As part of the graduation requirement for my biology major during my senior year in college, I needed to take an upper-level course. I settled on a general neuroscience class. I knew it would be quite a challenge, but I reasoned that at least I could gain some insight into the inner-workings of the human mind, an area to which I had not previously been heavily exposed. Luckily, the course developed into my favorite undergraduate academic encounter and piqued my interest in the field.
As a first-year medical student not so long ago, I eagerly awaited the much-lauded Principles of Neuroscience portion of our curriculum, and it certainly lived up to its billing. Yet again, I found myself ardently enjoying nearly any topic that in some way related to the human nervous system. Now, in my third year, I am finally able to see real-life cases of what previously had been clusters of words and diagrams in textbooks. But more importantly, I have for the first time been directly given the wonderful yet frightening charge of caring for the people behind these medical cases.
At the close of my third rotation of the Major Clinical Year, I still strongly feel that we third-years have an incredibly dauntingseemingly impossibletask ahead of us. Most of the first two years has been spent attempting to learn and retain as many details about the mechanisms behind the body's organ systems and relevant disease processes. On the wards, we are required to assemble those details into clinical composites that will explain our patients' medical conditions. Of course, this is most often much more easily said than done. Personally, I have reached a stage where I feel relatively confident analyzing a patient and describing what I see, but the gap between this descriptive capacity and the aptitude to apply it accurately to a patient's situation is mammoth. Finding a relative afferent pupillary defect, or a pupil that does not react to light, is one thing; understanding the patient's underlying syndrome is quite another.
In Oliver Sacks' "The Man Who Mistook His Wife for a Hat," the renowned neurologist and author describes Dr. P., a musician whose neurological condition restricts his ability to interact fully with life around him. Specifically, Dr. P. is unable to assemble the details of his life into a comprehensive picture. He relates to the external world by struggling to remember minutiae that are characteristic of an object, rather than automatically understanding the object's intrinsic nature in totality.
When Dr. Sacks hands the patient a glove and asks him what it is, the response is eerily mechanical: "A continuous surface infolded on itself. It appears to have five outpouchings." He has no concept of the glove in its entirety or of its use, being able to focus solely on abstract details. Sacks compares Dr. P. to an automaton: "It wasn't merely that he displayed the same indifference to the visual world as a computer buteven more strikinglyhe construed the world as a computer construes it in an identi-kit' waywithout the reality being grasped at all."
It is not a great stretch to compare these characteristics of Dr. Sacks' patient to those of a third-year medical student. On the wards, we are continually challenged to describe what is within reach. We are not grasping a glove, but the outstretched hand of one in need. At this early stage, however, our task often appears no easier for us than does Dr. P.'s task to him. Fortunately, we can continue to improve, whereas Dr. P. is doomed to live in a "world of lifeless abstractions." Eventually, we will reach a level of experience where the integration of signs, symptoms, and data is as customary to us as the description of these concepts has already become.
Of critical import for all students developing their clinical skills is the knowledge that there are two distinct aspects to this integrative ability. First, as stated above, we must continue to practice using and applying our illustrative facility and basic science knowledge so that we are eventually able to gain a sense of the "scene-as-a-whole," as Dr. P. could not. Improvement of this analytical skill eventually occurs after much repetition, trial, and error. But such development occurs at all U.S. medical schools.
One of the most remarkable aspects about P&S is that we students are instructed early in the first-year, indeed from the White Coat Ceremony, not merely to treat disease, but to treat patients. We cannot act as emotionless robots but as caring individuals who respect and understand the plight of our patients.
Of course, I will wake up tomorrow and walk to the hospital, fully aware of my inadequacies as a medical student. I will examine patients and give my opinions about their conditions. And I will be wrong. But I am secure in the knowledge that I will be less wrong tomorrow than I was yesterday. Moreover, I am focused on providing the utmost care for my patients' well-being, not just for their illness. This commitment is a lesson from Columbia I will never forget.
William (Rusty) Vance Shappley III is a third-year medical student at P&S. He wrote this piece in October 2002.