In second grade my teacher, Mrs. Kittleson, gave my class an assignment: write an instructive paragraph on making peanut butter and jelly sandwiches. She told us to be as specific and as detail oriented as we could, because the next day she would be reading and following our directions. I spent the full writing period carefully crafting, what I thought were, the most perfect peanut butter and jelly sandwich instructions of all time.
The next day, standing at the front of the class with the ingredients for the sandwich du jour, Mrs. Kittleson asked whose instructions she should follow first. I, being the overly confident, bright-eyed second grader that I was, shot my hand up straight in the air (Hermione Granger style) all too eager to be picked first. As I marched my recipe up to the front of the class, I looked back on my fellow classmates (the poor schmucks) because I just knew that my instructions were going to make the best peanut butter and jelly sandwich. Like, ever.
It wasn't until Mrs Kittleson opened up the jar of peanut butter and placed the entire lid-less jar onto a slice of bread, followed by the lid-less jar of jelly, that I realized I had left out a couple key pieces of information. Mrs. Kittleson was literally following our instructions and mine, and the rest of my class's, were found wanting. My teacher's creative way of improving our instructive writing styles came at the steep price of one 8-year old ego.
I was reminded of that story this past week. Thursday marked my first ever encounter with a real, non-standardized, honest-to-goodness patient. And the moment I remembered that I had omitted spreading the peanut butter onto the bread with a knife felt very similar to having my case presentation annihilated by the internal medicine attending. Multiplied by about 500, minus the smell of peanut butter.
I have learned many a lesson in humility since my second grade PB&J days, so I was not expecting to give the most perfect case presentation of all time. But, overall I thought the encounter had gone well and was excited to present my findings on a real patient to a real doctor in a real hospital. So, when Dr. Attending asked who wanted to go first, I volunteered. And then 25 minutes of this happened:
Student Dr. Day, don't you think it is important to figure out exactly why your patient was weak, instead of just assuming he had overdosed on his glucovan?
Student Dr. Day, don't you think obtaining peripheral pulses in an elderly diabetic patient with a history of systemic vascular disease and bilateral diabetic foot ulcers is pretty important?
Student Dr. Day, are you telling me that you did not palpate for the PMI and compromised your physical exam and because your patient was "upset?"
Student Dr. Day, list the classes of diabetes medications. Go.
As what I can only describe as the longest 25 minutes in my medical school career (and maybe even my life) dragged on, I felt more and more like a total failure. It wasn't until the H&P blitz was finally over, when Dr. Attending smiled at me and said nice job that it hit me. He was telling me to make a PB&J.
He did not expect me to know that I absolutely needed to figure out why an elderly patient was weak. (It's to rule out a stroke.)
He did not expect me to check the patient's peripheral pulses. (The patient already had foot ulcers, so blood flow is already compromised. But it still needs to be something I at least think of.)
He knew I wouldn't know how to react to a complicated case where the patient was emotionally and physically upset. (When a patient has upset themself to the point they are vomiting, as long as they are not dying, you can go always go back! Like, when the vomiting has stopped and the world is good again.)
He knew I wouldn't be able to completely list all of the classes of diabetes medications. (sulfonylureas, meglitinides, biguanides, incretins, thiazolidinediones - to name a few)
Dr. Attending did not expect me to effectively give a case presentation (or perform a thorough history and physical exam) any more than Mrs. Kittleson expected a room full of 8 year-olds to write exact instructions on making a sandwich. The point of the exercise was to show us how much more we still had to learn, and to let us experience a patient interaction in the real world, with a real sick person.
After all cases were presented (and inside tears cried), Dr. Attending told us that he hoped we enjoyed our patients, but even more importantly, he hoped our patients were able to enjoy us. He told us to work really hard at remembering why we wanted to go into medicine in the first place, and that he works with doctors every day who have forgotten just that. He told us that being a physician is the greatest job in the world and that eventually, we'll be able to help people and maybe even bring some joy into their lives.
And even though my patient (with dementia) probably forgot about the entire interaction about 7 minutes after I left, while I was shaking his hand and thanking him for his time, he looked up at me and told me that I was a nice person. So, in some very small way, maybe I already have.
