First Patient Encounter

Editor's Note: Sorry posts have been so infrequent...who would have thought medical school would be so hard? Anyway, I'm working on a number of write-ups that should be posted in mid-December. Until then, here's a brief follow-up to my last post.

Looking in the mirror before heading out the door for my first patient encounter, I slouched. Something looked off. I had on my new, absurdly short white coat complemented nicely by the equally as new black stethoscope draped around my neck; yet the way I looked wasn’t the problem. It was the way I felt. No matter how well I dressed the part (and I must say I did quite a good job of that), I didn’t quite feel the part yet. This was a feeling that started the day I got my white coat: the belief that I would not be able to fill the coat well enough or accomplish my dream of becoming a great doctor. I hoped seeing my first patient would abate this growing feeling of worthlessness, and I have to say it did.

Striding in to the student-run clinic at my school 15 minutes before my team’s scheduled appointment, I did my best to look doctorly (however that might look). I constantly took my stethoscope off from around my neck and then put it back on, trying to decide if I was accomplished enough to pull of such a distinguished look. I finally relented to the peer pressure of my fellow classmates and left the stethoscope around my neck.

Slowly, my team of upperclassmen arrived and proceeded to fill me in on the details of our patient. He was a 26-year-old male with a congenital heart defect, which had caused him to have two heart attacks in his early twenties. On his previous visit, he had complained of a lingering foot infection and seemed to show signs of depression, which prompted our team to ask that a psychiatric resident be on call for that day’s visit. After receiving the past medical history, our patient arrived and we brought him in to the examination room. Before entering, the fourth year on my team asked if I had learned how to do a physical or interview yet. I told him I had just learned the interview the day before, prompting him to tell me in so many words to sit this one out. I felt a strong sense of relief, mixed with a slight feeling of inadequacy. Here I was all dressed up and ready to go (stethoscope around the neck and all!), yet my coach had just told me I was benched.

When we entered the room, I was shocked at what I saw: a man who could have been my brother. How was it that this relatively healthy person had already had two heart attacks? As I would soon find out due to the astute history taking skills of the third year on my team, this healthy-looking man was actually, well, not so healthy. For a little over an hour, he rattled off a host of issues ranging from depression to joint pain to a frequent urge to urinate in the middle of the night. Somewhere in the back of my head I wondered if medicine was this easy and if perhaps our patient was diabetic, a point my fourth year would later praise me for pondering, while informing me that our patient was not in fact diabetic.

After the interview, another medical student on our team conducted a physical, with the oldest student showing me how to mimic all of her actions. It wasn’t until this point that my feelings of worthlessness began to subside and new feelings of importance started to wash over me. I was actually (sort of) providing care for this patient! All of the techniques my doctors had performed on me, I was now (kind of) able to perform on my patient. As weird as I felt looking in the mirror before going to clinic, I felt just as comfortable now performing the physical exam.

After an unremarkable exam and a decision by our patient to forego the psychiatric consult, my team quickly presented to the attending physician on call and scheduled a follow up appointment. Upon returning home from the appointment, I looked in the mirror again. Though I was unable to do anything of value for our patient, I had been able to accomplish something very beneficial for myself: prescribe myself confidence in my ability to eventually become a competent physician. This time I saw something a little different in the mirror than I had before: a student in training who was able to stand just a little taller and feel just a little more confident in his future in medicine.

The White Coat Ceremony: Induction into the World of Medicine

By Timothy Dempsey and Pamela Savitz

Last month, the National Football League inducted seven of its all-time great players into its Hall of Fame in a ceremony filled with nostalgia and memories of legendary careers long-finished. While this was going on, there was another type of induction ceremony taking place around the country. Yet, these celebrations lacked recollections of past achievements by retired legends finally receiving their due. There weren’t even any bronze busts awarded to the participants (although that would have been awesome). No, this ceremony was less about past accomplishments and more about future potential as physicians. I speak of course about the White Coat Ceremony, an event put on by medical schools around the country to indoctrinate its new students into the world of medicine by providing the students with the ultimate symbol of doctoring, the white coat.

