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Vol. 32, No. 2Summer 2009

Special in this issue

 

The real (and funny) scoop on
clinical transition

Keynote Address: The UW School of Medicine’s Clinical Transition Ceremony
May 22, 2009

Hugh M. Foy, Res. ’83, Fel. ’84
Professor, Department of Surgery
Director, Surgical Specialties Clinic, Harborview Medical Center
Head, Wind River College, UW School of Medicine

 

Welcome, students, parents, spouses, significant others, grandparents and friends. This is a wonderful celebration — so wonderful, in fact, that many, if not most of you, wonder what it’s all about. Clinical transition? White Coat Ceremony? “But we’re not even done with finals!”

Well, let me help explain, if I may. See, this is one of the two most important days in your educational life. If my math is right, it has been at least 19 years since you last visited the world of what is known as experiential education. Nineteen years and three months ago on a late August or early September morning you let go of your mother’s hand and walked boldly through those kindergarten doors. Gone were the great days of casually discovering the world bit by bit, day by day, mostly at your own pace. Get up, eat, hang out, watch a little Sesame Street, play with your toys, the dog, and the cat, and hang out with your mom, your brother and sister, maybe your dad, your friends. Eat some lunch, take a nap, and repeat. No bells, no pressed clothes, no hard desk, no stern teacher with folded hands and zipped, closed mouth.

Then it started: day after day, month after month, with only the summers as respite. Sit in the chair, be still, be quiet, listen, take notes, take tests, etc., etc., etc.

Nineteen long years. Two decades of wondering what your fate will be. What will be your career, what will be your profession?  Many of you knew early you wanted to be a doctor. Some may still be unsure, but, ready or not, here you come. In six short weeks you will be liberated from the chair. You will put on that coat, walk into the clinic or the hospital, and you will begin to live the dream that you have held close to your heart for many years.

Scared? Excited? You should be both and much more. For it is a very different world,  a very different educational setting, and one that you have probably forgotten as you haven’t enjoyed it since you were 5 years old. You are about to re-enter the wonderful world of experiential learning. That is why this is such a big deal.

It may be helpful, and I can’t resist the opportunity to share a few tips on how best to enjoy it and make it more meaningful and productive.

First:  You need to understand the principles of experiential or “adult” education.

Second: You might benefit from some practical tips on how to survive, and

Third: You need to learn to put it in the proper perspective.

This past year (and now for the seventh year) we, your College mentors, have had the honor to introduce you, the finishing second-year students, to your new world of clinical education.

But now it is time to enter it, savor it, and take this career, this profession of medicine and hold it dear until the day you retire. To prepare you for this bold new world, I thought it might be helpful to give you a brief preview of its rationale, so that — as Steven Covey remarked in his eloquent book, The 7 Habits of Highly Effective People — you can “begin with the end in mind.”

The principles of adult education, as espoused by the father of adult education theory, Malcolm Knowles, include the following:

  1. Adult education is problem-centered.
  2. Adult education is an active process (not passive, like your education to date).
  3. Adult education is experience-oriented.
  4. Adult education is immediately applicable (“right here, right now”).
  5. Adult education is most effective when learners are involved in setting goals and objectives.
  6. Adult education achieves its goals best when it is in a supportive environment.
  7. Adult education is characterized by frequent feedback.

Problem-centered

That’s what it is all about. Patients come to us because they have problems. At first, this may seem to burden you. I remember when I was a third-year student at the VA, and it felt like each morning an invisible doorman handed me a lead balloon to carry around all day on my heart. Carry it, but don’t forget to check it at the door. Learn to embrace chaos, not shun it. F. Scott Peck, the psychiatrist and philosopher, opened his famous book, The Road Less Traveled, with this: 

“Life is difficult; this is a great truth, one of the greatest truths. It is a great truth because once we truly see this truth we transcend it. Once we truly know that life is difficult, once we truly understand and accept it, then life is no longer difficult. Because once it is accepted, the fact that life is difficult no longer matters.” 

Active process

For me (a recovering ADD poster boy), this was the best. Your white coat is license to go anywhere and ask anyone any question imaginable. You now can go past the doors that say, “authorized personnel only.” So, go. Go with your patient to the echo lab, to X-ray, to the OR. Learn by watching, by asking questions, and by doing — when possible. Take advantage of each and every moment of every day. Treat each and every day with the same reverence, respect and resourcefulness that the Lakota people treated a fallen buffalo: utilizing every single gram of that great animal’s body: for food, tools and for shelter. Waste nothing of your day.

