On see one, do one, teach one

The model of “See one, do one, teach one” is a rough sketch of how quickly a medical student/resident is expected to pick up skills and disseminate information to others.

  • See one: Watch an attending or more experienced resident complete a procedure, such as a lumbar puncture or an intubation. Maybe they tell you what they’re doing and how to approach the procedure. Maybe they just do it and expect you to understand the process from watching over their shoulder.
  • Do one: With the knowledge gleamed from observing the procedure, then you are expected to complete that procedure yourself. Perhaps under supervision. Perhaps not.
  • Teach one: Now that you have the notch under your belt to signify, “I did this without killing a patient,” you then teach someone else on how to do this.

Knowledge and skills need to flow quickly in medicine. In each specialty, there are so many aspects to modern medical care that you cannot dwell too long in one phase. See, do, teach.

These are two stories about my recent “see one, do one, teach one.”

See one

‘T’ came into the hospital for severe headaches.

Earlier this year, he was admitted and diagnosed with giant cell arteritis, a rare inflammation of the large blood vessels in the head and neck which threatens irreversible vision loss in an eye if untreated. For the past three months, he has been tapering down his corticosteroids, the mainstay of treatment for his condition. Last week, he transitioned from 15mg every day to 10mg every day.

T presented to the hospital on this admission because of a 10/10 headache, exactly like the one which started his diagnosis of giant cell arteritis. Started in his L eye, transitioned to his R, then spread across his whole head. According to the medical record, he was frustrated and angry with his care and just wanted relief from the headache.

After poking through T’s chart, I walked over to his room to sit down and speak with him. The rheumatology fellow was on his way out as I approached. We spoke a bit about his case, outside of earshot. As giant cell arteritis (GCA) is considered a rheumatological condition, they were the team managing his steroids.

The fellow said they had a low suspicion for a GCA flare, but since the symptoms of the headache were so similar to his initial presentation, they couldn’t rule it out. Maybe they needed to increase his steroids again and then taper them down more slowly, perhaps up to 20mg for a while, then 15mg to 12.5mg and finally back down to 10mg.

As we wrapped up, the fellow told me to let him talk. “He gets pretty angry if you redirect him.” I thanked him for this heads up and walked into the room.

T was sitting at the side of his bed, facing the door, with his elbows resting on the bedside table. Throughout the conversation, T would rearrange the pens and his cup on that table. Straightening and moving them around, a nervous fidget if I’ve ever seen one.

It took me a while to get to the meat of the conversation, as T perseverated on his other medical conditions. He suffers from new-onset diabetes as a result of the long-term steroids. He is short of breath as a result of his chronic heart failure. One issue affects another, leaving him in a precarious state where fixing one issue may worsen another.

Much like the patient I wrote about last week, I wanted to get the fuck out of that room. T is a big guy, with a deep and booming voice. His presence caused me to lean back in my seat, away from his simmering rage. Rage at what? I’m not sure.

I gathered as much history as I could and conducted a neurological examination. I thanked him for his time and left the room. Then, I waited for my attending so that I may present his case and be done with him.

After a while, the neurologist came around and I presented to her. After I finished, I told her that I think there is a good amount of psych on board. Couldn’t quite put my finger on it, but I knew that there was something else going on with him. She accepted this info and we walked back into his room.

The attending got the history she needed. She thought it was a GCA flare, especially since the headaches were similar and it is unlikely that he would begin to have cluster or migraine headaches in his sixties. Then, she did something that surprised me.

She asked T if he had any reason to be more stressed recently, or anything that might raise his blood pressure.

She didn’t have to ask this question. She’s a neurologist, not a psychiatrist, and her neurological assessment was completed without asking that question. But she did ask and I will remember this patient encounter because she asked.

T sighed.

He explained that his daughter has been struggling with anorexia for the past few years. She tried to commit suicide a few times. She lives at home but doesn’t listen to him.

Then, he told us that about 30yrs ago, his son died. He was 7yo at the time and he died of meningitis, a brain infection. He already lost one child, he didn’t want to lose another.

The attending asked him when his son died. She said, “Anniversaries can be a bitch. My brother died and every year I feel myself anticipating that day.”

T said he died in May, 1989. I was taken aback, that was approximately my birthday. His son will be dead for 30yrs on the dot in only a few months.

“But I don’t think about him much these days.” He said, while wiping away tears.

The neurologist wrapped up the encounter in an empathetic and caring way.

I will always remember this lesson: if you don’t ask the question, you will never know the answer.

Do one

‘G’ came into the hospital for R sided weakness in his upper and lower extremities.

G is a sour, grumpy man. He scowled when you woke him up, he answered sarcastically when you asked him any question, and he would only nominally participate in a neurological exam. In short, I would call him a human version of Oscar the Grouch.

Throughout this past week, I saw G every day. And every day, he would refuse to participate in a meaningful conversation. He even took a swing at my attending, trying to punch him in the head for conducting a physical exam.

