NEJM: MGH doc and med student get real on clinical clerkships

From the New England Journal of Medicine:

 This Perspective article about the effect of the clinical clerkships on the professional development of medical students was written from the alternating perspectives of a teacher and long-time clinician, Katharine Treadway, and a third-year medical student, Neal Chatterjee, who is now an intern in internal medicine.

It ain’t pretty

Chatterjee: At the end of the year, we were asked to reflect, in writing, on our first year in the hospital. What eventually filled my computer screen had nothing to do with vital signs or chest pain.

I began to write, “I have seen a 24-hour-old child die. I saw that same child at 12 hours and had the audacity to tell her parents that she was beautiful and healthy. Apparently, at the sight of his child — blue, limp, quiet — her father vomited on the spot. I say `apparently’ because I was at home, sleeping under my own covers, when she coded.

“I have seen entirely too many people naked. I have seen 350 pounds of flesh, dead: dried red blood streaked across nude adipose, gauze, and useless EKG paper strips. I have met someone for the second time and seen them anesthetized, splayed, and filleted across an OR table within 10 minutes.

“I have seen, in the corner of my vision, an anesthesiologist present his middle finger to an anesthetized patient who was `taking too long to wake up.’ I have said nothing about that incident. I have delivered a baby. Alone. I have sawed off a man’s leg and dropped it into a metal bucket. I have seen three patients die from cancer in one night. I have seen and never want to see again a medical code in a CT scanner. He was 7 years old. It was elective surgery.”


Treadway on how powerful the clerkship experience is for med students: First, students are entering a foreign world where they face difficult, often overwhelming experiences. Second, the rules governing the responses to these experiences are unclear. It is not obvious to students that the beliefs and ideas with which they entered school still apply, so they take their cues from the behaviors they observe. Furthermore, since responses to these events are rarely discussed, students often erroneously ascribe a detachment and lack of caring to house staff and senior physicians. Third, these experiences have frequently gone unacknowledged and unexplored.

For the past few years, I have been a mentor to medical students during their clerkship year. As they have their first experiences with patients dying, they don’t know how they should respond, whether it’s OK to be upset. One student told me about his confusion when a patient he’d admitted to the hospital died and no one on his team even remarked on the death. It made him feel he wasn’t supposed to care. When, days later, his intern mentioned how bad she felt about losing the patient, he was relieved — it made him feel he was normal. His story revealed how vulnerable medical students are to the influence of behavior that contradicts their belief systems



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