The gift of clinical clerkship: reflecting on uncertainty, privilege, and self-discovery

Arnav Agarwal is an Internal Medicine Resident (R1) at the University of Toronto. Check back the last Thursday of each month for a new featured piece as part of his series (Doc Talks: Reflections to Reality)!

 

Arnav Agarwal, CC3. I starkly recall etching those three words as I signed off on my first clinical note on a warm September morning. I wish this could be in pencil, I remember thinking. The idea of permanently associating my identity with a patient’s story and offering a proposed impression and plan felt outlandish — I barely had my own impression and plan figured out. How was I going to help patients and make a difference when I could hardly find my way to the right area of the hospital for my first day? And, a more weighted question: could I really practice medicine?

Indeed, the two years that followed were defined by gruelling academic intensity unparalleled by the prior two years of pre-clerkship. A rigorous clinical schedule was now paired with the expectation to prove theoretical capabilities every six to eight weeks. Uncountable sleepless overnight shifts on-call were matched by long days and weekend shifts. The unwavering anticipation of new learning experiences was paralleled by the uncomfortable sense of needing to constantly impress those around us and hold our own in a seemingly foreign environment. Books after books of mindboggling quantities of information were read, learned, forgotten, and re-learned. Perhaps most challengingly, a growing sense of familiarity with a clinical area and team was constantly disrupted by the inevitable uprooting and move to the next unfamiliar setting, necessitating the capacity to stay afloat in a constantly turbulent river of evolving demands and expectations.  Nonetheless, with every passing week, a sense of clinical pictures began to emerge — my differential diagnosis for chest pain started including tension pneumothorax after my surgery rotation, and my interpretations of electrocardiograms began including anti-psychotics as potential causes of prolonged QTc findings after psychiatry. With each history and physical exam performed, a clearer sense of how each patient finding contributed to different clinical pictures became more distinct.

What was most unforeseen, though, were the incredibly impactful moments I walked away with. Empathizing with a depressed middle-aged man with active suicidal ideation as I worked letter-by-letter through MSIGECAPS; riding the emotional highs of an uncomplicated term delivery and the lows of parents struggling to see their newborns in respiratory distress in the Neonatal Intensive Care Unit; sharing the last agonal breaths of an elderly lady with congestive heart failure as three generations of family surrounded her; witnessing the sense of relief in the eyes of family members as their loved ones emerged from the operating room following successful efforts to save their lives in impending surgical emergencies — these encounters, some only seconds long, are among those I hold most closely from my 24 months of clinical clerkship.

Clinical clerkship provides an unequalled privilege in medicine. It provides medical students with an interface through which they may embrace and understand the entire spectrum of medicine, and a safe environment in which to nurture and fashion themselves as tomorrow’s care providers across this diverse spectrum. While clinical staff may be restricted to narrow clinical specialties and strict timelines within which to complete a laundry list of patient-centred and other administrative responsibilities, clinical clerks have the time and flexibility to listen to full patient stories, as well as to experience the diverse range of flavours and roles encompassed by the medical profession as undifferentiated learners. Most importantly, clinical clerks are licensed with the unrestrained freedom and privilege to experience and contribute a segment to the narratives of hundreds of patients. From experiencing their deepest fears to some of their most prized moments, they are empowered with the opportunity to share a relationship of trust — however transient — and be a part of these beautiful stories in an unrivalled manner. This is, perhaps, the greatest gift in medicine.

To incoming clinical clerks: in the whirlwind of uncertainties, new challenges, and expectations from yourself and others, remember your privilege. It is likely the unscripted version of your “Why I want to be a doctor” monologue from when you completed your medical school applications and prepared for interviews. Clerkship represents a unique opportunity to experience the rich diversity in our community, from its most privileged to its least, with some of their most significant vulnerabilities. You will spend countless hours this year and beyond gathering comprehensive histories, auscultating chests, and palpating and percussing abdomens — but the most precious contribution to your patients will be the few minutes you invest in listening to their fears, wiping their tears, and empowering them with your compassion.

To mentors and staff: words cannot capture our gratitude as learners and junior doctors for your mentorship, guidance, and friendship. Your clinical pearls, words of wisdom, and faith are empowering, and the relationships you cultivate with your patients are reminders to us as to why we chose medicine. Please be aware that every word of reassurance or criticism, every smile or frown, and every moment that you invest in your junior learners — and future colleagues — often stay with them for years to come.  Continue to reflect humility, kindness, and sincerity; we learn more than medicine from you.

As I close the chapter on clerkship and begin a new chapter with residency, I reflect on the questions I began clerkship with: How can I make a significant difference knowing such an insignificant amount? Can I practice medicine? While the years have brought many more questions than answers, I am assured that the answers to these questions are simple: recognize your privilege in sharing moments of vulnerability with your patients, empathize with and understand their experience, and hold on to the nervous excitement that carried you through your clinical clerkship year — and you will be a good doctor.

 


Note: All patients in this work are fictitious. Any resemblance to real persons, living or dead, is purely coincidental.

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