For many students, dreams of putting on the white coat begin the day they are accepted into medical school. This coat finalizes our hard-fought journey toward gaining admittance as years of constant, rigorous work have finally paid off; all of the pre-requisites of high school, SATs, college, MCATs, AMCAS, and every other acronym you can think of are behind us; and becoming a doctor seems to be in sight at last. These feelings accurately describe the way I felt in preparation for receiving my white coat. Yet the moment I actually put on my coat, I could not have taken it off fast enough. This weird feeling of apathy toward my “dream coat” left me terribly conflicted. Yes, this was one of the most exciting moments of my life, something I had looked forward to since 6^th grade. But just because I get a shiny (and absurdly short) white coat doesn’t mean I automatically become a doctor. No, my classmates and I will not receive our true indoctrination into the world of medicine until we have created our own experiences: interviewing our first patient, pulling our first all-nighter, and witnessing our first death. Perhaps then I will feel less awkward in my white coat and more at home as a physician in the making.

Conversely, not every first year medical student in the country receives a white coat to start. A number of schools around the country take different approaches toward welcoming their students into the medical world. These institutions subscribe to the belief that students must earn the honor of having a white coat bestowed upon them. My fellow blogger, Pamela Savitz, is at one of those medical schools and shares her thoughts below:

“As a first year student at a different medical school, I must complete my first two years comprised of rigorous study before receiving a white coat, a symbol of the transition to the clinical world. At first, I was somewhat disappointed in the notion of having to wait, but hopefully I can feel much more at ease and at home in my coat when that day comes. The incentive to succeed now has some tangible reward, one that will visibly distinguish me as a medical professional.

Unlike Tim’s ceremony, I experienced an initiation to the medical world and medical school quite differently. Occurring at the end of our week-long orientation in August, my induction ceremony symbolized the transition from freshly accepted students to official doctors in training. During our ceremony we eagerly stood in front of our dean, who proudly placed upon our shoulders not a white coat, but instead, a stethoscope. Afterward, the class recited the pledge of honor that declares our loyalty and passion toward medicine and patients, along with our professional and academic duties as students. I must say it initially seemed quite corny, but while I was reciting the oath with my 114 classmates, I felt a strong sense of unity – we were all facing the journey ahead together. Any fears I had about classes, practicing medicine, and lacking the proper skills an excellent physician should demonstrate, were all momentarily set aside. We were one step closer and just a little bit more prepared now that we felt the weight of the stethoscope resting on our shoulders.”

A few days after the white coat ceremony and hearing Pam’s story, I found myself thinking back on my ambivalent feelings toward what should now be considered my prized possession. I realized then that these feelings were not so much a reflection of the ceremony or the white coat itself, as I was very grateful toward my school for giving us such a wonderful welcoming party. No, my real issues were with my anxieties about starting medical school, my fear of failing to become a great physician, and myself. Upon further reflection, the apathy I felt toward my white coat was really directed toward my own fear that I will be unable to fill it well enough.

This realization brought me back to the NFL Hall of Fame inductees and the fact that they were honored for their incredible, yet long crafted skills. At the start of their careers, the same talent that would eventually lead them to Hall of Fame greatness probably seemed unattainable and reminded them of their inadequacies, just as my induction ceremony reminded me of my own. Remembering that every great player has to start somewhere reminded me that every physician starts out just like Pam, my classmates, and I - as a scared student staring up at a seemingly impossible task - a 4^th and long if you will- with nothing protecting us but a short white coat.

The views and opinions expressed in this page are strictly those of the authors. The contents have not been reviewed or approved by the students’ medical schools.

