Advice To The Young Clinician: Practice Makes for Better Practice
Younger clinicians often lament that they need to know it all. It is a misunderstanding. Even the best-seasoned clinicians start out young, green, naïve, and with little clinical experience. When I chose to go into private practice, I specifically sought out a group of several doctors older than myself thinking that I would be able to learn from them. I was not disappointed—and I did not even realize how much I did not know.
Shortly after joining the practice, a venerable and wise senior physician of our group said that I’d find my groove in about 10 years. I was astounded at the thought that it would take 10 years—but he was right. The longer you practice medicine, the better you get at it.
Another academic physician, who had been practicing for 25 years, was urged by his wife to give up obstetrics. When asked why he decided to stay in the field, he said he was just getting good at it.
Understand Your Limits
The young healer must understand that you are not required to know it all during your studies, upon graduation from professional school, or even through further training. But once you are practicing on your own, you are responsible for knowing what you know and being humble enough to acknowledge what you do not know in order to achieve a standard of care.
One of the best skills to develop as a young healer is the ability to simply acknowledge what you do not know. The next step is to evaluate the situation and decide how next to proceed. Simplified, this comes down to whether or not the given situation, in the clinical area you are unfamiliar with, is or is not an emergency. If you come upon a victim of a motor vehicle accident on the side of the road and blood is shooting from his carotid artery, apply compression. This is an emergency. If the patient’s airway, breathing, or circulation is compromised—call for immediate help.
Short of situations as dire as this, most everything else is either urgent or elective. Urgent matters can be clarified by talking with a colleague, picking up the phone, referring to a textbook, or looking something up on the Internet. An urgent clinical issue implies that if you do not attend to the matter promptly, harm may be done to the patient.
For example, a young female patient who presented to the ski patrol with a painful swollen ankle (no chest pain or shortness of breath) could be categorized as someone in need of urgent care. She should have her ankle problem addressed promptly. As opposed to urgent problems, elective problems can generally wait be addressed (eg, a woman who is overdue for her well-woman exam).
Elective clinical problems are those in which you are unsure of how to next proceed, and these can typically wait until you obtain the information you need to make an appropriate decision. A decision to start a cholesterol-lowering agent in a patient for whom you are unclear as to the proper application of the latest recommendations for drug interactions can wait until you have the chance to check the literature.
In researching for my book, Advice to the Healer, I spoke to many physicians and contacted colleagues who I personally hold in high esteem to gain their insights on the art of caring. I asked them whom they considered exemplary figures throughout history—those who practiced the art of caring in a manner to which we all should aspire. Many shook their heads and let their voices trail off after naming only 1 or 2 figures. But when I asked doctors how it was that they learned the art of medicine, most replied that the greatest lessons came from working alongside a revered mentor.
The truth is that all of us look to role models for the types of behavior we want to emulate. This modeling of good practices is one of the most important ways we learn the art of medicine. We practice it and inspire those around us to do the same. Sir William Osler tells us, “The Practice of Medicine is an art based on a science.”1 It entails skills and crafts that we learn from seeing others do it.
Most interns have heard the adage, “See one, do one, teach one.” This applies not only to procedure—directing how to put in an intravenous line or drain an abscess—but also to many of the softer, subtler ways that physicians practice their craft, their art.
Learn From Example
When I was a third-year resident, I remember doing a rotation with J. Roy Guyther, MD, a family medicine practitioner in Mechanicsville, MD. Dr. Guyther was one of Maryland’s giants, who helped develop the specialty from the horse-and-buggy general practitioner to the current residency-trained family physician. Dr. Guyther taught me much about evidence-based medicine and the art of its practice.
I recall one memorable moment in particular. I was watching Dr Guyther help an elderly woman on a particularly busy afternoon. She arrived with a litany of complaints, all of which he addressed, causing him to be even further behind than he already was. Thinking the extended visit was finally over, he walked toward the door. The patient said, “Dr Guyther, there is one more thing.” When asked, the patient said she would like to talk to him about her constipation.
I never expected what happened next. Dr Guyther returned to his seat, and over the next several minutes he took the time to listen to her concerns, ask more details, and help her with her problem.
These “oh by the way” questions—also known as the hand on the doorknob concerns—occur quite often and can be a significant source of stress for the physician as they are interpreted as an inconvenience or obligation.
Often, if physicians do not take the time to address these concerns, the patient interaction is rushed and incomplete. This is as important a lesson to learn as properly completing the procedure to obtain an arterial blood gas.
Another example of this type of approach to medicine comes from Edward Kowalewski, MD, one of the founding fathers of the American Academy of Family Physicians and the first chair of the department of family and community medicine at the University of Maryland School of Medicine, who proved that taking the necessary time to provide thorough and expert care can truly change the patient’s life.
A patient once sought Dr Kowalewski’s help in an office visit, during which he disclosed that he had just killed another man. As the story goes, Dr Kowalewski installed a switch that could be activated from his exam room desk, which turned on a “do not disturb” red light outside the room. Ninety minutes after having indicated that he did not want to be interrupted during this patient visit, the 2 men emerged from the consultation and walked to the police station, where the patient turned himself into authorities.
Many seasoned clinicians describe their experience of learning the essentials of the physician–patient relationship as simply observing ordinary healers doing extraordinary things for their patients. Yet, we learn to be better healers, both through diligent study and committed practice, and by seeking out mentors and striving to model exceptional behaviors. Their lessons have withstood the test of time and should not be forgotten.
Richard Colgan, MD, is a professor at the University of Maryland School of Medicine in Baltimore, MD, and the vice chair of medical student education and clinical operations in the Department of Family and Community Medicine. He is also the author of Advice to the Healer: On the Art of Caring by Springer.
1.The Osler Society of New York. http://www.americanosler.org. Accessed October 2014.
Further Reading and Resources
•McGee S. Oral case presentation guidelines. University of Washington.
•Oral presentation on rounds. Loyola University. www.medicalvideos.us.
•Selzer R. Letters to a Young Doctor. Boston, MA: Mariner Books, 1996.
•Groopman J. How Doctors Think. Boston, MA: Mariner Books, 2008.