Progress Notes

How fears change

Anup Shah
Anup Shah

By Anup Shah, MS4

When medical students start their clinical rotations, there seems to be a fear that comes with presenting a patient to residents and attendings. A large part of it has to do with individuals worrying about their evaluations, and what the rare but ruthless resident or attending may write about our performance. And everyone knows that a single bad evaluation can destroy your grade in a rotation, no matter how hard you work.

The first time I had to present a patient was on my pediatrics rotation. Nobody had ever explained to me how to present a patient. Apparently, there’s a system known as the SOAP note. Subjective (what the patients says), Objective (what the labs and test results say), Assessment (why the patient is there) and Plan (what you want to do for the patient). Now in my fourth year, this is second nature to me. But when I failed miserably once with my pediatrics resident, I wasn’t surprised when I ended up with 2/9 down the board on my evaluation.

Additionally, whenever we’d present history and physicals for new patients, I’d never know what was the important information that my attending wanted to know. It was a constant game of “What are they thinking?”  Those that could read minds best are the ones that end up with the best scores. When it came time for feedback, we often received the same non-constructive response: “You’re where we expect you to be, you’ll improve with time.”

The fact that our grades are almost solely dependent on these subjective evaluations breeds a fear in medical students that I came to realize as detrimental to my development as a physician. This fear, I’ve found, is misguided.

I feel lucky enough to have recognized this early on, and upon reflecting on my presentations I figured out what exactly I needed to work on. The conclusion I’ve come to is that expanding your knowledge base is the only way to improve your presentations. Not speaking quickly. Not writing every tidbit down in microscopic handwriting on a single sheet of paper. But knowing the right questions to ask and being effective in your presentation comes from knowing what can cause that condition. For example, if someone comes in with blood in their urine, it’s important to ask whether they’ve had kidney stones, trauma to the genitourinary tract, history of strictures (or narrowing) of the urethra, urinary tract infections, bladder or kidney cancer, etc. This may not be something a second year student would know.

In the last year, my fear has transformed from not presenting well to not knowing something important about my patient. I’ll use another example in urology, since that is the field to which I’m applying. If a patient comes in with bladder cancer invasive into the muscle of the bladder and the plan is to take out their bladder and create a new one using the intestines (aka radical cystectomy with neobladder formation), my biggest fear is not knowing something about the patient. What if they’ve had surgery on their intestines before? What if they have an allergy to the antibiotic we give them during surgery? And the absolute worst – what if the patient already has signs of metastatic cancer? In this case, a cystectomy would certainly not be the right treatment.

The fear of not doing the best for my patients has transcended any fear I’ve ever had of receiving a poor evaluation. Sure there are many levels above the medical student to catch you if you falter, but I think this is the first sign of my classmates and I becoming true doctors. When I started to feel this responsibility to my patients is when I stopped caring what the attending thought of me. I care more now about what information I didn’t gather, what questions I still need to ask, and the best intervention we can provide for our patients.

I think this is the best kind of fear to have. It’s what will make us great doctors.

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