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Instructive Ignorance: Reflections from My First Clinical Rotation

By Rich Joseph

Since my last post, I have reached a new milestone in my medical training—third year—the year when we transition from the classroom into the hospital, from the preclinical to the clinical curriculum. Those who have come before me understand that this is a major turning point in one’s medical education where the theory and memorizing from the first two years is put into play in order to manage patients with complex conditions. It is an exciting transition, yet one inevitably fraught with doubt and uncertainty. Consider that for 4, 6, or 8 weeks at a time, you are thrown into a new field of medicine, forced not only to recall and add to your previous knowledge, but to understand the protocols, decision trees, and organization of clinical care. This is not to mention the minor details—how to log onto and navigate patient records on the computer system, how to scrub in for surgery, where the nearest bathroom is, and where and when you are supposed to meet your team. Each rotation brings new expectations, new personalities, a new culture, and even a new hospital! The most apt comparison is traveling to a new country every few weeks and clinging to the locals in an attempt to learn the language, all the while being evaluated on your performance. Hence the persistent angst…

Despite a somewhat rocky adjustment, I see the silver lining. Not only does this year provide a backstage tour of various versions of medical care, but it provides a unique perspective. Consider that third year medical students are novices to a vastly complex world of clinical medicine—the medical industrial complex, if you will. We are starting with an understanding not much greater than the patients we see, minus a few buzz words and pneumonics memorized for our Step 1 boards. The medical institution we enter is as foreign to us as it is to them. They are anxious as are we due to a lack of understanding, an information gap, and impending evaluations. Our perspective is unique in that we relate best with the patients because we are not jaded, we do not cut corners, and we are too ignorant and unseasoned to be overly efficient at the expense of the patient’s understanding.

Through a veil of ignorance, the oversights in patient care, the communication breakdowns, and the patient safety pitfalls are magnified. We are too optimistic and eager to become complacent and simply accept the ills of a broken system. The concern of our one patient is our primary concern because we cannot yet write orders, file for reimbursement, or understand the severity of one patient’s condition relative to another’s. We are too inexperienced to assess whether one patient’s concern is more or less valid than another’s. Ignorance is not bliss, but it is instructive. The fear of our patient is palpable, and the frustration of misunderstanding, conflicting instructions, and discordant care becomes our own. Before going to see 45A, I want to know her name as well as her room number.

The documenting is endless, and endlessly confusing. Certainly there are benefits like having a patient’s prenatal care records easily accessible to confirm essential information at test results when they arrive in Labor triage. We are able to get a comprehensive view of the patient before even entering the room. Yet this is problematic in that we develop preconceived assumptions about the patient before ever conversing face to face. If the records don’t match the story, we become skeptical, untrusting, and frustrated by inconsistencies. And then, with nearly 100 mouse clicks to write orders and compose notes, it is no wonder that errors abound. The patient is immediately deconstructed into formulaic questions with check boxes, and the faster the interaction with the patient, the faster the documenting will get done. With the burden of documenting every detail of every encounter, it is no wonder that encounters become shorter and less frequent. The patient represents more tedious work rather than an opportunity to help.

As medical students, we cannot write orders and our ability to help is limited by our inexperience and limited access. Yet our ignorance provides invaluable insight that those before us have oft forgotten. Often we feel lost, neglected, confused, and frustrated by our inability to help and take an active role. In this respect, we are much like our patients—lost in a system that is supposed to be helping us but is too complex, overburdened, and exhausted to fulfill its most basic function: patient-centered care. 

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