Wakley Prize Essay

Whos meant to be teaching us?

Jo Stutchbury
Lancet 2011; 378: 213637 See Comment page 2060 c/o The Lancet, 32 Jamestown Road, London, UK (J Stutchbury) Correspondence to: c/o The Lancet, 32 Jamestown Road, London NW1 7BY, UK jostutchbury@gmail.com

Whos meant to be teaching you? The harassed registrar looks up expectantly from her bleep. We dont know, three of us chime at once; we know the drill, weve spoken these lines many times. It just says on our timetable ward teaching. The smell of alcohol gel lls the air as we all move to one side in unison, still rubbing our hands together. The porter with his trolley looks back at us with amusement as he passes. If only we would just blend in a bit more. We stare blankly at the registrar. She stares back. Well what do you want to do then? What do we want to do? We want to turn up for teaching to nd an enthusiastic teacher who is expecting us to be there. We want to be taken round in small groups, practising histories and examinations, seeing physical signs and symptoms whilst getting an insight into the patients perspective. We want to be able to ask questions in an approachable and constructive setting, and learn new things. We want no longer to feel that we are an inconvenience to everyone involved, and that we have not wasted the 380 bus fare getting here. And to go home soon if this is not possible. Her bleep goes o again. Maybe see some patients?, I suggest meekly. We can hear someone vomiting in the background. A wave of relief washes over the registrar. She is free from babysitting duty and can now see to the orderly queue of other doctors, nurses, and patients forming behind us, wishing to speak to her. That can be arranged, she smiles as she whips out her handover sheet. You, Parkinsons, bed nine, she gestures to one student. You, MS, bed seven. Another scuttles o. And You, this time its me looking back at the MDU (Medical Defence Union) pen. I wonder if she, like me, feigned interest in their stall once upon a time to stock up on pens. Probably not. Now this lady is an interesting one! Bed two. The others look on sympathetically, relieved not to have an interesting one. Well at least by not having a diagnosis, my patient qualies for a gender. O I trot to bed two, MDU pen in one hand, notebook in the other. Im hiding behind as many ID badges as I can nd, my stethoscope resting round my neck. Its not required of course, just another piece of medical paraphernalia to justify my presence on the ward. Mainly to myself. All the other patients in the bay stare as I enter. I try to look as though I know what Im doing as I reach bed two. No Im not a doctor. Yes, a medical student, third year. About half an hour, then Ill leave you in peace. Thank you. Ill just get a chair.

I pull the curtains around; an inadequate barrier between us and the groaning coming from the next bed. We can both pretend that if we cant see the rest of the bay, and they cant see us, maybe they wont hear every word we say. Judith looks frail, years beyond her 56. And scared. She is happy to talk to me. The longer I chat to you the less time I have to dwell on just lying here, she says, before going on to tell me the short and shocking history of her rapidly progressing neurological symptoms. How, in a matter of weeks she can no longer walk, wash, dress, or feed herself. Usually on taking a history I try and have a stab at a diagnosis. This is partly for the satisfaction gained from applying years of medical lectures to real life situations. For the most part, however, it is because I know that afterwards all I will be asked about this consultation is the diagnosis, and I dont want to look stupid. Quickly encapsulating the horrible experience a patient is having into one, neat medical word, makes it easier to become detached. Diseases dont have families, pets, and hobbies like people do. Equally, and perhaps more worryingly, it helps us feel somewhat included in the medical world. I soon realise that I am out of my depth, just like, as I later found out, everyone else. The conversation naturally becomes less of a medical history and more of a chat. Despite 3 years of medical training this is still my natural territory. I go on to explore her feelings about the situation, the eect it was having on her mood and the relationship with her husband. What sticks with me the most is hearing how she is very frustrated with no longer being treated as a human being. She has been for countless scans and tests, only to nd her symptoms worsening and still no diagnosis. She explains how not knowing was worse than she could have imagined, as there is no named disease, no thing to grapple with, try to understand and digest, or, in fact, treat. She describes how she feels that the doctors see her more as a guineapig or an interesting disease than a woman who would rather be anywhere else right now. Its not the rst time that as a medical student I feel as though Im not the right person to be here or the right person to oer support. Yet, paradoxically, as a medical student I am the only one who is. Im the only one who has the time to sit here for so long, and the only one whom she has not come to associate with numerous investigations and anxiety. I wish her all the best, and say that I hope they nd out what it is soon. And I really do. I leave feeling truly helpless and overwhelmed. Looking round for some of the other students to talk to I realise they are long gone; I have been talking to Judith for an hour.
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Wakley Prize Essay

