(All patient names have been edited to ensure anonymity.)
“I want you to know that you’re such an accomplished person for being here, and I hope the rest of your day is nothing but happy,” Mr. Lebowski said to me.
“Thank you so much, Mr. Lebowski, I wish you the best as well,” I replied on my way out to finish the rest of my pre-rounding. It was the first day of my neurology rotation, and the slog of clerkships had very much been getting to me. I was already counting down the weeks until the end of the year, even though there were four months left. Mr. Lebowski was a patient that I’d never see or hear from again – he was scheduled to be discharged to a skilled nursing facility later that day, and my senior resident had just assigned him to be my patient because I needed someone to present on during rounds that morning. That interaction ran through my mind for the rest of my day. It did in fact make me happier, brightened the rest of my day, and honestly, the rest of my rotation.
Mr. Lebowski knew he would most likely never see me again. He had no idea who I was, what I was thinking when I walked in to go see him, or that clerkships had been getting me down. His problems were far worse than mine – he had bilateral leg weakness that rendered him almost unable to walk, and no one knew what was going on. Yet through two sentences, he changed the way I approached my day, my rotation, and made me feel that much happier as a result. He helped me to realize that as clerkship students, we have a unique opportunity that we might never have again. We are given a fresh perspective and ample time to be mindful and empathetic with our patients.
For every Mr. Lebowski in the hospital, someone who feels on top of the world despite being stuck in a place that can bring the best of people down, there are many patients who are extremely worried, and for good reason. Having health problems can be extremely stressful for people even if they have a complete understanding of what is happening to them due to the uncertainty about the future. This uncertainty is only magnified for everyone outside of healthcare who could have both a very limited understanding of what is going on and what this means for them. Further, many parts of healthcare are terrifying, especially when poorly explained. For example, think about how it would feel to be lying on a bed in a shiny pavilion OR while one anesthesiologist is sticking a weird mask over your head, another one is sticking needles into you willy-nilly, the nurse is opening a huge metal box with more surgical instruments than you’d ever thought you would see in your lifetime, and the surgeon is in the corner discussing this morning’s M&M with his residents about how a patient slid off of the operating table during the surgery.
As clerkship students, we have a unique advantage in our ability to help reassure these patients. We aren’t desensitized to medicine just yet – like the anesthesiologist who intubates 5 patients a day or the scrub nurse that handles 5 surgery kits a day – but we know just enough about medicine that we can be reassuring to patients and enjoy the responsibility of their trust. Basically, we can realize how insanely crazy the situations that patients go through are because we are not used to them, and therefore we are better able to show empathy and be compassionate towards our patients because we have not gotten used to the medical world. Additionally, many patients view us as a part of the medical team so our reassurances carry additional weight, which means our increased ability for empathy and time to spend with our patients becomes even more powerful. One of my amazing classmates told me about a similar episode when a patient getting ready for bariatric surgery was being poked and prodded as I described above. In this moment, she was able to both recognize the discomfort that the patient was going through and had time to do something about it, so she stood next to the patient and held their hand until they went under from the anesthesia. After the surgery, the patient wanted to thank the surgeon, but also sought out my classmate to give her special thanks and told her how much of an impact just that simple act of being present for the patient had for them.
Herein lies one of the biggest ways we as clinical medical students can effect change in the hospital. On rounds, most of what we say during our presentations are things that the team already knows. Many times, we make recommendations that we think are novel and well thought out, only to find out that the team had already thought about them yesterday while we were at didactics and enacted or disregarded them. With this aspect of medical education, it can be easy to feel disheartened, to feel like while we are learning a lot every day we come to work, our actual work is making minimal impacts in the lives of our patients. But to subscribe to that line of thinking would be to disregard our greatest strength as clerkship students. Routine things in the hospital are foreign to us, and as a result, we can recognize how hard it is for patients and families to struggle with whatever medical issues (along with psychosocial issues) are afflicting them. While our attending neurologist has probably seen thousands of patients with lower extremity weakness and an inability to walk, we have seen less than five, and therefore are better able to appreciate how much of a deviation from the norm the patient is enduring, and therefore, are better able to provide compassionate and empathetic support. Further, we are one of the few members on the team that has the time to act on these feelings of empathy and compassion. Therefore, as medical students, while we have to get to every patient in the morning to pre-round and prep our presentation, we should be cognizant of how much asking about a patient’s grandkids or about the prep they’re doing for their son’s wedding can mean. More than anything, we must practice stepping out of our whirlwind of minute stresses concerning round presentations or team impressions to be present and mindful of what our patients are going through so we can do our part to make their hospital experience the best it can be.
When thinking about how to improve patient care in the hospital through mindfulness, it is important to realize that not only can we impact patients, but also patients can impact us. Some of these patient experiences can be positive, like that of Mr. Lebowski, but some of them can impact us negatively. In my psychiatry clerkship, we were treating Mr. Arramide. He was an older man, who came in with extreme treatment refractory depression and obsessive-compulsive disorder. He had attempted suicide a year earlier and since then had become obsessed with the idea that he was having significant cognitive impairment due to having suffered an anoxic brain injury during his suicide attempt through toxic ingestion. Despite the mountain of evidence to the contrary, he was admitted to our ward for a major depressive episode secondary to his worries about his cognitive slowing and a feeling of life being not worth living if he had to suffer with a mind that wasn’t in tip-top shape.
