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Taking the training wheels off on the road to becoming a “real doctor”

When working in a clinic as a medical student, there’s a balance between “learning from the support we have available, and relying on it too much.” So writes Stanford fourth-year medical student Nathaniel Fleming.

Working in a clinic as a medical student is the best of all worlds. We have the opportunity to expand our knowledge and skills by working with some incredible patients, all while knowing that we have the support and backup of our fully trained, expert attending physicians every step of the way. This apprenticeship type of system is absolutely essential to medical training, allowing us to get our feet underneath us while learning how to manage the care of real patients for the first time.

At some point, though, the training wheels need to come off, and as we advance in our training, there exists a balance between learning from the support we have available, and relying on it too much. This is especially true in outpatient clinics, where the predictable, scheduled structure means that the patient knows all too well that the "real doctor" will be in the room in only a few minutes to discuss the plan and clear up any questions or concerns.

Because of this, it's all too easy to get into the habit of instinctively deferring any kind of difficult conversation to the senior members of the team. It's easier, and much more fun, to be the good cop. Only exercising one day a week? Not taking your medications regularly? Taking some mysterious herbal supplements against doctor's advice? Well, nobody's perfect, right? After all, who am I, as a medical student, to be admonishing patients twice my age, especially when I know that my attending is going to address it five minutes later?

The problem with this is that it completely undermines one of the essential learning goals of our clinical rotations, which is that we begin to transition beyond reporting our patient's condition to truly managing it. And making this transition requires a different mindset from everybody involved. My attending has to trust me enough to give me ownership over the encounter. My patient has to have enough confidence in me to take what I say seriously. As for me, I need to walk into the room as though I am the only medically trained person within a 50-mile radius - if I don't do it, nobody will.

As I gain valuable experience, little by little, all of those separate pieces are starting to all come together more and more. During one shift in the emergency department, I met a young woman who had been diagnosed with cancer several months before. She had noticed a new lump, and unfortunately her CT scan came back confirming that her cancer had most likely spread. I was mentally preparing myself to follow the senior doctor I was working with into the room, to watch him break the news and lead the discussion, when I heard him say, "Go ahead and update them - I'll be here if you need anything." Surely, I had misheard him? Why would he let a medical student break this bad news alone?

I was asking myself the wrong question. Why wouldn't he ask me to do it? When she came into the ED, I was the first one there to see her, to shake her hand, to examine her, to see the fear in her eyes as she told me her story, and to suggest a plan for diagnosing her. I had ownership over her care. And somehow, although I still have a long way to go, I was starting to feel like a "real doctor" myself.

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. 

Photo by Shutterstock

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