Hewo Friends!!

I had a few “difficult” cannulas I had been putting off—mostly because the patients were asleep, and I am a merciful coward—but I realised there was no better use of the morning than converting these students into free labour.

Introduction

There is something deeply unsettling about the phrase, “Is it okay if the medical student has a go?” It is usually whispered while a 20-year-old is advancing a needle toward your forearm with the intensity of someone defusing a bomb, despite having only learned bomb disposal from a WikiHow article.

What we are really saying is: “Would you be willing to let this terrified youth, who has hitherto only practiced on plastic arms, pierce your tender flesh with a sharp object while I watch and silently pray I don’t have to intervene?”

And yet, this remains the core paradox of our profession. At some point, every doctor—from your friendly local GP to the “giga chads” of cardiology who “wear the hides of vanquished foes” —had to perform a procedure for the very first time on a real, living, and hopefully consenting human. Medicine has a nasty habit of requiring experience for competence, meaning the only way to become safe is to start off distinctly unsafe.

We are left with the paradox of the healing apprentice: How do we teach medicine without betraying it?

Patients as a Means and an End

Philosophy 101 tells us we shouldn’t treat people merely as a means to an end. This becomes awkward when you realise medical education essentially views patients as very complex, breathing textbooks.

There is a tension here. When a patient agrees to be a guinea pig, I feel a genuine enjoyment in my role as a bedside teacher. But is that enjoyment selfish? Doctors are often criticised for finding pathology “cool”. We might call a rare disease “exciting” or “crazy”, while to the patient it is “life altering”.

But here is the counterargument: Is it ethical to shield patients from learners if the alternative is a future filled with incompetent doctors? If we refuse to treat today’s patients as a teaching opportunity, we ensure that tomorrow’s patients suffer from our short-sighted strive for virtue.

The reality is simple. You need practice. You need the “black humour and insensitive language” that helps you cope. And unfortunately, you need to sometimes be rubbish at something, ideally while someone more experienced—like a taciturn and serene senior—is watching, ready to step in before you accidentally puncture an artery.

This doesn’t mean the patient disappears as a moral subject. It means we have to care for them differently: not as passive recipients of perfect care, but as co-participants in medicine’s grand, messy apprenticeship. As I’ve seen, some patients actually “revel in being ‘rare cases’” and join in on grilling the candidates.

And sometimes, the greatest act of moral courage in healthcare isn’t what the doctor does — it’s what the patient lets them do.

Embracing the Chaos

Medicine loves certainty in the same way that cleaning product advertisements love “before-and-after” photos. Neat, definitive, and sparkling. What we omit is that reality is the “during” photo: a blurry, chaotic mess.

We compare patients post-admission to their state pre-admission and see a definitive change. But the decisions that led there are often plagued by uncertainty. No amount of simulation or exams can eliminate the fact that medicine is often a carefully weighed coin toss taking inputs from experience, improvisation, and gut feeling. Both Daniel Kahneman (2011) and Groopman (2007) speak to terrifying complexities of thinking that makes up this job.

Added to this is the pressure of time. There is a brilliant analogy in How Doctors Think (Groopman 2007) that captures the cognitive load perfectly

Imagine watching a train go by. You are looking for one face in the window. Car after car passes. If you become distracted or inattentive, you risk missing the person. Or, if the train picks up too much speed, the faces begin to blur and you can’t see the one you are seeking. “That’s what primary care medicine is like”

I find this extends to medical practice as a whole, not just primary care. When you are an intern, the train is always moving at Mach 10. Part of what separates the experienced from the inexperienced isn’t just knowing the face you are looking for, but having the ability to decide which carriages require extended deliberation and which ones can just blur on by.

The Ontology of Expertise

But when does the inexperienced become the experienced? When does a medical student actually become a doctor? When does an intern go from incompetent floundering intern to competent resident?

Legally, it’s what the pay cheque says. But spiritually? Is it the first time you prescribe paracetamol without asking an adult? Is it the first time you get an intra-osseous access in an arrest?

The uncomfortable truth is that competency isn’t binary. You don’t go to sleep a danger to society and wake up a healer.

To explain this, I’m going to borrow from Lev Vygotsky’s “Zone of Proximal Development,” but because I’m a child, I will explain it using Pokémon.

Think of a medical student as a Charmander. Cute, full of potential, but if left alone to battle high level trainers on victory road (the Emergency Department), they will faint immediately. The Zone of Proximal Development is the battle they can win if they have a trainer using potions on them (a Consultant listening to their incomplete histories) and substituting them out for more experienced pokemon (a Registrar) when necessary.

True expertise is evolving into Charizard. You no longer need the trainer. You can handle the battle alone, but you know when to turn to your trainer if need be (i.e. true expertise is being able to handle the cases and just as important, knowing when you can’t). However, expertise isn’t just about Flamethrowing the correct diagnosis. A massive chunk of the job is untestable. It is the soft skills. It is knowing how to de-escalate an angry relative, or perhaps the most valuable skill in the hospital: knowing exactly when to shut your mouth during the morning handover so you don’t extend the meeting by twenty minutes.

Medicine is simply the long, slow grind of XP farming.

Learning as a Ritual

Medicine survives by teaching. The only thing more dangerous than a trainee… is a doctor who forgot they once were one. Every competent doctor is standing on a pile of someone else’s patience. Those students who I supervised that morning got the cannula. The student moved on. And medicine, quietly and unceremoniously, began again.

References