Medical

The Year of Privilege: A New Perspective on Third Year

During my pediatrics clerkship, one of our core faculty gave a lecture during orientation. This orientation lecture was particularly good, as the professor giving it was one of our most-loved faculty members who is deeply in tune with medical students at all stages. This was back in the summer when we were just getting started with our clinical experiences, but what he said stuck with me all year. He noted with a bit of humor that third-year medical students are the lowest of the low—barely even acknowledged by many team members, ignored by some patients who refuse to talk to anyone but a “real doctor,” disregarded by residents unless it is to point out something you are doing wrong. We chuckled, already able to relate with this view, but he turned the conventional description on its head by encouraging us to think of the third year of medical school as “the year of privilege.”
What makes this the year of privilege? Third-year medical students are uniquely positioned to do things that no one else can do, including other members of the healthcare team—even those with more training and experience. There are a few reasons for this: medical students are not burdened by administrative responsibilities such as billing, managing staff members, or insurance haggling; medical students generally manage fewer patients than residents and certainly fewer than attendings; and medical students often have, to put it bluntly, low expectations. Besides the endless stream of information that requires learning and passing shelf exams, third-year medical students have very little responsibility. We write notes, but they are for our benefit, to learn proper documentation; they are often marked as not part of the medical record. (At one hospital, we were told it didn’t matter what we wrote because our notes disappeared as soon as the patient was discharged). Our patient presentations are critiqued, sometimes for the sake of critiquing them, rather than listened to in order to learn about patients. We assist in the operating room but find ourselves in the way more often than not.
These negatives are all the cynical ways of looking at the role of a third-year student and are examples of the perspective that my professor wanted to challenge by showing us how these lower expectations can actually benefit us and our patients. The point is that these comparatively fewer responsibilities make sense given our context: we are thrust around from specialty to specialty, often spending as little as one week with any given team before shuffling to the next. This isn’t our choice, of course, but sometimes it feels as though residents or attendings interpret this as a lack of commitment to a field. Even so, this creates a sense of freedom which engenders a privilege: the privilege of soaking it all in—really having time to appreciate what’s happening, to notice the details and the beauty that pervades much of medicine, and to value moments and aspects of each specialty that those in it are either accustomed to or hardened to. Above all, we have the privilege of sitting and talking at length to our patients. This is what we can do that no one else can, because we have what no one else has: time.
It is perhaps ironic to suggest that medical students have an abundance of time, since common thought and the average medical student’s story would suggest that we have no free time. While we do work long hours and somehow must also find time to study, this isn’t where the extra time exists. Instead, we are given more time within the required hours of work. I may spend just as much time at the hospital as my intern (usually not, but for the sake of argument imagine I do meet the 80-hr per week cap) but I don’t manage as many patients. By default, then, I have more time to spend with the patients I do see, and more time to polish and perfect my notes and presentations, and more time to read about and research their diseases and treatments and side effects. The extra time in the context of equal work hours allows me to do wonderful things that can really benefit patients.
Consider a few anecdotes that highlight this marvelous privilege of being a medical student. During my obstetrics rotation, I worked at a local military hospital, fairly small but surprisingly busy with clinic, surgeries, and deliveries. In the morning, the medical students would arrive and divvy up patients, or just claim one to see in the order that we got there. One morning I came in and picked a patient who was in labor. My resident wasn’t around, so I just went to see her. I went into the room, introduced myself to the patient and her family, and told them I would be the medical student working with the team. They were extremely kind, very excited about the baby, and seemed glad to meet me. I left the room and walked over to my attending and resident, who were talking about the patient. I told them I had just seen her, and my attending put down her papers and looked at me. “What did you say to her?” she asked. “Nothing… just introduced myself as the medical student… why?” I replied. She raised her eyebrows and proceeded to tell me that my chosen patient was an immediate family member of the hospital commander, and everyone was going to great lengths to make sure everything went perfectly. I had no idea, but my role as a third year offered me a tiny bit of immunity and the opportunity to shamelessly work with a family others were nervous about. (They were wonderful, and everything went well with the delivery.)
Or consider another experience from my surgery rotation. Similarly, I would arrive early, pick one or two patients from our list, and go see them before the residents. I was encouraged to keep following the same patients, and especially to see any patients whose surgery I had scrubbed in for the previous day. One morning I went to see a patient who had had surgery the previous day, and his colon resection had been somewhat complicated. It was only my third day of the rotation (his had been one of the first surgeries I saw), so I was still learning a lot of the lingo, and even the indications for his procedure were not entirely clear to me. I went into his room and began asking the standard post-op questions: how did he sleep, how was his pain control, had he been eating or drinking, and had he had a bowel movement. He stopped me after a few minutes: “How did the surgery go?” I paused. “Did anyone come talk to you after the operation yesterday?” He shook his head no. I hesitated. Was it my place to explain how the surgery went? Did I even know enough to tell him? “It went well. There were no complications,” I said. “Good. So they got the cancer?” I stared at him. We had removed his tumor with clear margins, but I was shocked that I would be the one to tell him. “Well, we took out the tumor…” I said. I began to explain that we didn’t know about final pathology results and that there would still be follow-up, but he already looked relieved and soon drifted back to sleep. I left his room with a sort of giddy feeling. I may not have done much during the operation other than retract some of his intestines, but I had the privilege of telling a man his cancer—at least the tumor we could see—had been removed.
These are just two of the many remarkable moments I’ve had over the course of a very busy year. In both cases, the humility of this role—a student doctor, with few true responsibilities but often placed in situations that require important tasks—is apparent. Almost daily I realize how little I know and how much more I will always have to learn; this, among other aspects, is what makes medicine a remarkable field. Even so, I have learned much, and learn new things almost daily. Even on the days I don’t, though, I get to talk to other people—people who are usually vulnerable and sometimes scared. I can’t write prescriptions or do my own procedures yet, but these moments shared with another person do help to heal them, I think.
Central to the skillset of every physician is the differential diagnosis; this is the process by which new patients are evaluated to establish the most likely diagnosis. Similarly, the first clinical year of medical school is like a differential for each student, except instead of a medical diagnosis, students are seeking to determine which specialty they will choose. This column explores this differential: experiences from each rotation by a current third year student.

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Brent Schnipke, MD is a writer based in Dayton, OH. He graduated medical school in 2018 and is psychiatry resident at Wright State University Boonshof...