Monthly Archives: November 2014

Deliberate Practice

I’ve never really spent much time looking at the bricks inlaid on the path that runs past the Li Ka Shing Center, but yesterday morning I snapped pictures of the following words while on break between lectures.  I was trying to catch an impression that I wanted to write about without exactly knowing what it was, but today I think I know.

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It came together after reading from the Harvard Business Review.

I hadn’t realized how breathtakingly relevant pieces from this journal could be to my training in medicine. As part of my Managing Difficult Conversations class, however, I was reading through an article in the HBR this morning when the following sentences jumped off the page and into my lap like an oversized tabby cat:

“Not all practice makes perfect. You need a particular kind of practice—deliberate practice—to develop expertise. When most people practice, they focus on the things they already know how to do. Deliberate practice is different. It entails considerable, specific, and sustained efforts to do something you can’t do well—or even at all.”

This was particularly relevant because, just yesterday, I was mulling over how I am hesitant to do some parts of the physical exam when working with actual patients. The parts where I’m not yet confident of my skills.

Certain things I’ve practiced enough to feel mostly comfortable with—for example, placing the stethoscope in the four positions on the chest wall to listen to the heart. And some things are straightforward enough that they are no longer intimidating.  I am confident while feeling for the rush of blood through the carotid arteries, listening for bowel sounds, or examining the extremities for edema.

Other things leave me feeling like I’m approaching a forest with mist swirling about my feet. How exactly do I test strength and reflexes in a patient who is unable to leave the hospital bed?  Is that really the thyroid gland I’m feeling…or should I ask them to swallow one more time as I feel for the subtle slide of lobes beneath the skin? What if I forget to test one of the cranial nerves while doing the neurological exam?  What if I don’t feel something that is there, or if I think I feel something there that isn’t?

What if I mess up?

For me, our Practicum sessions this quarter have brought some of these anxieties to the forefront of my consciousness. In Practicum, we spend an afternoon in the hospital every other week, and during this time we each meet with an assigned patient to gather their history and perform parts of the physical exam. After the history and physical, we join our preceptor and present our patient’s case in (what is hopefully) a concise, organized manner. All this comes together to prepare us for when we start our clinical rotations, and it is an invaluable opportunity to gain actual experience in the hospital setting.

As I reflect on my own performance, however, I realize that my times of practice aren’t fully yielding the dividends I seek. This isn’t a fault of the sessions–Practicum gives me all the opportunities I need.  Since a good portion of my time is spent alone with my patient, I am the one who decides which questions to ask and which physical exam maneuvers to perform.  And as a student, I have the rare gift of time to do so.

But I have been drawn towards the things I already know how to do fairly well. I have the human love of discovery, but I also very much have the human love of competence. It’s uncomfortable pushing myself out onto the tight wire that spans the cliffs between what I am and what I can become.

As I read on, one other sentence in the HBR article caught my attention.  It especially stood out since we’ve been receiving coaching on how to improve the cohesiveness, clarity and delivery of our oral presentations in Practicum:

“Bear in mind that even Winston Churchill, one of the most charismatic figures of the twentieth century, practiced his oratory style in front of a mirror.”

It’s awkward to do so, perhaps, but this echoes what I’ve told about improving my presentation delivery by practicing out loud on my own.  More than any other time since starting medical school, I’m sensing that the way forward is through focused, intentional practice above and beyond what I would normally do in my sessions.  I need this deliberate practice–the sort of practice that drives me into the realms where I am not skilled, past all the whispering shadows of fears that would try to keep me out.

By embracing the discomfort of what I can’t do well, I will be in position to move forward in the way I need and want to.  I know who I am and who I have been; I am not one to back down in the face of challenges.  But somehow, my journey as a medical student is revealing vulnerabilities that have laid latent within my soul.

That’s okay, though.  As I talk with some of my classmates about these areas, I find that I’m not alone in how I feel.  We all have our own uncertainties, hopes, visions and vulnerabilities, and although on individual journeys, we’re still in this together.

I’m excited to see how far we’ll all have come a few years from now!  And since I’ve realized how to engage in deliberate practice, I’m not as afraid of falling short of my vision of who I want to be as a third- and fourth-year medical student.  I have a plan moving forward, and I believe I can actually get there.

I really do.

Patient-Physician

Yesterday, I performed my first rectal exam.

