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January 28, 2018

A Reflection on Advanced Doctoring

By Reese Imhof

By Cynthia Chweya

The onset of second year is abrupt and finds many first year students remaining undifferentiated multipotent stem cells at this stage of their medical journey. At the Mayo Clinic School of Medicine, this undifferentiated status is met with graduation to advanced doctoring, our second year longitudinal clinical skills course in tow with clinical experiences largely based in internal medicine. Some say advanced doctoring is an early differentiator of the internists and the non-internists.

As an "advanced doctor" past the halfway mark of the course, the days of ungraceful fumbling in the exam room and punctate history taking are somewhat behind me. I've had my share of real patients, real write ups and patient presentations, real rounds, and ever so real pimping* (read as learning opportunities).

Inpatient workup, presentation, and rounds - the core triad of advanced doctoring sessions sprinkled into the second year curriculum often complement the concurrent organ system block. At this point, it is our mission to master the looks and sounds of normal physical exam findings. After all, who hasn't heard the preceptor mantra "you have to hear enough normal to know abnormal?" Additionally, advanced doctoring represents an opportunity to learn from our group members, preceptors, and patients. More profoundly, it is a generous and humbling introduction to the art of medicine and cultivation of the sacred doctor-patient relationship. When else will we have the opportunity to spend as much time as patients are willing to permit discussing the impact of illness on their lives and uncovering an identity beyond that of a patient?

For me, each patient encounter is a chance to step outside the prescribed stresses of medical school and emerge from the trees to see the forest. Each one provokes a different set of emotions and challenges me to ensure I am worthy of sharing in a person's most vulnerable state. My first inpatient workup experience provoked an unprecedented acute episode of imposter syndrome. As I listened to the patient list her diagnoses, recite a medication list that sent my head reeling, and detail her social history, I was overcome with sadness for this woman I couldn't do anything for except listen. After a few sessions, I eased into the experience and realized that I wasn't expected to know everything. In fact, I had so much to learn from the patients since their knowledge of their condition was expansive relative to mine. Most importantly, direct feedback from patients has taught me not to discount the value of a listening ear for patients who are subjected to a barrage of unfamiliar diagnostic tests, rounding teams, and a shuffle of hospital personnel.

Overall, the patients I have encountered have been generous with their time and gracious in sharing their experiences. No two patients are the same and the range of demeanors has been vast. With a jovial patient, thirty minutes of engaging in normal conversation may pass before reorienting to the hospital environment and the topic of his or her illness. Then there are the difficult patients, such as my first patient. Difficult, not in the sense of being non-compliant or unpleasant, but in the sense of triggering a heaviness of heart. They weigh on my mind because of their tragic circumstance or because it's not with great frequency that I encounter someone quite so ill. These are the patients that have worn down my imposter syndrome and continue to catalyze the assimilation of a provider role into my identity.

In my time in the advanced doctoring course, I have seen many conditions including CREST syndrome, dermatomyositis, acute renal injury, refractory celiac disease, lupus, IgA nephropathy, Churg-Strauss syndrome, and cystic fibrosis. I have solidified the reality of various pathologies existing outside of Robbins and Pathoma, and I have seen beyond the diagnosis to the individual bearing the diagnosis. These experiences continue to provide a sense of renewed purpose to draw upon in the face of minutiae and esoteric detail. As for my differentiation status, I can confidently say that I am unsure of where my medical journey will take me and that despite this uncertainty, the experiences and lessons learned in advanced doctoring will serve me well, internist or not.

*Derived from the German Pümpfrage, pimping refers to the practice of a teacher asking a student a series of questions.

About the Author: Cynthia is a second year medical student from Minneapolis, MN. Currently, she is interested in surgical specialities.  In her free time, Cynthia enjoys reading, Netflixing, taking naps, and going to Zumba.

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