouth', which included his medication to control his epliepsy being withdrawn, resulting in 5 seizures in 7 hours; and my father being unable to talk, move or recognise his family. All attempts to get an explanation result in vague references to establishing some yet undefined health issue. The nurses although they try their best do not seem to know what is going on; and when given specific tasks such as monitoring the output of fluids do not seem to notice when my father's arm swells up like a balloon. This system of health professionals being specialists although beneficial for staff does not help patients. My father's epilepsy could not be managed on the isolation ward as it was not their role therefore he had to be transferred to the medical assessment unit. They kept him for a few hours then he was transferred back. When I spoke to a doctor about the lack of awareness of his heart condition, I was told that she was only there to address his seizures.
I hope Katie Groom is able to hold onto her feelings of discomfort over the coming years as this may then enable her to be the kind of doctor that we all want, one who actually sees people first and a collection of symptoms second.

#890 Emma
Medical Student
Manchester Medical School

I am also at the end of my first clinical year and our experiences are similar yet very different.
I have struggled from the beginning to get caught up in that frenzy you describe of looking for the best clinical signs, the most severe pathology etc. For me patients are always and foremost people, and vulnerable ones at that. I'll chat to patients for ages when I go and take histories from them, forgetting structure and my search for a diagnosis. I then justify it to myself that that is what they needed: they were lonely and wanted somebody to talk to... That way though my history taking was horrendous by the time I got to my exams and I only managed to pass decently because I had a friend who was willing to spend endless hours letting me take histories from him. The same applies for venepuncture, cannulation and all the other skills really. I am painfully aware that there is not much I can give to patients in exchange for their time and sometimes for causing them pain (eg. ABGs), even when the patient is understanding and very positive about letting me learn from them. As you say, we need to strike a balance, in both directions. In a way, losing a bit of empathy can be a defence mechanism...

I also wanted to add that, as students, we don't always have to do what consultants tell us, if we think it may cause the patient harm. One of our consultants took us to a patient who had just been diagnosed with cancer and was adamant that we should take a history from her. She was evidently upset and her son had just arrived. She said she wasn't ready to talk to anyone yet, but the consultant insisted. My group simply walked away and refused to take a history from a patient who so evidently did not want us to. The consultant was not impressed, but I think it was the right thing to do.

#891 Shravan
Anaesthetist

Hi Katie
Your account just reminded me what every doctor goes through before what they become in future 'a caring professional'. Emotions are hard to deal with especially when we are in the midst of uncomfortable environment, especially when we are discussing terminal illness or end-of-life decisions, etc. But I feel this art of controlling your emotions and not deviating from your goal of learning keeps getting better as you mature. This experience is difficult to replicate and you are not being completely selfish by learning through patients as you will be giving back to them much more what they need in future. A good caring doctor.

#892 Sagefemme
student midwife

I thought this account was interesting, and as student midwives we do, at times, also face this issue. However, I am shocked that 'reflective practice' is not built in to your education as it is into ours: it is how we make sense of what we've learned. Part of reflective practice is researching the issue which concerns us. I am sure a great deal of research has been done into this area, and perhaps you would benefit from reading around the subject. One area which might interest you is Antonovsky's theory of salutogenesis, developed in the 1970's. He was a doctor who proposes an alternative to the risk discourse which predominates in medicine. I hope you don't lose the empathy you still have during the rest of your training: what value is this training without it? Medical training is just a tool, after all: judgement is still key. What kind of medical professionals would we want?

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