A brief(ish) comment on the ethics of the medical trainee at home and abroad

           There’s a natural conflict inherent to medical training that often goes unspoken.  On the one hand, patients typically receive the best care (and least harm) when treated by the most experienced and seasoned clinicians.  On the other hand, it’s impossible to create seasoned clinicians without having novices gain experience treating real patients.  Medical education has created certain ways in which novices can gain experience without putting patients at risk: case-based book learning, a well-regimented hierarchy of supervision for trainees, and high-fidelity simulations, to name a few.  Nevertheless, we have yet to figure how to completely protect patients from the learning curve of trainees and other less-experienced doctors.  It’s a puzzling and tremendously challenging Catch-22 in medical education.
           I’ve reflected on this much during my training at home, and have continued to do so now in a Global Health context.  In the U.S., I work hard to maintain a subtle balance in my training: on the one hand proactively challenging myself to take on new responsibilities while on the other hand knowing when something is so far beyond my level of expertise that it would ultimately compromise patient care.  Of course, much of the decisions about what is or is not appropriate for a medical student of a certain level of training to do comes from medical educators.  Some of these boundaries are designed directly into medical school curriculums, but in my experience much of the decision behind “do I feel comfortable with medical student X doing patient care task Y” falls on the individual level of trust built between a student and a preceptor.  If the student shows they are well-read, comfortable, professional, and capable, then they get to take on patient care responsibilities possibly above the level of some peers.  If they exhibit a critical lack of knowledge, poor clinical skills, unprofessional behavior, immaturity, or significant discomfort with basic patient care tasks, then they stay working on the basic patient care tasks and possibly get closer supervision to boot.  For me, I’ve consistently felt that I learn the most when I’m challenged with the most amount of patient care responsibility, within reason.
         
           Abroad in the Global Health context, however, things are a bit different.  Not since my first clerkship a year and a half ago have I so often been a simple observer rather than an active participant in patient care and medical decision making.  However this is the spot I often find myself now in the emergency departments here in Peru.  I am still learning a lot, but not in the same hands-on taking care of my own patients sort of way I’ve become accustomed to.  I’ve thought about it a lot and I’m not certain that pushing for more than this would be appropriate, for a couple of reasons.  First, the patient care resources here are both vastly different and generally less abundant than in the U.S.  For this reason, applying my knowledge and experience of American medicine to medical decision making in Peruvian patients will, while for the most part be OK, create at times an unacceptably high risk of making serious errors due to a lack of understanding of Peru’s medical resources.  Secondly, while I speak Spanish well enough to get by in the majority of both conversational and medical interactions, I am still far from the level of a native speaker.  As such, taking histories without supervision and presenting patients to non-English speakers does have a risk that subtle but critical details will be lost in translation.  

Props to Joe: taking a BP on somebody running on a treadmill is tough.  Oh, and yeah my stress test was normal.

          So what has this meant for my learning here in Peru?  For the time here to be a valuable addition to my clinical training, I needed to be challenged in a way similar to domestic clerkships that test my clinical skills and clinical knowledge.  Despite taking a far more conservative than normal approach to clinical training here in Peru, I still think these learning goals have satisfactorily been met.  On the one hand, a large part of my interest in doing a Global Health experience was the possibility to greatly improve my clinical communication abilities with Spanish-speaking patients.  This certainly has been the case, as working directly alongside doctors and patients who don’t speak a word of English has forced me to get better very quickly.  Additionally, I’ve learned a lot from analysing both the direct medical decision making as well as the greater healthcare system as a whole in Peru and comparing it to what I know at home.  Both the similarities and differences are illuminating, and I think I’m gaining some great perspective with every comparison of what seems to work and what doesn’t.  And finally, it’s been interesting to see many presentations of diseases that are rare but important in the U.S., like TB or stomach cancer.  So, though I might not be putting in central lines or evaluating multiple critical patients on my own before staffing them with a preceptor, I feel that the clinical experience has been well worth it and a strong addition to my final year before residency.