A medical student reflects on the clinical year transition

So this is what it feels like to have a rush of adrenaline in crisis—a potent mix of excitement and panic.

I yelled out the patient’s name and shook him. No response. The only sounds were the shuffling of the sole nurse at the foot of the bed and the electronic hum of the myriad medical machines decorating the room. I slammed my fingers into the patient’s carotid arteries. No pulse.

As I called out for a code blue and started chest compressions, I began running through a mental checklist. A week ago, I absolutely would not have been able to call up this list of next steps from memory, but this day—to my utter relief—it was there when I needed it, in the midst of racing thoughts and a pounding heart. I heard my voice rattling off orders for a backboard, stool, bag-valve mask, and heart monitor, though I was convinced that the real me was paralyzed with uncertainty and inaction.

V-fib appeared on the heart monitor, and shocks from the defibrillator followed as I had the nurse take over chest compressions and I navigated the forest of wires and pressed paddles onto the patient’s chest. Thump. Silence. Restart chest compressions. Thump. A pregnant silence. A long moan. The patient was back.

A disembodied voice came over the intercom: “You’ve saved your patient. Good job.” End of the simulation. I exited the room, leaving the robot patient with a mess of tubes and wires hanging from its plastic body. Out in the hallway, I wondered: what had just happened over the past ten minutes?

This has been the story of the past three weeks. As second-year medical students at Johns Hopkins, my classmates and I have been in a nebulous stage of our training called “Transition to the Wards”—a point at which didactic lectures are in the rearview mirror while the anticipation of entering the hospital wards looms. Through a series of diverse training modules, we spend this time evolving from medical students wading through books to members of a patient care team with full-blooded responsibilities. Suddenly the theoretical becomes practical, the “nice-to-knows” become “must-knows,” and simple clinical scenarios become ethical dilemmas. The vicissitudes can be quite intense: one moment you feel ready to save a life as you stand triumphant over a mannequin, then suddenly you’re hovering in the pediatrics emergency department hearing the gurgle of a seizing child and feel completely helpless to handle such situations.

Nevertheless, you begin to sense that these highs and lows will eventually even out. All the concepts we have learned over the past year-and-a-half will gel and become useful in caring for a patient. The awkward history-taking and physical exams we have had with various real and standardized patients will become more natural. Above all, we will learn that medicine is ultimately a long, imperfect, and continuous process. Nothing is guaranteed except that through the steady infusion of time and preparation, we can minimize uncertainties and shortcomings. At first, the art of patient care will elude even the most knowledgeable medical scientist. Then somehow, with time and repetition, it all comes together. As surgeon-author Atul Gawande writes in Complications, “Practice is funny that way. For days and days, you make out only the fragments of what to do. And then one day you’ve got the thing whole. Conscious learning becomes unconscious knowledge, and you cannot say precisely how.”

Over the last three weeks, we have had a potpourri of training from placing Foley catheters and IVs to debating malpractice to managing patients’ electronic records. Now, we leave our medical education building for the hallowed halls of the hospital—just a little bit wiser, still apprehensive, but surer about the path that we are on. I expect we will continue to have moments at which we suddenly have an implicit understanding of what needs to be done in a given situation, and wonder when that flip was switched. However, I also suspect that no one will ever actually reach a point at which he or she feels there is nothing else to learn or master. Gawande writes, “No matter what measures are taken, doctors will sometimes falter, and it isn’t reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.” We cannot become the “perfect physician,” but we can establish a pattern of continuous learning and improvement that generates iterations of a “more perfect” physician.

So it all starts now as we seek to become the physicians that we always dreamt of becoming, weaving individual concepts and skills into a masterful patchwork quilt for patient care. It is only the beginning, but the road ahead is clearer than it ever has been before and that is exciting. Transitioning is an ongoing process, and we charge forward towards the hospital knowing that each step will prove to support the next.

June-Ho Kim is a medical student who blogs at another me.

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