Medical education these days makes a big deal about early clinical exposure. Traditionally, the first two years of medical school were spent in a classroom, and the second two years were spent in the hospital and clinics. Somewhere along the line, I don’t know exactly when, people started to object to this system for a variety of reasons. Students who came to medical school in order to be doctors were frustrated at spending two more years sitting on their butts reading textbooks without being able to apply any of that knowledge, and (I think, though I’m not certain) someone probably had the bright idea that maybe the transition to third year might be a little bit smoother if the med students had actually seen a patient before. So the concept of early clinical exposure was born. Clinical experiences became grafted integrated into the first two years. Pre-medical students were instructed that this was something to look for when choosing a medical school. Admissions brochures brag about how much early clinical exposure their school has.
This is one of those ideas that looks really great in theory, but has the possibility of sucking astronomically in practice. And I’m sure that it’s worked out well somewhere, but GUMS hasn’t gotten it down quite yet.
I am perhaps not the ideal person to be critiquing the system. Unlike many pre-meds, my “patient contact” before medical school was not confined to volunteering at an information desk and following a physician around for a day.* I worked my way through undergrad in an actual hospital where I did actual things for patients that involved touch and bodily fluids and responsibility and occasional unpleasantness. I kept my eyes and my ears open and put myself out there as someone who was willing to learn how to do anything and who was eager to stay late/come in early to see anything. So I had a lot of opportunity to look and learn, and I took advantage of it to the best of my ability. Therefore this whole early clinical exposure bit is perhaps not as exciting for me as it might be for someone who has never actually seen 4+ pitting edema or heard a heart murmur or looked at an infected incision. However, none of my classmates seem enthralled with the experience we’re having, either, so I think it’s more than just me.
Our clinical exposure in the second year comes in a few flavors. Every week we each are required to locate a patient in one of the approved areas of the hospital and do a history and physical (or, as much of the physical as we have learned up until that point). We then write it up and present it to our attending mentors. I think this part is a nice idea that fails in practice because, as big a hospital as GUMS is, there are only a finite number of patients who are suitable for learning how to do a history (i.e. it helps if they can speak and is even better if they know who they are and where they are). There is also only a finite amount of time in which we are not in other classes. The upshot of this is that you have a small army of medical students descending on the wards and practically arm-wrestling each other to get to the fraction of patients that are good candidates. Invariably these saints get tired of suffering through question/exam sessions that take two hours (because we aren’t allowed to do a focused history and have to run through the entire ROS and because, let’s face it, we’re new at this) and don’t want to talk to any more students. So the rest get stuck trying to get a history from someone who thinks it’s 1954 and is wondering where their pants are so that they can go home. While this is not a horrible experience in and of itself (heaven knows we’ll need to deal with it at some point), it’s really not a great learning exercise when you’re not actually on the team and you can’t do any of the ordinary things like call up a family member or get the med list from the pharmacy or any of that stuff.
But that’s not the part I really have a problem with, as I think that even at worst it has the redeeming value of having you go through the motions.
The part I have a problem with are the “examination rounds,” in which we are supposed to go around in groups of four with a resident for an hour so that we can see patients with any interesting physical exam findings that the resident may be aware of on the floor. This, again, is not a terrible idea in theory. But in practice, since they are unable to find enough residents to handle us all, we get lumped together in groups of eight. We then traipse in and out of people’s rooms in a white-coated conga line begging to see whatever abnormal finding they might have. But because there are so many of us, in a show of amazing sensitivity, we only each listen to half their lungs or at one spot for their heart or what have you.
I would be more understanding about this if we were looking at really incredibly unusual things. But, for example, in today’s hour, we saw three patients. One had leg edema (which was 1+ if that) and ascites (we weren’t permitted to do an actual abdominal exam, however, because of how many of us there were). One had crackles in the right base (so only half of us heard them, as the other half were listening to the left). And the last one was… wait for it… pale. To her everlasting credit, the poor resident whose job it was to chaperone us through this wonderland of excitement tried really, really hard to make it worth our while by telling us about how each patient was being worked up for their problems and what was being done to treat them. But it was a sad waste of our time and her time, and she knew it.
More importantly, though, I think that it was really not worth doing that to the patients. These were not people who were happy and excited to be a part of our medical education (well, except for the lady that was pale — she, kind woman, clearly didn’t mind a bit, but then again, we weren’t undressing her and poking and prodding at her). These were people who were given less than half a chance to agree to our invasion and were clearly reluctant to be involved. The glib answer that is given by GUMS to these concerns is that it is a teaching hospital and that all these people know that when they choose to come here they will have to deal with students. Even if that were true for every patient (the idea of choice is laughable in many cases), I still don’t like it. I think that if you are going to have parts of your body bared to a crowded room of eight rank newbies that the newbies should at least be getting something important out of the experience.
The only thing that I’ve gotten out of this experience so far is the conviction that, if I’m ever in charge, I won’t do things this way.
*It may seem here as if I am slightly scornful of the pre-meds who choose this path. I try not to be, but I suppose I am. It’s really that I just don’t understand how anyone could make the gigantically life-altering decision to put themselves under mountains of debt and years of work to pursue a career of which they seem to have, at best, the barest minimum of comprehension. I mean, it’s not like I had some incredible perception of what the life of a doctor actually is all about, but at least I gave it a bit more of a try. I also received a lot of condescension from people who couldn’t understand why I would bother doing a job that actually required contact with urine and feces — they felt that such a thing would be so beneath them. This obviously does not refer to all pre-meds — there are certainly valuable reasons to choose to spend your time doing research or teaching projects or what have you. It does refer to the ones who were total dicks about it, however. 
So I got my scheduling permit for Step 1. 
One more exam. Just one more. I can do thizzzzzzzzzzzzz.
It’s that most wonderful time of year — exams! Three are done and two to go.
e I first walked out of the apartment this morning. Most of this can be attributed to the fact that I resist wearing a true winter coat as long as is remotely possible, but I expected to warm up once I got home and changed into warm, dry, fluffy sweats. But I didn’t.