A couple of days later I pop back to do a quick neurological exam to complete my case presentation for later in the week. Judith smiles on seeing me, although becomes visibly deated when I ask to examine her. She agrees, as long as I am quick, since shes very tired of being poked and prodded. I immediately regret asking. Ive become just another doctor wanting to see her signs for myself. Unlike the doctors, as a student, all interactions with patients are predominantly for my benet, not theirs. These occasions consequently require the condence and conviction acquired from being safe in the knowledge that, in the long run, the inconvenience for this patient will benet countless others after them. This selfassurance is something I still struggle with, and this occasion is no dierent. With a pang of shame I do a token examination, thank her perhaps too profusely, and make a swift exit. 4 days on, we are sitting in a Grand Round. Two cases are presented, and to my surprise Judith is one of them. The doctor presenting her case had videoed the neurological examination to show everyone else her signs. Judith looks even frailer and slightly bewildered, paraded on a large screen, while the doctor waes on in jargon, managing to avoid using any plain English to talk about her. I want to stand up and tell everyone what I had learned about Judith. About how she was far more concerned about her husband who was unable to work, since he relied on her for transport, and the eect that the 6-hour round trip to visit her was having on his health, rather than whether she has a positive Babinski sign or not. But I just sit there. I approach the doctor at the end, keen to hear what they think her diagnosis and therefore prognosis is. He too is clutching an MDU pen. I soon realise that not revealing the diagnosis was not just to test the other doctors; it was because nobody knew. Im shocked to hear they thought she would die soon. So why hasnt she been told? Why hasnt she been referred to the palliative care team? Why are you still doing so many scans, which are clearly causing her so much distress? With a condescending smile he tells me that they couldnt give up investigations and refer her to palliative care until they were sure it was terminal. I wonder whether the doctors giving up on her might actually save her, in many ways. I attempt to describe this muddle of feelings and instincts to some of the other students in the hope they might shed some light on them. They predictably try and have a stab at the diagnosis.

And that was it for my neurology teaching. I expected that to be the last I heard of Judith, since, as a student I almost never nd out the outcomes for the patients Ive met. 4 months later, the picture painted about one patient by a palliative care registrar became increasingly familiar. On talking to the doctor afterwards I discovered she was referring to Judith, and told her about my brief involvement in her case. Although I knew she had probably died soon after I had spoken to her, I still felt my stomach twist when the doctor conrmed this. She had been in hospital for a week or so after I saw her, then was at home for 10 days. I was pleased that she was at home when she died. And they never did get a diagnosis; she and her husband had decided against a post mortem. And Im still left with the question that has troubled me throughout: is it possible to provide holistic care without becoming emotionally involved? As a student I am not in a position to be instrumental to someones care. Yet as a student many things are easier. I still have naivety on my side. I have time to chat to people; and for patients, I seem far enough detached from invasive investigations and medical jargon. Yet, I am able to engage with the doctors and patients about their experiences, results, and prognosis. In a funny way, I did get what I wanted out of that original ward teaching session. I learnt more about medicine than I could have imagined I would on that April afternoon, and just by talking to someone, not about or at them. Whos meant to be teaching you?
Jo Stutchbury is now a fourth year medical student at Newcastle University, Newcastle, UK.

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Imran Mahmud