Basic knowledge is fundamental. For example, London has the best cab drivers in the world in large part because drivers spend a whopping thirty-four months preparing for an exam called “The Knowledge” that tests their intimate knowledge of London’s labyrinthine street routes and shifting traffic patterns throughout the day. The exam exists to ensure that the cab drivers will be able to demonstrate not only knowledge of London’s streets, but also the decision-making capability to respond swiftly to a new destination request or emergent conditions. Prospective cab drivers oftentimes need at least twelve attempts at the final test in order to pass.
Similarly, the first twenty-four months of medical school cumulates in five weeks of preparation for the USMLE board exam. Otherwise known as “Step One,” it is an eight-hour multiple-choice beast that medical students must pass in order to qualify for residency training. To describe this experience graciously, it is five weeks of panicked memorization of every enzyme and blood vessel in sight while trying to keep ourselves from going stark raving mad from terror and dread.
The first lesson of third year is that knowing does not preclude you from thinking. A few short days later after the exam, fledgling third-year medical students are thrown into the wards. The shift is a drastic one; our frazzled brains at first recoil in outrage that our patients do not come prepared with a multiple choice list with a “please choose one best answer.” When verbally presenting a plan to treat a patient to my resident and superior, I must quickly volley answers in response a barrage of questions that assess my ability to understand the patient’s shifting needs, as well as the repercussions of the underlying condition.
Medical education is doing its best to catch up to the changing demands of the medical profession; an ever-demanding and ever-complicated health care system demands its providers to navigate a system almost as complicated as the convoluted streets of London. Critical to this progress is developing providers with strong communications skills who can empathize with the patient and the rest of the care team, in order to fully understand the goals of care as well as the challenges of administering care. The New York Times ran a report on the spread of the use of the multiple mini interview, or M.M.I. in the medical school admissions process. The process subjects the candidates to nine short interviews and vignettes with various patient scenarios and ethical questions. Students are graded on their ability to respond on their feet and their ability to work and communicate in teams.
I was lucky enough to learn the importance of patient communication early in my medical career. Last spring, as a second year medical student, I was paired with a nurse for a twelve-hour shift on the hospital in-patient floor. A patient had developed hepatic encephalopathy, a condition where toxic substances accumulate in the bloodstream due to a failing liver which affects mental status. The treatment for hepatic encephalopathy is lactulose (a fact I knew well from my Step One preparation). I had also typed in parentheses on my study flashcards that lactulose has a “laxative effect.” What I didn’t know from my studying and memorizing was that “laxative effect” translates into unremitting debilitating diarrhea. For a weakened 300-pound man over six feet tall, the five-foot trip to the bathroom becomes a humiliating fifteen minute experience. The patient mumbled embarrassed apologies as we assisted in his wiping. Then, painful heavy step after painful heavy step, we lumbered back into bed only to repeat the process a few minutes later.
Later, I overheard a doctor talking to the patient, “I just don’t understand why you are refusing your lactulose.” He walked through the chemistry of lactulose and hepatic encephalopathy, which I myself had tenderly memorized as well. The man refused. After all, all the golden magic of science will fall flat on its face when you just want the diarrhea to stop. I knew how much of an ordeal going to the bathroom was, only because I had been assigned to work with the nurses that day. The man eventually accepted a bedside bowel regimen, a more dignified experience that allowed him to accept the therapy that would save his life.