February 11, 2010

There have been so few postings on here because, apparently, people have begun to find out about this blog. Suddenly, the simplest post becomes even more nerve-wracking. It's even harder when you realize that the people you write about may actually be reading this thing.

It's a question of confidence, really.

In thinking about my extraordinary inabilities to actually post on this blog, I realized that much of medical school has been about the development of confidence. And not necessarily by increasing competency, but rather, we're taught at the minimum to portray a phenotype of outward confidence.

This lesson is often taught in  one of the rituals of teaching in medical school known as "pimping"-- when the resident or attending physician asks a series of questions where the student must answer on the spot. Much has been written about its efficacy (and pitfalls), but in the proper hands of an experienced physician-teacher, pimping works very well in engaging the student and transferring knowledge.

The secret un-spoken lesson that is taught, however, is that sometimes you need to exude confidence even in the face of complete uncertainty. One of my attendings was very explicit about this fact, embodied in his sometimes-not-so-gentle ribbing of students who would answer his questions awkwardly or in the tone of a question. In the OR, he might ask, "What innervates the section of the foot I'm cutting?"

"The superficial peroneal nerve?" you might answer.

"I don't know, you tell me!" he might reply. Or, he might ask why you're asking him. Or, he might just blatantly accuse you of answering his question with another question. You quickly learned to give the answer in a direct tone, even if you didn't have the least bit of a clue as to what he was talking about.

One day on rounds, we had started to joke about these almost-cheesy responses to our answers, he suddenly explained himself. "When you walk into a patient's room to tell them they have cancer," he said, "you can't be wishy-washy about it. Even if you have no idea what's happening, you need to be confident in your plan."

At that moment, I couldn't help but think about how I would personally respond if my physician gave me bad news, filled with "ums" and hints of uncertainty.

Our attending's point wasn't that we should deceive our patients, nor misrepresent how much we knew. In fact, he encouraged us to be honest with our patients about our knowledge or uncertainty, but to be certain and confident in our mannerisms and the next steps we would take.

A similar lesson is found in our interactions with standardized patients, who are all real actors with fake illnesses in fake clinic rooms with hidden cameras. Every effort is made to ensure realism, but sometimes it's hard to forget you're being videotaped and that nothing is real. And in these simulation sessions, I found it horribly ironic that outside of our medical knowledge, what we're really being assessed for is our acting abilities-- and sometimes explicitly so. "I didn't feel you had any empathy for me," I once heard a standardized patient tell one of my classmates. "You either need to get some empathy or learn how to fake it."

The hidden lesson is many of these simulations is that we need to present ourselves in a certain manner-- one that is empathic, confident, and caring, despite what we're actually feeling inside. Of course, ideally we should be expressing these factors genuinely, but at an absolute minimum, we need to know how to fake them if the need arises.

In the past year, I've learned to be more confident despite my own ignorance--  becoming more confident of my own ignorance. I do genuinely care about my patients, but I'm also very aware of my own gaps of knowledge as a medical student. I stride into a patient's room confidently. "My name is Howard, and I'm a student doctor," I'd say. "I'm the lowest person on the ladder here, and I have the least amount of experience. But, I usually have the most amount of time. Feel free to ask me any questions you have, and if I don't know the answer, I'll find it out for you. It's my job to make sure that you know what's going on."