BUCKLEY AIR FORCE BASE, Colo. -- Unless you live under a rock, you have probably watched a medical drama. If not, let me bring you up to speed. In a medical drama there is one or more young medical students that are followed through a long story arc. The students are initially hilarious in their naiveté, always stumbling, making harmless mistakes and being humbled by their senior staff. During the second season the students begin to demonstrate new technical skills that are expanded and enhanced until they are proficient, credible medical professionals and also arrogant fools who think they can control the diseases and injuries they battle. This goes on for a few seasons, and finally, after you aren’t even sympathetic with the characters anymore, they begin to accept their roles as healers, teachers and life-long students. The students continue to develop into physicians and then the show is cancelled and you go back to finishing your professional military education. Get it done already!
This process is dramatized, but fairly accurate. Your military healthcare providers are developed in much the same way no matter where they trained. A review of the process can be instructive for any leader of young officers and enlisted staff. For simplicity, the process can be broken down into three stages: reporter, assessor and planner. I hope to describe the important elements of each stage with the same drama you have come to expect from binge-streamed dramas.
Our third-year medical students are bright, talented and excessively dangerous. They look like doctors, but have almost no practical knowledge. When we develop a third-year, we expect that they spent the first two years of medical school mastering the health sciences and familiarizing themselves with diseases and injuries of the mind and body. From this starting point we teach them to take a history and perform a physical. As you can imagine, the first attempts can be hilarious. One of my patients in residency was a young child with a glass eye, a prosthetic that was the necessary result of a successful cancer treatment. Her glass eye was so perfect that a third-year was convinced that the pupil could actually move when examined with a pen light! When the student reported this finding to me, the parents and I had a good laugh. Though humbling, this was an opportunity to understand the importance of thorough and accurate reporting. When physicians listen to reports during rounds, we try to identify growth. Can the students discriminate from subjective and objective findings? Can they trend data? Can they place the data into context and begin to report information? Can they prioritize and synthesize the information? Mostly we listen, but will often help summarize the case. When we’re at our best, we are providing continuous feedback until we have competent reporters.
Our fourth-year medical students are gaining confidence, skill and experience. When we develop a fourth-year, we expect a holistic report of the patient’s health at every encounter. From this foundation we begin to teach the student to take this health information and develop an assessment. The first assessment is often called gestalt, a word borrowed from German meaning the character of a whole thing. This is a snap judgment of whether the patient is sick or well. Can you proceed with your exam or does the patient need immediate critical care from an entire team? This is a key step that can’t be skipped. When I worked in the Emergency Department we would regularly have patients arrive at the moment of decompensation and students would skip the gestalt assessment. They would examine the patient or order tests and miss the heart rate of 220 (very high) or 30 (very low)! Or just the opposite – they would get excited about a healthy, smiling teen with a heart rate of 120 after passing out at church (and being quite embarrassed). The gestalt assessment helps us identify what is critical, get help quickly and give others a shared understanding of the care priorities.
Next, fourth-year medical students consider the differential diagnosis. The differential diagnosis is just a list of possible causes for the identified problems. If you’ve used WebMD or other health websites, then you’ve seen a differential. The students formally assess the subjective and objective information and bin the differential diagnoses into things that are (1) common, (2) serious and (3) treatable. The students use this assessment to mitigate the risk of a life-threatening illness, while devoting testing and treatment resources to common conditions with good evidence for treatment. As an example, cough can be a cold (common), pneumonia (serious) or asthma (treatable) – and this process must be repeated with each ill patient. By the end of their fourth year they can reliably provide a gestalt and formal assessment, and know when each is required.
Finally, the medical students graduate and become interns. The intern year is a challenging, last year before they can practice independently. At this point in their training, we expect interns to be able to assess each patient and deliver a comprehensive care plan. These plans must prevent further injury, improve function, be evidence-based and balance the demands of multiple injured or ill organ systems. Furthermore, the interns must track, re-assess and adjust their plans over time. I have seen interns brilliantly manage a newborn or trauma patient, and then lose track of life-threatening infections. By the end of the intern year, the young physician can produce flexible, long-term plans that meet the physiologic and personal goals of the patient.
As a staff member you begin to automatically assess the development level of junior medics. I still use the reporter-assessor-planner model to characterize company grade officer and NCO briefers during meetings. The subject doesn’t need to be medical – the model can be used with any briefer. Consider the quality and completeness of the data reported. Listen for an assessment of critical near-term requirements and an assessment of common, high-risk and actionable root causes. Gauge the rigor of the planning and the readiness to adjust the plan when conditions and requirements change. Finally, summarize the issue, identify the developmental level of the briefer and provide feedback. Over time, I expect senior captains and technical sergeants to provide mature plans or their show may be canceled!
In summary, the approach that medics take to real-life dramas is informed by lessons learned over decades and I hope that you can draw parallels to your community. Independent of the mission, a standard model for developing our junior staff can improve the safety and effectiveness of any operation. I appreciate the opportunity to share some medical lessons and hope they help. Take care, Dr. Hanson.