On watching a student learn something new

It is during our teaching of second year when we take our students, go into the hospital, and talk and examine patients as students learn how to put together all that they have learned so far to gather a complete history and physical.

“Pay attention to timing,” we say, hoping that this instruction will help, only to realize there is “when did it start?”, how long did it last, how often does it happen, has it ever happened before and the all-important, now which episode are you talking about?

Belatedly we tell our students, after 2 or 3 of them have gotten into trouble, that the qualifier, what brought you in “this time” is something we should have stressed from the beginning.

If what comes out of our students’ mouths is “when were you last well?” and the 79 year old in front of them starts with “when I was 15…”, we quickly realize that if we are ever going to finish our day, that they better quickly think of another strategy for this specific patient.  I remember having a particularly talkative and tangential uncle, and when I was growing up, I came to work with him in one of my first jobs.  His longtime colleague once described him by saying, “if you ask him the time, he will tell you how the watch was made.”  I use this sometimes when I am talking to colleagues about why my clinic might have run late that day.

There are an endless variety of patients and story tellers and we experienced physicians have lost track of many of the strategies we use with patients, until we watch our students gathering a history practiced in their absence.  This is the basis of our teaching, and the students sometimes think it is wisdom.

We have moved past thinking of it as wisdom and have stopped noticing subtle changes we have made until one day, we look back and find that our point of view has changed completely.  We can no longer recall the steps we take in gathering a history because we have practiced it so much that it has become habit.  I remember when I was in their shoes, as a second-year student, feeling challenged to ask a question that got a straight answer from a patient.  I walked in one day to see the patient assigned to me.  Someone must have thought they were giving me an interesting patient and, in fact they were, if interesting is defined by their pathology.  This patient had suffered a stroke, and had clear findings of this stroke, of right sided weakness, but what was most memorable to me, in the days where I worked hard to try to ask the perfect question, was that the patient could not speak.  I was completely paralyzed, trying to figure out what to do next since the hour-long history that I usually gathered was not available to me.  It was years later, as a busy resident, that I now look back and recall a complete shift in my point of view where knowing that the patient couldn’t speak was met with a profound sense of relief as I realized that coaxing out a history was not necessary, copying what was on the sheet from the ED was followed by a directed PE, a look at the labs for this confused, elderly patient, and a return, hopefully to a night without further interruptions.

As we teach our students in their second year, they make progress, some faster than others, but this day, I was with one of my students, his last session, before immersing himself in the busyness of studying for their looming Board exam.  Over the two weeks prior other students had come upon patients who required an extraordinary integration of their skills, gathering an accurate history, using appropriate empathy, performing directed physical examinations.

This was our last day, the last student in the group, a final examination of sorts.  We heard that we had a 40-year-old woman with back pain.  He heard about the back pain, he asked what it was like.

He asked what made it better and what made it worse, just like he was taught.  He asked what she was doing when it started, and the story become more interesting and complicated.

She told him that right before the pain started, she was bending over to look at her legs, looking for veins.  She was looking to shoot heroin and she had run out of veins in her arms. 

This landed him in the part of the story we call “Social History.”  He asked about her job and she said she worked as a prostitute to support her habit.  He asked about home, and she said she was homeless. 

Now the whole semester, I had stressed to my students to get to know something about their patients as people and not to reduce their social history to their habits, smoking, drinking and drugs.  I was proud that he was seeming to do this.  He asked about her supports.  Just as I was remarking to myself how much progress he seemed like he was making, I heard him ask her the next personal question “what do you like to do?”, and without a real pause, “do you have any hobbies?”

I reacted inside.  What kind of question is that for someone living on the streets, spending her days prostituting to support her drug habit? What kind of answer was he expecting with such a question?  Hobbies?  hobbies? I thought of my quest for the perfect, or even a good question.  I found myself thinking that surely, this was not it…

I caught myself finishing this detour of a thought, having gotten wrapped up in my own head and my own world….  He had asked about hobbies…

and then I turned back…to silence.    I took a moment to look up.  She was sitting there, she was struck dumb, she was not speaking, looking down, looking a bit stunned.

She looked down at her legs, but she was not seeing them, she was no longer there, she was somewhere far away. 

“This is so sad,” she said, and paused….”I don’t even know what I like any more”

We sat there in silence for a minute.   We let what she said sink in.   I found myself being taught, by a student and a patient together.  I wish I had learned this lesson much earlier.  We don’t have to ask the right question.  We just have to ask a question, then stop, and listen.  We need to see where the question takes the patient in front of us, and where it takes us next, sitting with curiosity, not sitting with judgment as we all do our work together.

David Hatem is a General Internist here at UMass since 1988. Early in his practice he realized the personal value of reflecting on his day to day practice through writing. He and Emily Ferrara have been leading a Writing Elective for medical students since 1997. He has been involved in numerous Medical Humanities initiatives throughout his tenure at UMass Memorial Healthcare.

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