Because of Mr. Arramide’s perceptions, as a team we would have to see him separately after rounds because he would stop us every day and ask the same questions about whether we thought his Anaphranil overdose caused an anoxic brain injury. We would have to answer the same questions every day, for half an hour or more, and within these sessions, he would repeat the same questions over and over again and question our team’s medical judgment.
One day, after a particularly difficult encounter with Mr. Arramide, before we sat down to finish our notes for the day, our attending called us over and asked us, “How did that encounter make you feel?” We were all confused, so he started off and said, “I hate the guy. I think he’s really annoying and just never want to talk to him. He’s one of the least likable patients I’ve ever treated.” I was shocked at what my attending was saying – was he just openly blasting one of his patients? But he continued: “But when we encounter difficult patients like him, I think that it is really important to acknowledge how they make us feel. It’s important and our responsibility that we separate our feelings about the patients from the care that we provide, and to separate our feelings, we must first be aware of our feelings.” My attending’s honesty taught me a lesson that I think is critical to ensure mindful patient care. It is human to be reactionary to the patients that you encounter. Being free from emotional impulses is almost impossible; it is part of who we are. It is very easy in everyday life to get carried by the wave of these emotional impulses and have them influence our actions without even realizing that it is happening. However, as medical professionals, it is our responsibility to be aware of these emotions welling up inside of us so that they don’t impact patient care and the decisions that we make. The first step toward achieving this goal is to acknowledge that these emotions exist so that we can be better at putting them aside in the moment and address what needs to be done when we aren’t working with our patients.
Importantly, while these emotions can be on the scale of the anger that Mr. Arramide was evoking in our team, they can also be the little emotions and thoughts we feel day to day. Most, if not all clerkship students, have fallen prey to wishing that the last surgery gets canceled or that the last patient doesn’t show up to clinic. It is only human to want to get home early, and as clerkship students, we are not going to have as much of an impact on how the surgery or the clinical visit goes. However, as we progress in our medical training, we could be the resident conducting a visit in a resident clinic or an attending conducting the surgery, but we will still be human and want to get home some days. When we get to this stage, we will have a greater impact on patient care, even full responsibility for the patient sometimes, so it is important starting now to be aware of these emotions, acknowledge these emotions, think about how they might affect our patient care, and set them aside so that we can give our patients our best. There is nothing inherently wrong about having emotional reactions to the world around us – it is part of being human. But, part of our duty as future clinicians is to provide the same patient care to every patient, regardless of our emotions.
My most important lessons learned about mindfulness this year have been about balancing clerkships with the rest of my life. I’ve learned that clerkships aren’t just about learning how to handle yourself in the hospital and clinical medicine. It’s also about learning to balance clinical medicine with the rest of the important parts of your life. We’re not just learning cardiology this year; we’re also learning how to work hospital hours and go on dates with your significant other, maintain relationships with our family, see our friends, and most importantly, take care of ourselves. The most important part of my mindfulness practices this year has been learning to step back, look at the bigger picture, and remember my priorities.
If you take nothing else away from this article, remember that Penn will make sure that you match well. Just looking at their past match lists will confirm this for you. Keeping that lesson in mind just makes clerkship year that much more palatable. Yes, it is very important to work hard, but it is also just as important to invest in your relationships because they are what will get you through the slog of clerkship year and residency. UWorld will literally always be there, but that random college friend who happens to be in town and texts you won’t.
These were just a couple of examples of things that were important in my life, and what is important in your life might be different. The important thing is to go into clerkship year with an idea of your priorities and keeping them in mind as you make your decisions on how to spend the limited time that you do have. What works best for me is to take a step back, think about two facts: first, the probability that one singular clerkship grade will affect the long-term trajectory of my career is minimal, and second, even if I don’t do as well as I hoped, Penn’s got my back.
My biggest takeaway of this year is that with the demands on our time and the suffering we witness, it is incredibly important to be aware of the mental health of both ourselves and of those around us. My interaction with Mr. Lebowski taught me how important and impactful it is to be there for our patients as a medical student, and Mr. Arramide taught me how important it is to be mindful of my emotions while providing care. Being aware of what is happening with both your patient and your mental state while you interact with them can have such a large impact on both of your states of mind. Being aware of the subconscious choices that you make with how you spend your time and their consequences with regards to your larger life during clerkships will make your quality of life that much better and make it that much easier to get through the bear that is clerkship year. And MS2’s, if you take nothing else from this essay, just remember – you will make it through the year, and regardless of what happens, you will be an amazing doctor in 10 years.
Pranav Rekapalli is an MS3 at the Perelman School of Medicine.
Image by Phoebe Cunningham, an MS2 at the Perelman School of Medicine.
