A conversation I had with a medical student years ago in PBL stays with me. She attended a top high school, graduated third in her class at Dartmouth College and came to UConn School of Medicine. She was (and is) a high-achiever, accustomed to placing well on exams and class rankings. Her name is Amy. She is now well through residency in New Hampshire.
She told me this: “By the time I showed up at medical school, I was pretty accustomed to being the smartest person in the room. Now that I’m here and have taken several exams, it turns out that there are many much smarter people in this class… and so I’ve had to reinvent myself as ‘average’. The bell curve applies to medical students, too, I guess. Also, I’ve gone from obsessing over grades most of the time to simply hoping for a 70% on that last tough exam” (which represents a pass in a pass-fail curriculum).
In observing brand-new medical students over the years in PBL, I have noticed that the first semester of medical school often requires some mental adjustments and perhaps a time of internal re-invention for them. Some of their comments echo what Amy said years ago, about a necessary transition from placing first in their class, to getting scores solidly in the middle of the bell curve. Which is still a Pass in medical school.
Author Stephen King in his 2007 book, Lisey’s Story, writes about the critical thinking/decision-making that the two main characters go through as dire things begin to happen (as things always do in Stephen King novels). The process for gathering their courage is defined as SOWISA (an acronym for “Strap On When It Seems Appropriate”). This analogy leads me to consider other analogies or acronyms used in general life (or medicine) such as:
– SWOT: Assess the Strengths, Weakness, Opportunities and Threats of a course of action. SWOT as opposed to SWAT (Special Weapons And Tactics) which is the polar opposite of the first line of the Socratic Oath which states “First Do No Harm”.
– PERRLA: Pupils Equal Round Reactive to Light & Accommodation
– TLC: Tube, Lavage and Charcoal (given to a poisoning victim)
– SVRI: Something Very Wrong Inside
– TLC: Tube, Lavage and Charcoal (given to a poisoning victim)
– GOMER: Get Out of My Emergency Room
– ABCDE Angina Treatment Mnemonic. The ten most important treatment elements of stable angina management are: A = aspirin & anti-anginal therapy, B = beta-blocker & blood pressure, C = cigarette smoking & cholesterol, D = Diet & diabetes, E = Education & exercise
Ambiguity is an element in life, whether we disapprove of it or embrace it. When a life stage or course of action is unplanned or unclear, a positive opportunity may appear in that lack of a plan. In life – as in medicine – a planned course of action never represents a guaranteed (or even a positive) outcome. Learning to become comfortable with uncertainty and ambiguity is important aptitude as we (and our loved ones) age.
A patient being told by their physician: “With this disease [that you have] our best course is to take a Watch and Wait approach”. That can sound pretty ambiguous. How long does one watch and wait… a lifetime, two months, six years… ?!
This leads me to describe an acronym used in my life, which is Holy Crap! Straighten Posture, Stand and Deliver, or HC!StDeliv. Following are some instances when this acronym has come in handy:
- 19-year old know-it-all enrolls in Large University. Parents drive her (4-hour trip from small hometown) to campus, unpack car, start ignition, drive away. 19-year old (in tears) says, I don’t know a single person here! This turns out to be a positive element, as one moves from having everyone knows your name, your mom and dad, your brother, your grandmother and all your business, to being anonymous – at last! Good deal, straighten posture, make some friends, HC!StDeliv.
- Former know-it-all, now a 22-year old graduate student in Fine Arts. Dean of Fine Arts walks her down the hall, into an empty classroom and hands over a sheet: “Here is your class list. There are 22 freshmen students in your basic design course, they’ll be here in about ten minutes, good luck”. Holy Crap — think fast! What do they need to know about learning to draw? Straighten posture, take a deep breath, HC!StDeliv.
- Some years later. Young mother gives birth, baby is beautiful and healthy. A week later, at 7:11 am, anxiety sets in when tired husband puts coat on. “Where are you going? Well. I’m going to work for the day… I’m the sole breadwinner now. Bye”. Door closes, ignition starts, car and husband drive away. Gulp. Babies don’t come with written instructions, so figure it out. Straighten posture, look at adorable newborn. HC!StDeliv.
- Fast forward. A long illness, a parent’s funeral, the hardest thing. Come back to the family home, where two generations have lived. Stoical brother says, “No Naps. Time to pack it up, take what you want, the new owners will be here in 2 days”. HC!StDeliv. Goodbye, childhood home.
- Fast forward again. Husband comes home, says “I was laid off today after 12 years at the company. Now you’re the primary breadwinner”. Former adorable baby is now Kid in College! Holy Crap! Straighten posture, stand and deliver (and go to work).
A veteran oncology nurse once said to me, “We lose a lot of people in this business. Some we cure. Those are our success stories. For some patients there is no therapy that we can offer that will help them in the long-term. Mostly it’s the youngest patients who are the hardest to lose…”
Numbers needed to treat, responders, non-responders, few guarantees. Type 1 Errors versus Type 2 errors. Patients (like babies) who haven’t read the clinical textbooks and don’t come with instructions. Some patients can’t be helped. If their early results are favorable, over time a different patient will die from an unrelated illness, or be lost to follow up. A clinician may never learn of their long-term outcome.
A physician once explained in PBL: “ 80% of the time, the patients’ presentation is straightforward, the treatment is standard and well-documented, we can have confidence in a fairly certain outcome. 20% of the time: the patient hasn’t read any of the textbooks, he presents totally unlike any other previous case you’ve seen…. that’s when you get into the uncertain territory, without a standardized course of action “.
Holy Crap, straighten posture, Stand and Deliver.
Following are a few reference sites which were used for details about Medical Acronyms: