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Teaching and Learning Moments

Notorious

Fisher, Joslyn W. MD, MPH

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doi: 10.1097/ACM.0000000000003761
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“Sam was a truly outstanding student … our attending this month was notoriously rigorous in her questioning on patient histories, and Sam always knew her patients forwards, backwards, and sideways.” As I skimmed the evaluation comments about Sam, a fourth-year medical student for whom I was writing a recommendation letter, the words slapped me in the face. I paused. I re-read. Yes, I agree—Sam performed well. But … the attending was notorious? I looked up the definition to ensure I was remembering correctly. Yes—it has an undesirable connotation. As per Merriam-Webster, it means “widely and unfavorably known.”

The comment may not have been about me—students work with 2 to 4 attendings per month and are evaluated by multiple residents. Still, I suddenly felt confronted with indirect, and negative, feedback. With a sense of guilt, I questioned my approach. Do I expect too much of my learners? I have noted the residents’ impatient feet shifting when I take too much time with patients at the bedside. Are the details of the history that important?

I mulled over recent teaching encounters with trainees, particularly ones where rigorous attention to the social history led to positive outcomes. Dan, a third-year student, discovered that our patient hospitalized with a severe COPD exacerbation, now requiring home oxygen, did not have a home—a vital detail prompting earlier social work intervention. Dr. Randall, a second-year resident, recognized that her patient complaining of fatigue and shoulder pain had a new grandbaby in the home causing sleepless nights and requiring much lifting—thus explaining her symptoms.

One experience is engraved in my memory, though. Watching Mr. Boda, cachectic, bloated with refractory ascites, and repeatedly hospitalized, our team felt helpless to remedy the system that was failing him. When able to work, he scraped together enough for living expenses; however, this meager income disqualified him from discounted care in our county health system. He was listed as “undocumented”—not eligible for Medicaid in Texas. One day while rounding with the team, feeling like we had exhausted all accessible resources for our patient, we probed further into his social history. Mr. Boda explained he was originally from Sudan and followed with, “I am a Lost Boy,” one of the thousands of children orphaned during the civil war there. Upon discovering this new avenue for our patient as a refugee, we were able to find more support services to meet his chronic medical needs and our hope was renewed.

Encouraging learners to go beyond asking patients about tobacco, alcohol, or drug use has led to rich, clinically valuable histories. It seems clear that knowledge of key details of the social history positively enhanced the care that we provided our patients. Why then would the expectation that students rigorously gather patients’ important details be interpreted as a negative quality? It is true—ordering a CT scan can be done more quickly than soliciting a patient’s social story. Certainly, learners would not disapprove of a comprehensive exam revealing a cardiac murmur or a thorough interpretation of abnormal labs that had direct consequences for patient management.

I pondered the possibility that I had become outdated—that the newest generation of physicians-in-training now relied infinitely more on the power of technology to develop a meaningful assessment and plan. Or perhaps the link between history and patient outcomes is more obscure. As a teacher, I can do better. If learners find it tedious to explore patient histories, I must strive to effectively clarify the connection between rigorous patient history-taking and the clinical impact that these findings can have. Perhaps I can foster a compassionate and relevant approach to clinical care, not a notorious one.

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