Experience-oriented

You and you alone must take responsibility for your education. The syllabus is a thing of the past. You and you alone need to make it up each and every morning. You are responsible for setting the goals and objectives of each day. Jump out of bed and resolve each day that you will make the very best of your education.

It is your sole responsibility, because everyone above you in the food chain — your interns, residents and attendings — are so busy taking care of patients that they struggle with the feeling that they do not have time to teach you. It will often seem that you are being ignored. Unfortunately, that is the default option. Not out of malice will you be ignored, but out of necessity, particularly if you stand back quietly and timidly and blend into the woodwork. You need to step up, get into the game, and interject yourself into the process. Be fun to teach, and you will be taught, gladly and effectively. Stay back and blend into the woodwork, and you will become the breakfast of termites.

Immediately applicable

Pay attention! Get your head up! Be acutely aware that the information you are hearing each minute is potentially life-saving when you turn the corner in the hall.

One day, we were making rounds and came to the door of a patient who had a wet spot on the chest of her hospital gown. Looking closer, we noticed her central line had become disconnected. Dutifully, we reconnected it. I turned to my team and asked: “what is the most significant complication of a central-line disconnect?” They chimed back, “air embolism, Dr. Foy.” I then asked: “how do you treat a patient with an air embolus?”  They replied: “Put her left-side down, and aspirate the air from the line and the right atrium.” On cue, the patient rolled her eyes back and arrested.

Well, we did just that. We put her left-side down, aspirated the air from the line, pumped on her chest, and she came right back. You never know. “You never see the punch that knocks you out,” as the old boxing coach admonishes. Be aware. As military strategists say, “maintain situational awareness.” Be clueful, not clueless; pay attention. Get your head up.

Supportive environment

Many of your rotations may not be too touchy-feely. Enjoy it when they are, when you are well-supported and nurtured, but be ready to thrive in times of struggle as well. Some of your rotations will be just plain hard work.

One of my previous second-year students rotated on our surgery service at Harborview at the peak of the busy summer trauma season. After working for 20 hours, one Saturday morning at 2:30 we were cleaning up the operating room, transferring the patient to the stretcher, and I looked at her across the stretcher. Exhausted, she exclaimed, “I never dreamed this would be so physical!”

You will be amazed at how hard you will work, and your capacity for work is so much greater than you ever dreamed. Unless you were an athlete in college, or have been through basic training, or have been in combat where your life was in danger each and every minute, you have never worked as hard as you will in the next five years. Savor it, don’t begrudge it; it is done in the name of helping others.

Many of you are already dreading your surgery clerkship. I did, too. I tried to take it in the easiest hospital, the private hospital, where you ate nice food, saw a lot of elective cases, and read and slept the night away. But I lost the lottery and went to the VA. I would never have imagined in my worst nightmare that I would become one of those “surgeons.”

Yeah, I know. I was going to “return to rural America and help alleviate the disparities in health-care delivery,” the same lies you told the admissions committee. Not really lying, but many of us were surely naïve.

Don’t be imprisoned by your naïve, preconceived biases — expecting all to be delivered to your educational table on fine china with linen napkins. Enjoy the fact that you will be surprised and that you will be surprised on a regular basis.

I was pleasantly surprised to find my surgery residents were not the monsters I expected, but very bright and well-rounded as well. My R2 was one of the most incredible human beings I had ever met: a concert organist, sculptor, scholar, and one of the funniest people on the planet. When I go to a national meeting, (and I really hate going to meetings), the first thing I do is scan the large lecture hall for his inimitable physical presence and go sit down next to him and wait expectantly for his first wisecrack. You know the experience of being with old, dear friends; it’s like the past 25 years was just an hour.

Now, not all surgeons are like Bob. Some are a bit testy. Some psychiatrists and internists just won’t fit your preconceived notions. For them, put on your anthropologist’s hat, like Indiana Jones, and visit these strange, curious subcultures of medicine. Learn from them what you can, knowing that you only have to visit this or that strange land for a month or two, not a lifetime. Suspend your disbelief of their strange ways and habits, and live among them to learn their perspective, for each is a vital part of taking care of the whole patient. When necessary, breathe deep and keep chanting; “it’s only six weeks, it’s only six weeks.” I had to do the same while on several rotations. It worked.

