snoitcelfer - 7 years on...

Recently I was preparing for a humongous, horrible and highly significant medical-interview. At stake, was my entire career - well future prospects anyway. One of the things one does in this situation is to review one's professional portfolio. In it I have a section - beyond all the publications and professional qualifications on Reflective Practice. 

This is there, because it is a requirement. Please don't misunderstand me, I think that reflecting on one's practice is vital, continuous and at the core of what we do. It's just that when someone gives me a piece of paper and tells me to "Reflect" I don't find it very helpful. Over my seven years of being a doctor there are a few interesting things I've put in there, often when things have not gone as well as we'd hoped. Learning how to deal with the unavoidable problems in medicine is - well - unavoidable... What really caught my eye though was something, again that was forced, which was a piece of reflective writing we had to do before qualifying.

My medical school - as do many - arranged for us to spend two weeks shadowing the doctor we would replace when we started work. This is a vital part of the process; learning where the blood bottles are kept, meeting the ward sister and learning how that particular job works. At the end of this time, we had to write something; this is what I wrote. 7 years on, I'm wondering what I would write now as a 'middle-grade' doctor.

Reflections on Shadowing

Thomas Sydenham (1642-1689) was in many ways the father of modern medicine, for he was the first to systematically collate patients’ histories. He made history-taking the centre of medical practice and thus invented clinical science. He wrote the following words:

“It becomes every man who purposes to give himself to the care of others, seriously to consider the four following things:

·         First, that he must one-day give an account to the Supreme Judge for all the lives entrusted to his care.

·         Secondly, that all his skill, and knowledge, and energy as they have been given him by God, so they should be exercised for his glory and not mere gain or ambition.

·         Thirdly, and not more beautifully than truly, let him reflect that he has undertaken the care of no mean creature, for, in order that he may estimate the value, the greatness of the human race, the only begotten Son of God became himself a mortal man, and thus ennobled it with His divine dignity, and far more than this, died to redeem it.

·         And fourthly, that the doctor being himself a mortal man, should be diligent and tender in relieving his suffering patients, inasmuch as he himself must one day be a like sufferer.“

My experience of shadowing was mixed in many ways, but what struck me most profoundly is how easily one’s highest aims for how medicine should be, disappear in the midst of process.

Working for a consultant with a preference for shorter rather than longer ward rounds means the house office is required to get the information down on paper very quickly. A brief history followed by how the patient is feeling, followed by the patient’s obs – blood pressure, pulse, temperature etc. are all recorded followed by the plan of what to do next. In all of this the identity of the patient and what is actually going on for them is rapidly lost – in my mind at least.

The same scenario occurs with blood tests and results. Having ordered 30-or-so sets of bloods and copied results into the patients’ notes it all became a complete blur to me. I no longer seemed to care that the patient’s renal function was improving, I was just glad that I remembered to write it down.

It seems to me that a good doctor has a fascination for patho-physiology and a hatred of disease. The hidden biological processes of cancer are amazing – one might almost say awesome but at the same time the way it robs a patient of their dignity, their health and their life is intensely sad. I do not know if it is true for all doctors but it seems to me that the fascination with biology – with disease processes and what we can do about it - is necessary to maintain an interest in the daily work. And with that a compassion for the patient and a dose of humanity is what makes a doctor a doctor rather than just a technician. It seems passé to talk in anything like these terms yet if not then we lose something important from our practice and are not providing the best service to our patients. Hippocrates described medicine as an art. Clearly in the previous two and a half millennia we had added much science and real understanding but I do not think that medicine stops being an art entirely. Treatment of disease depends on an understanding of the processes involved but also quite obviously on diagnosis. Despite many and various diagnostic techniques (CT, ultrasound, blood tests etc), the cornerstone of diagnosis remains the history and examination and those are an art. At very least they are skills – difficult to do well. It takes time, patience, skill and experience to unpick what the patient says and to fit it together as a coherent picture that points to a diagnosis.

In all of my undergraduate training there have been many patients and events I remember: the first patient I clerked on my own (at least in part because he had an oculo-gyric crisis whilst I was talking to him), fascinating unusual conditions, friendly patients, brave patients, etc. Strangely there are no patients who stand out from the ten days of shadowing. I think the reason for this is that the focus of that time was not on learning medicine but on learning the mechanics of working as a house officer. The mechanics got in the way. I was no longer thinking about the patient, only about what I needed to write down, what tests had to be ordered, which form was needed.  The question I have not yet answered is for how much of my first year of practice will this be a problem? Will I become an automaton who does not see the patient, only the blood results and chest x-ray? I hope not. I have spent five years at medical school to become a doctor. Medicine is a science but it is also so much more, it is inherently and unashamedly a moral pursuit. This is why I started with the words of Thomas Sydenham. He essentially invented clinical science and began the path towards scientific modern medicine and yet he still recognised that it comes down to each individual patient, who matters and who needs a doctor. Each patient needs my clinical knowledge, my understanding of how to start the processes involved in their treatment but they also need a human being who cares. That is the kind of doctor I would want to treat me and moreover that is the kind of doctor I want to be.

Alienfromzog, May 2005.