New M.D.

Turning Students Into Physicians

By Lauren A. Eckstein, M.D., Ph.D.

As I stood in the emergency department evaluating a patient with a traumatic head injury and diplopia on eccentric gaze, I asked the junior resident who had earlier been managing the case what the patient's CT scan had shown. She informed me that although the neuroradiologist was away from the reading room, she had examined the films herself and believed that the patient had an orbital wall fracture and an entrapped rectus muscle.

Based on our exam and ancillary testing, and supported by the resident's interpretation of the scans, we scheduled the patient for surgical repair. Returning soon after to the radiology reading room, we consulted with the neuroradiologist, who independently read the films and confirmed our clinical diagnosis.

Later that afternoon, the patient was brought to the operating theater for repair of his orbital fracture and release of the entrapped muscle. The surgery was successful and the patient did well postoperatively.

I was as impressed by the clinical skills and diagnostic acumen of the junior resident as I was by the initiative and responsibility she demonstrated in the care and management of this patient.

A Doctor Must Be Accountable

The process by which students become doctors involves far more than simply acquiring an understanding of the science of medicine. Among the numerous other competencies necessary to master during this maturation (and which my junior resident skillfully demonstrated in the work-up of her trauma patient) is assuming complete control of and accountability for a patient's care. This comprehensive approach to patient management is a vital component in the development of a successful and responsible physician. Unfortunately, this facility is not a skill that can be taken for granted. On the contrary, like many other aspects of medicine, it must be learned and practiced.

To be sure, this is not an easy skill to teach. Whereas didactic instruction excels in conveying information about diseases and their treatments, this formalized mode of education falters in attempts to engender behaviors and attitudes. Indeed, it is likely of minimal utility to formally instruct physicians-in-training to be responsible; other, less direct methodologies must be employed to cultivate this behavior.

Aiding the Maturation Process

Most successful is the well-established practice of teaching by example — demonstrating to our students the proficiencies they themselves must acquire by exercising them in the care of our own patients. We cannot demand performance from our subordinates that we do not ourselves routinely practice.

Also effective is providing detailed direction to guide trainees in the management of their own patients. We should explicitly outline precisely what needs to be done for a patient and allow the students to complete the tasks themselves (while simultaneously providing adequate, if unseen, support in case of failure). Unfortunately, limiting a medical student or a resident to an observational role, as is so often the case in ophthalmology where the physical exam is difficult to master and the treatments are seemingly arcane, creates a clinical environment in which remaining uninvolved (and uninvested) in the management of a patient is freely tolerated. If we wish to facilitate the maturation of our students, it is critical that we resist this temptation to divorce them from patient evaluation and care.

This process of instruction and learning is a dynamic one, an evolving negotiation between the senior physician and the junior resident. Responsibility may not be given freely by a supervising physician. Rather, it must be earned by the student through repeated demonstrations of facility and responsibility. During residency, we learn the fine details of clinical and surgical ophthalmology. As we demonstrate ever greater proficiency in these tasks, we gain ever deeper insight into the process of patient management.

To fully embrace our role as responsible physicians, concurrent with this expansion of our technical armamentarium, we must simultaneously assume greater responsibility for the care of our patients. Success as a healthcare provider, doctor and healer cannot be achieved absent this critical maturation. OM