Feedback

In this fast-paced world, your learning curve will be steep. People are busy, things happen fast. Everything is prioritized. The hidden curriculum is a reality. You need feedback. It is said that feedback is the currency of experiential education. You have to know what you are doing right, and where you need to improve (or where lie your “top opportunities for improvement”).

As a rule, you will not be given feedback because giving feedback is hard, inconvenient, and uncomfortable. Whole courses have been designed to train people how to do it right. Books have been written about it. It will not happen. It will not happen unless you ask for it. Ask and ask often. Listen when it is given. Act on it: change, grow.

Don’t forget to take care of yourself. Eat right. Eat lunch every six hours: good, balanced food. Stay away from the junk food and excessive coffee. Prioritize your life and your ADLs. (Sorry, I relapse into clinical acronymic jargon. It stands for “activities of daily living.”) If you have 15 minutes, shower. If you have only 10, eat. If you have only five, sit. Change your shoes and socks every 16 hours. After a long night on call, do your morning routine as near the normal time as you can: shower, eat, shave, and dress in clean clothes. You can fool your body, at least for 48 hours.

Don’t become a victim, wallowing in self-pity. When you go home, be a good spouse, friend, and parent as much as you can. You will get to sleep tonight, and tomorrow will be just another day. Thanks to the threat of federal legislation and the wisdom of brave leaders in Congress and American medicine, you only have to be in the hospital for 80 hours a week. Make good use of your spare time to exercise: run, climb, bike, ski — whatever helps you achieve balance. Stay informed about the world around you. Read the paper. Watch C-SPAN. Resolve to make the world a better place. Lord knows, it can surely stand a little improvement. Know that those brave souls who stood up for your rights to have a reasonable work week of 80 (instead of 120) hours are the same individuals who are battling against all odds for your patients’ rights to have access to care regardless of their ability to pay.

So, get your head up. Get in the game. Be an advocate for your patients. Be skeptical of those who wish to ignore that over 48 million people in America have no health insurance and that the No. 1 reason for filing personal bankruptcy in our country is because of medical expenses. Be aware that over 75 percent of those who did file for bankruptcy had health insurance when they fell ill or injured. Be aware that we import over 8,000 doctors from other, mostly poor countries each year because we don’t educate enough to take care of our own population.

So don’t be surprised that many patients will see you as the problem: as big a problem as their cancer, their gallstone, or their broken leg. Be mindful of the insidious pressure of your mounting debt — that it will lure you to a more lucrative specialty. Remember why you decided to be a doctor: to help alleviate the pain and the suffering of your fellow man.

Oow, sorry, I am supposed to be little lighter, to encourage and celebrate you. Okay then:  lighten up, think positive. Pay attention, get involved. Call your congressperson at least twice a month. Don’t despair, get active, be inspired by the words of Margaret Mead:

“Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it’s the only thing that ever has.”

My greatest hope is that by the time you graduate in two short years, you will be able to enroll in the U.S. Health Service Corps and have the same support in helping alleviating the suffering here in our country and abroad that you can have by joining the military. My even greater hope is that you will find that this profession of medicine is what you have been waiting for all your life.

This is it. This is you. This is your white coat. Wear it with pride, conviction, duty, and love. With this coat, we hereby empower you to listen, to care and to heal.

I want to close with a little poem that I wrote to break my writer’s block — to help send you on your way:

Here you sit all broken-hearted,
Palms real wet and hardly started.
Ready to assume the haste
Hoping all ’til now’s not waste.

Mom and Dad, spouse, S.O.,
Friends all ’round to see you go.
From now on you’ll seem to change
Medicine, like life, is oh-so strange.

Once you let go Mom’s warm hand
Into kindergarten, bold new land.
Sat and listened, took good notes
Puked back facts, got good at rote.

Sat there, listened for 17 years
Standing muscles uncommon gear.
But now you go on to the wards
Soleus muscles be forewarned.

Think, answer, stand and breathe?
Where’s the textbooks, notes to leave?
Real-life problems, pain and death,
Oh, so different, too much breadth!

But, wow! This is really why I came
And studied, worried, ignored the flame
Of business, law or dot-com fame.
I am a doctor, my time done came.

Thanks.

— Hugh M. Foy, Res. ’83, Fel. ’84

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