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Stanford University School of Medicine

The power of learning by experience as a clerkship student

It’s a common scenario on rotations: You, as a medical student, have seen your patient and shared your assessment and plan with your attending physician. You’ve put knowledge that you committed to memory for your board exams to use by explaining the most likely diagnosis and an appropriate treatment. Then, your attending asks, "what else should we be thinking about for this patient?” You rack your brain, but all that comes to mind is a random textbook chart or mnemonic that doesn’t seem to be relevant. “I’m not sure,” you say.

Inevitably, your attending will then say “I once had a patient who…” and will proceed to tell you a story of that one time during fellowship when they saw a patient who had a missed diagnosis -- or perhaps a rare, but serious, complication -- that has stayed with them ever since. Having been on the receiving end of these exchanges numerous times, remembering all of them is challenging. As much as I try to commit all of these maxims to memory, there are simply too many “what ifs” to keep track of, and we are left marveling at the incredible wisdom and knowledge of our more senior colleagues.

So how does one get to that point, as a doctor? I used to assume that the answer was always “more studying” (that’s certainly what it felt like when I was studying for Step 1 of my boards). More tables, more charts, more pictures, more books. Now, I know that the answer is something different: experience.

Over the course of third year, I’ve had more than a few of my own memorable cases. A man who came to the ED unconscious and with dangerously high blood pressure who was found to have a tear of his aorta. A woman who became sleepy and confused who ended up having an unusual autoimmune disease affecting her brain. Another man who was having mysterious spells of dropping blood pressures who was discovered to have a particular kind of severe heart failure when he was taken to surgery for his broken leg. All of these were medical “surprises” that didn’t fit the usual script that we typically learn and see.

The key thing that makes this so powerful is that patients that you’ve taken care of are much easier to remember than textbook facts. Doctoring is an immersive experience -- treating a patient comes with its own particular set of sights, sounds, smells, and faces -- all things that imprint the experiences into our memories so that they stay with us for years. As hard as it is to commit isolated facts to memory without using them regularly, I’m confident that these unusual or surprising cases will stay with me for much of my career.

The bottom line is that we can’t be too hard on ourselves as medical students for not knowing all of the possibilities. (There’s a reason why it takes so many years of training before you can be considered a fully independent physician.) But we can help ourselves greatly simply by being “in the moment” during our rotations so that we start to build our own collection of experiences that will shape our decision-making later on. One day, we too will be able to impress new students with our wisdom.

Stanford Medicine Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category. 

Nathaniel Fleming is a fourth-year medical student and a native Oregonian. His interests include health policy and clinical research. 

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