A few weeks ago, I was scrubbed in on a surgery that was winding down. The final step was to close the incision the surgeon had made in the skin. As is often the case, the attending (the senior surgeon) called for the medical student — in this case, me — to stitch it closed.
Having been on various rotations for more than a year, I had done quite a bit of suturing. I had a lot of room to improve, to be sure, but I could use a needle and thread. The surgeon didn’t know that, though. As I stepped up to the operating table, he took control of my hands and micromanaged each movement. At the end, he concluded that I needed a lot more practice before trying again.
My second operation that day was with a different attending with whom I had worked before. He maintained an easygoing atmosphere in the operating room. At various points, he jokingly told me, the resident, the scrub technician, and the nurses that we were all “the worst.” At the end of the surgery, I was once again asked to close the incision in the skin. This time the attending left me to the task, warning me that he would carefully check my work. After I finished, he looked over the incision and picked at it a few times. With his inspection complete, he shook my hand and announced to the room, “This is beautiful.” And then the words I had been waiting to hear: “You, sir, are not the worst.”
I was assigned the same task in both cases. The end result was the same: The patient had a well-closed incision. On the surface, nothing had changed but the physician’s expectations. But those expectations dramatically changed my learning environment.
In my experience, physicians who expect medical students and other trainees to do a good job involve us in patient care and make us a valuable part of the team. As a result, we feel useful, push ourselves to excel, and learn more in the process. Those who expect shoddy work limit our role and then conclude we had little to contribute. These encounters have far less educational value.
It’s difficult to determine how best to improve a skill when we get mixed signals on our performance, whether it is suturing, listening to a heartbeat, or talking with patients about their medical histories. At the same time, inconsistent feedback can lead to a crisis of confidence among medical students and residents. The way our teachers view us affects how we view ourselves. Erratic or demeaning feedback can contribute to the widely discussed issues of burnout and depression in medicine.
It’s worth noting that these problems aren’t unique to medical training. They are true in any hierarchical system, whether it is an employer and employee, coach and athlete, or even physician and patient.
Fortunately, there are solutions. I recognize that not all of my teachers will — or even should — have similar expectations for me. That means my fellow trainees and I must take personal responsibility for our education. With that in mind, maybe I should have spoken up when the senior surgeon grabbed my hands. But it is difficult to question superiors, especially in the middle of an operation. Evaluations, grades, and much more rely on their assessments.
However, there are other ways to take ownership of our training. These include learning how to process feedback to differentiate constructive criticism from generic platitudes and watching what our mentors do rather than simply listening to what they say. We can thus actively work on determining the most effective way to do things.
Medical schools and teaching hospitals also need to take steps to clarify expectations. In my suturing example, I’m convinced the first attending did not realize I already had some experience. I understand his point of view. He did not know if I would do a good job, so he intervened to ensure that the patient had a good outcome.
But learning suffers when students, residents, and attending physicians don’t understand each other’s roles. Early, structured communication can help teams define their members’ capabilities and responsibilities.
A model exists for this type of communication. It’s called the “surgical timeout” — before any surgery, every person in the operating room confirms that he or she is doing the correct procedure on the correct patient. Teaching hospitals should implement an “educational timeout” whenever a new team starts to work together. A short, simple interaction would let trainees introduce themselves, identify their skills, and set goals for improvement. While this is done in some institutions, I believe it should be formalized across medical training.
The purpose of these changes isn’t just to make students feels better. I believe they will ultimately improve patient care. A team that communicates well can respond to a patient’s needs more efficiently than one that doesn’t. When trainees have an undefined role, they hesitate to act without approval. In contrast, students who are confident about their position are empowered to advocate for their patients.
These suggestions won’t by themselves solve the challenge of inconsistent expectations. Teachers will always carry some inherent assumptions about their pupils. But as we recognize the issue, perhaps a few more medical students will prove that they are not the worst.
Akhilesh Pathipati is a fourth-year student in Stanford University’s MD/MBA program.
You will understand in a year. Your learning has just begun. Good luck.
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