"Dr.," but this practice was abandoned

after the hospital was advised it constituted misrepresentation that might have legal consequences. Student name tags now give only their names; those of interns and residents say "Dr."

It is not clear why medical students are called doctors in front of patients, especially since so few patients are fooled by the appellation. One can view the whole business as a harmless convention,

in which the hospital pretends that its students are doctors, and the patients pretend to be taken in.

Why bother? Instructors say that this small white lie comforts the patients, who would be upset to learn they were being examined by students. Something of the same sort happens with interns, who occasionally pass themselves off as residents in the belief that this soothes patients. It is true that the folklore-and the mass-media image-of the medical student and the intern is distinctly unfavorable, and these negative connotations persist until residency. (Dr. Kildare, that charming, all-knowing physician, was a resident who spent much prime time dealing with neurotic, guilt-ridden, fumbling interns and students.) "Even now," according to George Orwell, "doctors can be found whose motives are questionable. Anyone who has had much illness, or who has listened to medical students talking, will know what I mean." In a single, paradoxical stroke, he dismisses the motivations of some doctors, but all medical students.

The position of the medical student is thus peculiar, and occasionally comical. In society at large, he finds himself eminently marriageable and a good credit risk, thus enjoying the approval of those two bastions of conservative appraisal- matrons and bankers. In the hospital, however, those same matrons and bankers want nothing to do with students, and nearly every student has had the experience of examining a woman who grumbles and complains throughout the history and physical and then politely asks if the student is married.

In the end, one suspects that the practice of labeling students as doctors is misguided. Patients ought to be told explicitly who the students are; a moment's reflection shows many advantages to such a practice.

For one thing, most patients coming into a teaching hospital are already apprehensive about being used as guinea pigs. They have heard vague reports that "You'll be in the hands of students and interns," and this is not really true. Patients entering the hospital-already sick and afraid-are almost always unfamiliar with the hierarchy of decision-making that provides careful checks on junior men. Against this background of apprehension is added the fact that everyone introduces himself as a doctor, while the patient knows perfectly well that some of those doctors are students. Thus, failure to identify students increases anxiety instead of relieving it.

Further, it is a common observation on the wards that students are popular with patients. Students have more time to talk to patients; hospital life for a patient is boring; patients like the attention. (Frequently they will rank the house staff according to warmth and attentiveness. A friendly student who has had the experience of working with a brusque resident knows how often patients

conclude that the resident is a student, and vice versa.[This implies that patients associate brusqueness with professional ineptitude, and that may be valid])

Finally, it is explicit in the bargain any teaching hospital makes that a patient will receive better care, but in return must put up with teaching. The teaching function might as well be identified as such. In any case, as Frederick Cheever Shattuck said many years ago, "Before swerving from or denying the truth we should ask ourselves the searching question, 'For whose advantage is this denial?' If it is in any measure for our advantage, or seeming advantage, let us shame the devil."

How do students, house officers, and senior men combine to produce the ward teaching system? As exemplified by Mrs. Murphy's experience, the system works as follows.

When the ward is notified that a new patient is being admitted, the student goes down to the EW and examines the patient. On occasion, he has to hurry to beat the house officer, but students learn to do this, and the best house officers will go to great lengths to allow the student to perform the initial examination. The reason for this is that with each succeeding history and physical, the patient becomes more accustomed to the routine of delivering his story in an orderly but unnatural manner. Fresh patients are the most difficult to get a history from, and therefore the most prized.

After a student has examined the patient, the resident conducts a second examination, and then comes out to talk to the student about the case. The resident generally has only three questions: "What did you find?" "What do you think he has?" "What do you want to do for him?" Interestingly, these are the only really important questions in all clinical medicine.

A discussion of diagnosis and treatment follows; if the resident agrees with the student, he will let him write the orders, then countersign them. Diagnostic procedures such as lumbar puncture, bone-marrow biopsy, and so on are usually done by the student under the resident's supervision. By tradition, patients are expected to be "worked up" as much as possible on the day (or night) of admission. This means that in addition to the history and physical, the ward team is supposed to look at the blood morphology, do a white-cell count, a hema-tocrit, an electrocardiogram, urinalysis, review the chest X ray-and whatever other, more sophisticated, tests are necessary, all at the time of admission.

The student may do much or all of this, but he really has no control over the patient's care. Most of the decisions-decisions at the time of admission, and all later decisions-are made by the admitting house officer. This is why the medical service regards "admitting a patient" as directly equivalent to the surgeon's "doing a case." In each instance, only one person can have the responsibility of decisions on patient care. And while it is valuable to look on, it is not the same thing as doing it yourself. The experience of responsibility is not transferable.

Each house officer thus has a series of "his patients" on the ward; these are the patients he originally admitted, and he feels primary responsibility for them throughout their hospital stay. He is expected to know more about his patients than anyone else, though others must know enough to handle details of care when the resident is off duty. The sense of individual responsibility is so strong that it is couched in possessive terms. One house officer may ask another, "Is Mr. Jones your patient?" and be told, "No, he's Bob's."

The student's role in all this is to pretend that he is the admitting house officer, and to continue pretending so throughout the hospital stay. A student generally works closely with one intern or resident, keeping the same hours, following him along. Among students there is an active grapevine to keep everyone informed about which house officers are good to work with and which not. A good house officer is one who is confident of his skill (insecurity is catching); willing to take time to teach the student; and unwilling to delegate all routine work, termed "scut," to the student.

