Last night I had the pleasure to watch an HBO special documenting a masterclass given by singer Josh Groban to three young music students. Over the course the show, Groban coached the students through composition of an original song, and it culminated with their performance of a song that had not existed a week previously at his concert in Chicago. It was a great show that I quite enjoyed, and if you like Groban or music, you should check it out.
The show also made me think quite a bit about how my job teaching residents is quite a bit different than the job most teachers have.
As a physician, I occasionally encounter patients who feel like they know a great deal more about medicine than they actually do. Sometimes its a family member of a patient. Occasionally they are right, in that they have a particular cache of knowledge about a particular condition that surpasses me. In those circumstances, such patients or family members are able to augment their care. Far more often, however, their expertise is far less than they think.
For example, I once cared for someone who clearly needed a blood transfusion. A family member was in strong opposition, mostly because that family member was Jehovah Witness, even though the patient was not. That family member presented all kinds of information about alternatives to blood transfusion, and clearly right from a pamphlet they had read. At a fundamental level, said family member believed that there was always an alternative to blood transfusion and it was never actually necessary.
A few years ago, I was sitting in clinic with a student that seemed quite anxious. I asked her what was up, and she said she was close to having to pick her specialty, and still hadn’t made up her mind. She said she was caught between ob/gyn and orthopedic surgery, and couldn’t decide.
“So which one do you like better?” I asked.
“That’s interesting, as they are two quite different fields.”
Also on my mind was that as an OB/GYN student, I thought she was average at best. In all honesty she seemed quite bright but not at all intersted in OB/GYN.
“So OB/GYN huh? I didn’t peg you for that. You don’t come across as loving it.”
“Yeah, but I do like it. And my mother thinks I should do it.”
“So what about ortho? Do you love that?”
“I like that. My dad thinks it would be great for me to be a surgeon, and that I would make a lot of money.”
At this point it occurred to me that of the six weeks I had worked with this woman, I had only seen her truly excited on one occassion, and that moment was when she was presenting cancer cases at our tumor board conference. She had prepared a tremendous amount of information about the cases she was presenting, and had seemed to be particularly focused on the pathology slides. She presented all kinds of information about the slides that other students would have just ignored. More that that, she was just beaming as she presented it.
“So… remember when you presented those slides at path conference? How did you feel then? It seemed like you were really into it.”
“I love that stuff. I love those slides, I really like looking at them and trying to figure out what it means about the patient’s disease.”
“OK…. so you want to do OB/GYN because your mom thinks it would be good, and orthopedics because your dad thinks that would be good and you would make a lot of money. The thing is this – you don’t really love those things, but you love looking at slides. What if I were to tell you that there is a job out there where you can look at slides like that all day, hang out with people who also love looking at slides, have great hours, never work at night, and get paid tons of money……..
Its called being a pathologist.
Ever think of doing that?”
Her eyes flew open, almost startled, like she had never really considered it.
She went into pathology and loved it. Her parents were pleased she found a job she liked, because in the end, like all parents, they just wanted her to be happy.
I recently had the opportunity to go to the anatomy lab and help the first years go through the pelvic anatomy. What a blast! There is nothing like dissecting a cadaver to tune up one’s surgical anatomy skills, and helping young eager medical students through it is a great experience.
Prior to going into the lab, I spent many hours going through Netter’s atlas to brush up on the anatomy so I could accurately help the medical students. Its amazing what one can learn reviewing what one used to know. Here’s a few examples:
1. The small vessels we like to cut at cesarean have names, and we can avoid them.
Everybody that does cesarean deliveries knows that there are small vessels in the path of entry that sometimes get cut, but not everyone knows what they are called. So for the record, the small vessels in the subcutaneous fat that get cut are superficial epigastrics (most people know this one) and the vessels that sometimes go during the lateral extension of the fascial incision are ascending branches of the deep circumflex iliac artery. One can see that these ascending branches lie between above the transversalis muscle but beneath the obliques, which explains why sometimes taking the fascial layers separately allows one to miss them. I’ve always felt that the routine sacrificing of these vessels was a surgical faux pas, and knowing this anatomy helps one to avoid it.
When one is a medical student, pretty much everything one does is directly supervised. Though a student is allowed to assess patients and make recommendations, rarely is a student given the autonomy to make decisions that will affect patients. They practice these decisions, but there is always someone more senior ratifying them.
Once a student becomes a resident, things start to change. As residents are physicians, they have the power to write orders and have them executed without anyone else approving of them. In the beginning, this is a scary power for the resident, as they are terrified they will hurt someone. At the same time, it a welcome reward after years of having to ask someone’s permission to do anything at all.
When I was a high school math nerd I looked forward to the AP calculus class I would take my senior year, because once I had done that I really would have achieved the tops that mathematics had to offer. Once I finished that class, I remember thinking “now I really understand math.” When I studied mathematics and computer science in college I realized how wrong I had been. I realized then that calculus was not the end of the mathematics – it actually was just the beginning. In fact, it was the first thing I ever learned that could even be called mathematics at all. The rest was just arithmetic.
As an academic gynecologic surgeon, I often get asked a question that reminds of me of my calculus realization, and that question is “Who will be doing my surgery?”
On January 12, 2010, a magnitude 7.0 earthquake rocked the island country of Haiti, destroying much of the capital Port Au Prince and leading to the deaths of as many as 200,000 people. Since this time, thousands of images of the resulting carnage have been published in both traditional media and on internet sites.
Recently there has been some discussion about the appropriateness of some of these images, particularly those that depict individual humans in despair or even in death. Some have argued that such images should not be published without the express consent of the person depicted, or with the consent of the next-of-kin in cases of the dead. Media, for the most part, has held that in cases of extreme human events the benefit of publicizing the truth outweighs whatever emotional harm might come to an individual through publication of their plight. They argue that the many outweigh the few, in this case.