The flight of the butterfly

I had finished seeing my first patient of the day when a medical student arrived late for her first shift in emergency. I said hello, shook her hand and introduced myself. She seemed distracted and, perhaps because she avoided eye contact, I couldn't quite read her. I showed her around and explained how things worked. She didn't smile or ask questions and so didn't strike me as a typical, enthusiastic student.

I pulled out the heart tracing I had just ordered. “Here, kind of an interesting case, what do you think of this ECG?”

“I can't read cardiograms,” she said, pushing it back to me without even so much as looking. I was taken aback and failed to capitalize on the moment. A guided tour of basic cardiogram interpretation did not materialize.

“Oh. Okay,” I stammered. “You're what, a third year student?”

“No, fourth year, a medical student intern.”

Muttering under my breath, I experienced a sudden urge to be rid of her. It seemed already a burden to have her shadow me for the day. I shuffled her over to a weak and dizzy 81-year-old woman who was, according to the nurse, hard of hearing and an overinclusive historian. “Perfect medical student material,” I thought, feeling my strain lessen considerably.

As planned, she took a long time to assess the patient. While she recounted the patient's history and described the clinical findings, I struck a pose of boredom mixed with impatience. I stifled a sense of frustration as she struggled with my modest inquiries.

The next patient had fallen and gashed his head. After the student had made her assessment, I went over to the man's stretcher and re-examined him. It seemed to be a straightforward case.

“So you go ahead and suture him up,” I said. “I'll carry on, okay?” As I turned to leave I could see the hesitation in her face.

“Uhm …” she whispered.

“You're comfortable with this, aren't you?” My eyes blinked back incredulity.

“Surely by now you've stitched many times before? Haven't you?”

“Well, actually…”

“Well, what?”

“I'd like to. I would, really.” She glanced my way, eyes pleading with me not to pass judgement, and then looked away again. While I couldn't help but wonder how she had fallen so far behind her classmates, in this brief, silent, beseeching moment, I realized that I was peering at a struggling individual. She had joys and trials just like the rest of us; she was human.

Here then was the malleable young mind I had been entrusted to influence. With her only a short while, I had categorized her as unmotivated, uninterested or both. In turn, I had responded with irritation and indifference. Looking at her now, trying to comprehend, I suddenly perceived her as fragile. And I realized that a duty to teach sometimes requires a good measure of generosity. It was time, I reckoned, to drop the tough-guy act. Together, we had some work to do.

“Good,” I managed. “Let's get started. I'll put in the first one or two. then you take over while I watch. Okay?”

The patient seemed all right with this, too. I prepped the wound and threw in a couple of sutures, explaining the mechanics of the procedure.

“There, easy, eh? You go ahead.”

“Sure, thanks.” She smiled, false bravado marking her face. I watched the needle driver tremble as she prepared to puncture the skin. I was afraid that she wouldn't be able to overcome her apprehension, but she persevered.

“Good, that's it, exactly,” I said, after she had placed two or three sutures appropriately. “You're okay here now. You finish up, I'll go see the next patient.” By leaving her I hoped to project confidence in her abilities, so that she might respond in kind.

I checked her work when she was finished. “Nice job,” I said. Then I directed my comments to the patient. “There you go, sir, almost as good as new.” I explained how to look for signs of infection and told him to see his own doctor to get the stitches out in a week. As I walked with my student from the bedside I noted, out of the corner of my eye, her sense of relief and satisfaction.

For the rest of the day, I found myself feeling more talkative and willing to teach. The student herself seemed buoyed by success and, like a thirsty wanderer offered a ladle of cool water, eager for more.

We worked together four or five more times during her month with us. I remember one of our last shifts together. “I've just seen a new patient,” she said, making eye contact with me. “He's a 29-year-old sheet metal worker with a cut over the dorsum of the PIP joint of his left index. His sensation is intact. He can extend fully, which made me think it was okay at first. But then when I tested his strength, he was weak. I think we need to do a digital block and have a look at the extensor tendon, it's probably at least partly lacerated.”

“Ahh,” I thought, “well done.” I felt rewarded, as if I had witnessed a transformation. She was indeed bright and competent, not at all conforming to my first impression.

Though I never found out what had been bothering the student initially, I wondered if she had been exposed to a bullying style of teaching, a method I had come close to adopting myself. But medical students are not immune to the frailties that strike others and it was obvious that, regardless of the cause, she had suffered a crisis of confidence that had affected her ability to perform.

We learn in different ways, each according to the dictates of brain chemistry and the effects of chance and circumstance. What works well for one student may not for another. But in some ways it seems to me that medical students are delicate creatures. Like butterflies emerging from the chrysalis, they must dry their wings in the sun before flying. And the clinical educator who radiates patience and encouragement may witness the intangible joy of flight, a beautiful thing to behold.