Recently, a brilliant young premedical student with whom I’ve done Covid-19 research joined me on a shift in one of the emergency departments where I work. Despite the fact that we’ve logged many hours on phone and Zoom calls—resulting in our co-authoring a paper in a major medical journal—we’d never actually met in person. Ah, these pandemic times, I tell you.
This student had been trying to do some shadowing in my ER for a long time, but because of Covid, our practice of allowing pre-med students on site had been on hiatus. Finally, the ban had been lifted, and the timing worked out.
As much as I really like this young man—he’s quite brilliant—I must admit I was not exactly looking forward to having him join me. I probably would have preferred grabbing lunch with him as a way to get to know him better. It pains me to write this because I vividly remember trying to get similar opportunities to do some clinical shadowing when I was a pre-med and desperately wanting to make a good impression.
Very early in my career, I enjoyed having the occasional pre-med (or early medical student) come along for a shift. But by the time Covid hit I had already grown tired of it—although one college student who had shadowed me for a while and for whom I had written a letter of recommendation got accepted to medical school recently; this made me quite happy. The main reason I’d become averse to having a shadowing student is that the dynamic can be just a little…cumbersome. You might think having a one-person mini entourage following you around would be fun—and it is, kind of.
The problem is that being an ER doctor is a bit like being a basketball player. You have to be able to move around the zone freely, and you don’t always have time to stop and explain what you’re doing and why. Having a buddy attached to your hip asking lots of questions, even good ones, can cramp one’s style. This is not to say that I no longer like teaching. In fact, I often oversee emergency medicine and internal medicine resident physicians who are in the throes of their most formative years of training. I also teach Harvard medical students during some shifts; these are often my favorite shifts.
The way it works with residents and students is that they go to see patients on their own (that is, those who are medically stable; patients with immediately life- or organ-threatening conditions get seen by all of us at once right away). After they’ve met and examined a patient, they gather their thoughts and come to me and report them. The goal is that by the end of their presentation I should have a very good idea of what’s going on with the patient and what tests and treatments they might need, depending on how things play out. When I then meet the patient, I already know the punchline, and I am there to verify that everything is as stated and that nothing has been overlooked. With inexperienced students (and even residents), I often have to make big course corrections. With the more experienced ones, I might make a subtle refinement to the plan, or challenge them to think about what they might do in rare instances when complications unexpectedly arise. All of this is truly stimulating. The students teach me, too, and they keep me fresh on new medical knowledge, just as I had done with my mentors during my own training. Formal teaching interactions continue to be a source of great satisfaction—and learning—for me.
But it had been a while since I’d had a pre-med follow me around. It’s a different ballgame: They don’t see patients alone. They don’t “present” cases to me. They just walk around asking me questions. While I usually know the answers to their questions, sometimes I don’t. Even though most of the questions I don’t know the answer to are irrelevant to my job as an emergency physician, there’s still a sense that I’m “supposed to know everything.” So I sometimes feel a little sheepish if I don't know something off the top of my head.
Whenever this happens, I am reminded that I have come full circle. I remember hanging out in the clinic of a doctor I looked up to during medical school. He had prescribed an antibiotic to a patient, and I’d asked him how that antibiotic worked; he said he didn’t remember. I recall being sort of shocked that a physician would prescribe a medication whose biochemical mechanism he didn’t know. Of course, at some point during medical school, he had known it. He’d forgotten it because the biochemistry was literally irrelevant to his care of patients. Knowing which bacteria an antibiotic works on matters; knowing on the subcellular level why it works does not. So when my pre-med asked me a couple of questions whose answers I didn’t remember, I said, “I don’t remember entirely—let’s look it up together.”
The pre-med is always in a precarious spot in these situations. Ask too few questions and you’re seem unengaged. Ask too many and you’re annoying. Also, they can and should look stuff up on their smartphones, but they can’t be seen looking as if they’re bored and are zoning out on their phones. (By the way, it’s completely unfair for me to judge them on this, because, I am totally guilty of looking at my phone for non-medical reasons during fleeting moments of downtime.)
But having a shadower around has some real benefits. One thing that it does is make me slow down and think about everything I’d otherwise be doing automatically. It’s gratifying to remember that I’ve learned and decide what tiny slice of it might be a relevant teaching point at any particular moment.
And having a student shadow me might even benefit my patients. Although I am often able to determine what to do to help a patient in a matter of seconds, if not a minute or two—having a student present coaxes me into longer exchanges with my patients, and longer and more thorough explanations. Everyone seems happier.
At the extreme, teaching can improve the care I’m giving. I was once able to save a patient’s life, because in the process of pedagogically asking a student lots of what-ifs, the patient piped up after one of the questions and said, “Actually doc, I do have that symptom, too.” That led me to diagnose a hidden life-threatening condition—as if the problem that had apparently led to their ER visit hadn’t been serious enough!
We all go through the motions in life, especially in areas where we’ve gained comfort, familiarity, and expertise. The ER is no different. Okay, perhaps it’s a little bloodier than most jobs. Having a pre-med student around reminded me to be more deliberate and contemplative about why I am doing what I’m doing. That led, I think, to a better day at work for both my patients and me. But old habits die hard, and I’ll probably forget that again, and too soon. So I’d better get another student accompany me in the near future.
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