The First One: How One Book, One Trip, and One Disease Led Me to Medicine

One thing changes everything. While this may be a poor paraphrase of the cheesy slogan ESPN used for the recently finished World Cup, in my life this statement has revealed itself as a universal truth. For me, one book changed everything. It would lead me into research labs, on a trip to disease-riddled Gaborone, Botswana, and pique my interest into an epidemic whose global eradication would later become my passion and life's goal. But most importantly, this book would reaffirm my desire to practice clinical medicine and push me down the path to medical school.

And the Band Played On hardly sounds like a life-altering title. However, the text opened my eyes to the destruction a small particle like HIV can cause. The book, which details the beginnings of the HIV epidemic in America, showed me that a virus can touch every aspect of society, from the political to the medical to the economic. It showed that it was possible for a virus to outsmart even the most intelligent and dedicated of our scientific research community. Most importantly, though, it did more than show me these things- it compelled me to action. Immediately after finishing the book my junior year of high school, I decided I wanted to work in global health. I began shadowing infectious disease doctors, as I felt this was the discipline of medicine best suited to my interests. When I got to college, I took up HIV research and started a "FACE AIDS” chapter at my school, a national organization focused on helping AIDS patients in Rwanda and Zambia. My interests in HIV and international health only grew through these activities, leading to the decision that eventually I wanted to get both my MPH and MD, do an infectious disease fellowship, and then set up a clinic somewhere in sub-Saharan Africa, whether on my own or through Doctors Without Borders. It was about this time I decided I should study abroad in Africa, and truly test my desire to practice international medicine.

Just north of South Africa lies a country few people have heard of, and if they have, it has probably been for all the wrong reasons. Botswana, the country with the second highest HIV prevalence rate in the world, ended up being the perfect place (unfortunately) for me to start my journey into the world of global health. Through a two-month program with Ohio University, I was able to finally put a face to the AIDS disease I had viewed so many times under a microscope in my research lab at the University of Pittsburgh. While I was volunteering with a small hospice in Botswana I was able to view first-hand the injustices common to underdeveloped nations, such as HIV patients being shunned by society and forced to take expired antiretroviral medications. My trip was not the normal college student's study abroad experience in Europe; in fact, it was far from it. However, this opportunity was a necessity for me, something I needed to see in order to better prepare for the challenges I will undoubtedly face in my future as a health care professional. Was it, at times, frustrating and depressing to see so much and be able to do so little? Absolutely. Do I want to continue going back and helping the Botswanas of the world? I wouldn't be embarking on the journey of medical school if I didn't. If And the Band Played On aroused my interest in AIDS and global health, my trip to Gaborone solidified it. I came back a changed person, more motivated than ever to make an impact in the international medical community. No longer am I going into medicine to "help others" or "fulfill my potential"; now, I want to go into medicine in order to save the Tinys of the world, the AIDS victim who died a terrible death from ovarian cancer while I was working at the hospice in Botswana, or to help teenaged, mother of three, schizophrenic AIDS sufferer Basadi and her children fulfill their potential. While I used to think that even with my basic undergraduate education I could help change the world, Botswana showed me I needed much more help (and education) than that.

Upon returning from Southern Africa, I found it very difficult to cope with all I had dealt with in Gaborone. It was not easy to return to my normal life knowing that there was so much preventable suffering taking place an ocean away. Luckily, instead of dwelling on what I had witnessed in Africa, I turned it into motivation, working extremely hard my final semesters at Pitt and using this new-found drive to commence the first of my many ambitions by getting a Master's of Public Health Degree from The Dartmouth Institute for Clinical Practice and Health Policy. This educational experience has given me the knowledge not only to heal individuals (once I get my MD), but also to heal communities. However, the ultimate goal remains becoming an infectious disease doctor and ridding the world (and my hospice patients) of AIDS, an idea that would have remained dormant had it not been for one book back in high school that ended up changing everything.

This entry marks the first of a four-year long blogging project attempting to document the initiation of one medical student into the world of medicine. I hope you’ll follow me as I embark on this journey to achieving my dream of becoming a physician.

The views and opinions expressed in this page are strictly those of the author. The contents have not been reviewed or approved by the student's medical school.