On my first day seeing G, I called his wife and daughter to obtain collateral information, since I wasn’t getting anything from him. The wife said that she didn’t know he had stopped taking his meds, specifically his blood thinners. Probably why he suffered the strokes that brought him to the hospital.

She noticed that over the past few weeks, he has been weaker, not eating as much, and overall very sad. She thinks he stopped taking the medications because he knows deep down that there is something wrong with his health and he doesn’t want to face it. G has always been a very active and capable man, and to have that capability taken away from him is a terrible blow to his pride.

Finally, she told me that G has been in Alcoholic Anonymous (AA) for the past thirty years. She noticed that he stopped going to the meetings a few weeks ago, right around when he started to go downhill. His sponsor died a few years back and G has been keeping the AA chapter together, serving as a sponsor for many other members.

This got my attention, as I know how important the relationship between a sponsor and a member can be. Especially if it is a long-term relationship. The sponsor dying probably left a huge hole in G’s life, a lack of honest and deep support.

As the week progressed, I found G’s anger and irritability less and less intimidating. I saw more and more of a scared and angry man who lashes out at those who reach toward him, because he doesn’t know any other way to cope with his emotions.

My final day on the service, the attending and I rounded on G. I hadn’t seen him this awake or participatory in conversation since he was admitted. The attending didn’t get much out of him, as usual, and walked out of the room with a bit of frustration but also relief that he, too, was rotating off the service and wouldn’t need to interact with G again.

As the attending looked at his list to check which patient we’d round on next, I asked if I could go back and speak with G, alone. I think I could reach him. The attending smiled, laughed, and said, “He’s all yours. Give me a call when you are done and we’ll meet back up.”

I walked back into G’s room. I asked him for permission to speak with him a bit more. He agreed, without his usual sarcasm.

I rolled straight into it. I asked him if he wanted to die. He seemed taken aback. “No! Of course not.”

I told him, “I’m worried you’re trying to kill himself slowly.” Not taking his meds is concerning because that’s what caused the stroke that brought him in here. I told him that his wife noticed he hasn’t been going to AA.

Initially, he denied this. Then, when I pushed a bit harder, he admitted that he has stopped going.

I asked him about his sponsor. I told him that I know the relationship between a sponsor and a member is a powerful thing. He nodded. I asked him if he has anyone else in his life that supports him like his sponsor supported him.

He said no.

I told him that this concerns me. That it will be a lot easier to fall off the radar and allow himself to die than it would be to do the hard work everyday to try to get better. And he may not even get better, this might be the best he gets. But if he really wants to live, he’s going to need a lot of help and ask for a lot of help. If he wants to die, he can keep doing what he is doing.

This seemed to wake something up in him. He began looking me in the eyes when I spoke, instead of the television or off to the side. I think he needed to be asked directly if he wanted to die. I think this is how his sponsor spoke to him. Directly and not accepting any bullshit.

G agreed. He said he’s willing to do the work. I thanked him. I put out my hand, to shake his. He met mine. A gesture I haven’t seen from him for any other provider.

I call this handshake a victory.

I left his room and called his wife’s number. I figured this was a small window of opportunity to reach G, and if I didn’t hand it off correctly then it may close on us. The wife didn’t answer, but the son did.

I explained the conversation I just had with G. The son seemed to understand. He told me that he is in AA, too, like his father. That he is the only one in the family that can really reach G, probably because they have lived similar lives. The son told me that he could contact some of G’s fellow AA members and have them visit in the hospital later that day. I told him that would be great.

I returned to the floor, to let G’s nurse know that his son would be coming by with some visitors. I saw G on a stretcher, about to leave the floor for some testing. I asked him where he was going.

He rolled his eyes and said, “I don’t know!”

I told him that his son would be coming by, probably bringing some of his fellow AA members with him. I asked him if that would be okay.

He rolled his eyes again, this time less convincingly. “I don’t know.”

I thanked G. I told him to take care of himself.

As transport wheeled G away, he asked, “Are you in the program?”

Meaning, was I in AA?

“No, but I know what it means to people.”

And now, I think that was the best thank you that G could give me.

Teach one

As I transition from medical student to intern resident, I know that I will be in a teaching position for my fellow trainees. I will be a resident on the psych floors. I will be able to teach students about the various presentations of depression, anxiety, and psychosis.

And maybe I will one day be able to teach a student how to ask the question. How to prepare yourself for whatever may rest on the other side of that question. And how to support your patient and your team once you know the answer.

I will forever feel gratitude for that neurologist. She could have easily avoided asking him that question about life stressors. The answer wouldn’t change the medical management.

But it did affect me.

For days following that encounter, I followed up with T. I spoke with him about his Catholic faith, and how he stopped going to church because of his rage with God. And at one point, he said that I must be really into religion since I keep bringing it up.

I told him, “No, but I know the value of religion for folks that believe.” And I think he believes. He just needs some help returning to his faith.

Sometimes it just takes one good question to remind you of that faith.

If you don’t ask the question, you’ll never find the answer.

Long Form Sundays

On Death Podcast

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