On the morning after a patient's admission, during "work rounds" from 7:45 to 9:00, when the ward team goes from patient to patient, the student is expected to summarize informally the history, physical, and lab tests for the benefit of those team members who were off duty the previous night. A formal discussion is given by the student during "visit rounds" later in the day, when he relates the details of the case to the visiting physician, usually just called "the visit." The visit is a staff member of the hospital, assigned to the wards for a month, and legally responsible for all the patients on the ward.

The student's formal discussion is known as "presenting." To present a patient means to deliver the salient information in a brief, highly stylized form. The student is expected to do this from memory. A presentation begins with events leading up to admission for the present illness; then goes on to past medical history; then a review of organ systems; family and social history; physical findings beginning at the head and working down to the feet. Laboratory data is then presented in a specific order: blood studies, urine studies, cardiogram, X rays, and finally more specialized tests.

The entire process is not supposed to take more than five minutes.

A good presentation is difficult, for along with summarizing positive findings, the student is expected to include certain "pertinent negatives" from among the almost infinite number of symptoms and signs the patient does not have. These pertinent negatives are intended to exclude specific diagnoses. Thus, if a patient has jaundice and a large liver, the student should state that the patient does not drink, if this is the case.

Aggressive students can be quite abstruse in their negatives, hoping that the instructor will interrupt and ask (for example): "What were you thinking when you said the patient had never danced in Tibet?"

To this the student can triumphantly name some obscure disease that vaguely fits the situation, such as "the Kurelu Dancing Syndrome, sir." He thus appears well read. The game can be dangerous with a knowledgeable visit, however, for he is likely to shoot back: "The Kurelu Dancing Syndrome never occurs in males under forty, and your patient is thirty-six. If you want to do some reading, I refer you to the Kurelu Medical Journal, volume ten, number two." This is a signal for the student to crumble; he has lost the round-unless, of course, he has a rejoinder. There is only one acceptable form: "But, sir, in the Mauritanian Journal of Midwifery last week there was a report of a case in a ten-year-old boy." This may, or may not, work. The visit may reply, "The what journal? Wasn't that the one which reported that skimmed milk caused cancer?"

That ends the discussion.

Chapter 11

Among students, visits are classified into two groups-"benign," and the others. It depends on how the visits treat students. Generally the visit sits in silence throughout the presentation; he then begins by pointing out all the things the student forgot to mention; and then proceeds to ask questions. He is entitled to ask questions on anything he likes, so long as it vaguely relates to the case at hand. He can, if he wishes, keep the student hopping.

For example, a typical discussion about a case of stress duodenal ulcer might have the visit first asking the anatomy of the four parts of the duodenum; then the arterial supply to the stomach; the common complications of duodenal ulcer; the factors that classically increase and decrease ulcer pain; the features that distinguish ulcer pain from the pain of acute pancreatitis, gall bladder disease, or heart attack; the four indications for surgical intervention; the reasons for measuring serum pancreatic amylase and serum calcium; the mental changes one might expect with GI bleeding in the presence of liver disease, and the reason for the change; the other causes of upper GI bleeding; the way to distinguish upper and lower GI bleeding; and so on.

Furthermore, the visit can shift to a related topic at any point. If he asks about serum calcium and the student correctly answers that there is a relation between parathyroid disease and ulcer, the visit may go on to ask how calcium fluctuates in parathyroid disease; the associated changes in serum phosphate; what changes might be seen in the electrocardiogram; what mental changes are associated with increased and decreased serum calcium, in adults and in children.

Thus a student who began talking about ulcer disease is effectively shunted to calcium metabolism. And, at any time, the visit can turn around, demand to know six other conditions associated with ulcer, [Such as chronic lung disease, cirrhosis, rheumatoid arthritis, burns and strokes, pancreatitis, and the effects of certain drug therapies, especially steroids] and go on to discuss each of them. Visit rounds are two hours long. There is plenty of time.

For the most part, interns and residents are exempt from grilling; it is considered too undignified. The visit treats house officers as colleagues, but not students. A house officer who asks a question of the visit will get an answer. A student who asks a question will most often get a question back, as in "Sir, what does the serum calcium do in Chicken Little disease?" "Well, what do the plasma proteins do in Ridinghood's Macro-globulinemia?" If the student fails to see the light, he will get another hint, also in the form of a question: "Well, then, what about the serum phosphate in Heavyweight's Syndrome?"

This is a form of a game which is repeated over and over again in medical teaching. It is a game useful to the conduct of medical practice. A very simple example of the game is the following:

student: "The patient has a rash and fever."

visit: "Has he ever been to Martha's Vineyard?"

student: "No, he does not have Rocky Mountain spotted fever."

The point is that the student sees the implication behind the question-that each year one or two cases of Rocky Mountain spotted fever are contracted on Martha's Vineyard. Such deductive processes are precisely those important to the conduct of medicine, and therefore represent a useful teaching method. In the extreme, this can lead to a leap-frog interchange which is almost beyond the understanding of the casual observer:

student: "The patient has kidney disease consistent with glomerulonephritis."

visit: "Was there a recent history of infection?"

student: "Anti-streptolysin liters were low."

visit: "Was there a facial rash?"

student: "LE prep and anti-nuclear antibodies were negative."

visit: "Were there eyeground changes?"

student: "Glucose-tolerance test was normal."

visit: "Did you consider rectal biopsy?"

student: "The tongue was not enlarged."

This is jumping from mountaintop to mountain-top, skipping the valleys. In translation, the visit is asking, first, whether the glomerulonephritis was caused by streptococcal infection; second, whether it is due to lupus; third, to diabetes; and finally, whether due to amyloidosis. The student is denying each diagnosis by presenting negative data. Neither teacher nor student specifies the diagnosis; the game is to figure out what each is talking about without saying what it is.