We began our Project Prepare sessions this week, which is a training program to teach us how to perform the male and female genitourinary exams in a sensitive and skilled manner. This was a big milestone for me, as I’ve been anticipating this day with some apprehension for about a year now. I remember one of my Practice of Medicine TA’s telling me about Project Prepare when he was a student in it last fall, and although I knew I would have my own turn in the program this year, time flew by faster than I expected.

So here I was on a Wednesday afternoon, about to learn how to perform the male breast, GU and rectal exam.

I had been told that the educators in the program are fantastic teachers, but I hadn’t realized just how amazing they would be until I met my trainer. The Project Prepare educators are people who have dedicated themselves to teaching these exams on their own bodies, and they are truly incredible. Because of them, what could have been a very discomforting experience ended up being one of the most amazing educational moments I’ve had yet. (Here is a San Francisco Chronicle article from 2003 on Project Prepare.)

I entered the simulated exam room with my three classmates, feeling as on-edge as if I was the one about to get a GU exam instead of the one learning to give it. Our instructor quickly set me at ease with his warm and genuine manner, though, as he explained that he would be modeling for us the same sort of communication we would be using with our future patients.

It really was a whole-hearted experience for me.  Here, I was the vulnerable one, uncertain about what was about to happen, while he was the calm one with years of experience. The dynamics were immediately appreciable; his approach to the encounter made all the difference.

That afternoon, I felt that I was the patient seeing a doctor, rather than a medical student seeing a patient. Now that I’ve been in medical school for a year, I’ve begun seeing more distinction between the identities within me—I am both patient and physician-student. At times, I feel a tension between these pieces of myself.   I believe this tension is not a bad thing, for it reveals an effort to maintain multiple perspectives, but it makes me think. In some sense, we all have this tension within us, although it may be defined by different parameters for different people. It is the same tension within the mother who is also an employee, the son who is also a husband, and the sister who is also a student.

This multifaceted dynamic within me is something that I have to accept as part of living within two worlds—or rather, within multiple hemispheres of the sphere of humanity. Even as I write this, I am a bit hesitant to admit this. This isn’t a struggle that I wanted to have, but it is one that I expected. Our Project Prepare session threw it into new light for me, and it has made me think of it again.

As I sat across from the one who was both my patient and teacher, I keenly felt the importance of bringing compassion and warmth into an encounter. If I can be as help my patients relax as well as my teacher helped me to, I will be very satisfied.

Over the course of the following three hours, we learned how to examine the breast tissue and the surrounding lymph nodes (although breast cancer is rare in males, it can still occur and is essential to screen for). Step by step, we practiced the genital examination and learned how to properly word our dialogue to minimize unease or apprehension. We checked for inguinal hernias and learned how to properly set up for the rectal exam.

As we neared the end of the session, it was my turn to do the digital rectal exam. I had already filed the nail on my dominant index finger to a down hairline crescent of white (we were provided with nail clippers and emery boards earlier in the session to get our nails as short and smooth as possible), and so I coated my gloved finger with lubricant up to the main knuckle.

The rectal exam was actually the most amazing part of the experience for me. Using the pad of my fingertip, I defined the contours of the prostate gland as I swept my finger across it, feeling for any abnormal textures or lumps. I had a sense of awe at examining that which I could not see, like trying to read Braille written within our bodies.

Like trying to find shapes in the spaces between the clouds when looking at the sky.

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Afternoon sunlight and fall foliage at LKSC

I found it a bit funny how the day ended for me—I was participating in a poetry reading at the Cantor Center’s new Anderson Collection that evening, so I went almost straight from practicing the genitourinary exam to reading poetry at the event. It was a wonderful time; members of the Pegasus Physician Writers at Stanford shared original pieces of poetry inspired by the art collection, and the St. Lawrence String Quartet gave a stirring performance of Benjamin Britten’s Second String Quartet in Three Movements.

In a way, this odd juxtaposition of prostates and poetry seemed almost fitting to me. In Project Prepare, I looked again at my identity as a medical student within the greater world, which I relate to in part through writing. Creative writing is what helps me process the struggles of life, and I like to think that it will help me to better relate to my patients since it reminds me that everyone’s life is a story. We all have backstories, and we are all read as sentences and paragraphs, sometimes even as chapters.

Oftentimes, there are multiple storylines that run through our lives.

I am a patient.

I am a student-doctor.

I am human.