Leadership: Teaching and Learning Moments
As medical students annually make the transition from the basic sciences to the clinical years, significant challenges arise. The learning methodology in basic science course work is not greatly different from most undergraduate plans of study. However, the experientiallearning that is the essence of clinical science training represents a profoundlydifferent world; this unfamiliar environment of human illness and suffering is vastly more complex than the mundane confines of the classroom.
This different world of intensely personal patient care experiences shapes one's future attitudes and perspectives. As an introduction to my clinical years, my first assigned patient on my surgical clerkship was a young man just two years older than I was at the time. Suffering from significant abdominal pain and gross hematochezia, he was admitted directly from the state penitentiary where he had been incarcerated for a felony conviction. The colonoscopy revealed a 12-cm fungating mass at the splenic flexure obstructing his large bowel. He had an emergency laparotomy with subtotal colectomy to relieve his impending bowel obstruction. The pathology was positive for mucinocystic adenocarcinoma and abdominal CT scan revealed widely metastatic disease.
As I took care of him with the other members of the general surgery team, I discovered that we both grew up in the same city and went to rival schools.With the support of my parents and friends, I was successful through high school, whereas he, living with only his single, absentee mother, had a horrible home situation and dropped out early to try to make it on the streets. His first transgression with the law was at the age of 17 when he was caught shoplifting at a convenience store. Coincidentally, my first (and hopefully last) transgression with the law also occurred at 17—shoplifting at the college bookstore—and my charges were eventually dropped. The shoplifting charges against him were eventually dropped, too, but he continued to break the law, and when he was 21 years old, he had been convicted for assault with a deadly weapon. By the age of 21, I had successfully graduated from college and entered medical school. Two years later, our life's paths converged during my surgery rotation.
Through him, I learned a great deal about colostomy wounds, colostomy bags, and skin breakdown. I learned how to put in a central line and how to write for TPN orders. I learned about liver failure, ascites, chronic horrible pain, morphine drips, and palliation. I learned how important it is to really talk with your patient, to try to offer comfort and explain the limits of medical science. I also learned that life is not fair. Despite being raised in the same city, our worlds and our lives were so different. I reflected on the fact that if he had stronger mentors or if my parents would not have been so supportive, our current paths could have been different. Two days before my rotation ended, he fell into a coma and died.
I share this personal story with some of my present clerkship students as an introduction to the different world into which they are now embarking. It also serves as a reminder of the different yet similar worlds our patients share with us.
Jeffrey G. Wong, MD
Dr. Wong is senior associate dean for medical education, Medical University of South Carolina, Charleston, South Carolina.