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an online version of the magazine Winter 2005
Learning Curve

Living the Title

Dan Munoz
By Dan Munoz, '04

When I began writing this column two years ago, a few names came to mind for it. But none seemed more fitting than “The Learning Curve.”

At the time, I was a fresh product of the 20 months of exams, lectures and laboratories that define the medical student experience in the preclinical years. I was also embarking on a new learning curve as a student clerk, on the wards. Here, patient write-ups replaced note-taking, physical examinations replaced sit-down exams, and a white coat and tie replaced the jeans and baseball cap that happened to be closest to my bed in the morning. Instead of an 8 a.m. lecture, I now had 8 a.m. inpatient rounds. And because rookie clinical clerks learn the hard way, I quickly found that these sessions all too frequently could take place at 6 a.m.

But perhaps the most striking difference between preclinical and clinical training was the teaching I had come to rely on. During the first two years, professors streamed through the lecture halls sharing insights on their particular areas of scientific expertise. It was like an album of the Greatest Hits of Hopkins, featuring department chairs, renowned researchers and superb clinicians as the performers. Like any CD, some tracks were fast, some slow, some classic, some forgettable. Some reminded you why you fell in love with the band; others made you question why you bought the album in the first place. It all fit the image of medical school I had when I arrived in Baltimore —the experienced physician/scientist sharing knowledge with a collection of naive, enthusiastic doctors-to-be.

Then I hit the wards.

And here, although attending physicians retained ultimate responsibility for patient care, the daily functioning of the hospital relied heavily on the house staff, I found. This also applied to the teaching. The attending might make key points on rounds or give a lunchtime lecture on a topic of particular relevance, but I spent most of my day with a team of residents just a few years my senior.

Today, as I look back at the memorable moments and lasting lessons from my clinical years, virtually every one involves a resident. During an early rotation in pediatrics, I remember wondering if my intern, Ceila, was oddly superhuman. My first day on the inpatient service happened to be her first day of residency, yet she seemed unfazed by her new surroundings. Instead, she calmly taught me how to examine an infant, dose antibiotics and keep simultaneous track of multiple patients. And through it all, she maintained a sense of humor. How could I, in just two more years, mature into this sort of resident? It was decidedly unclear. Maybe Ceila was the exception.

As I progressed through my third year of medical school, I humbly realized that Ceila was representative. At 3:30 a.m. Greg talked me through techniques in administering anesthesia as he medicated and monitored a sick woman undergoing an emergency Caesarian section in the operating room. Eric walked me through lung anatomy and optimal surgical technique as he tried to control the persistent bleeding in a middle-aged man's pulmonary artery. And Julie coolly broadcast directions to everyone in the room at the same time she guided my hands as I, for the first time, delivered the head of a newborn out of the birth canal and into the world.

As a fourth-year medical student, I spent a month as a sub-intern on the Osler Medical Service. Charged with primary (though not ultimate) patient care responsibilities, I began to put some of my third-year lessons to use.

I'll never forget my first night on call. Even though I felt proudly independent from the in-house resident on my team, I also felt a powerful reliance. Ann listened carefully to the treatment plan I proposed for a patient with a likely heart infection, making suggestions and refinements along the way. After hearing my presentation the next morning on rounds though, the attending simply turned to another resident and asked what he thought of the plan.

The attending, Dr. Zaas, summed up the case and answered everybody's final questions. But most of the teaching—from the overnight evaluation of the patient to the treatment plan to the discussion—was driven by the house staff.

And now at last, with only one rotation and a three-hour graduation ceremony separating me from my own residency, I wonder what that beginner student clerk will think of me next July. Can I be an effective resident-teacher, even as I continue to fill the gaps in my own clinical knowledge? Maybe this is what they mean when they say the practice of medicine is a lifelong learning process.

Because for every question from a friend, family member, or third-year medical student that I can now answer about heart disease, pregnancy or diabetes, there are four questions that I want to pose to my attending.

On the other hand, maybe I'll ask my senior resident first.

 Medical School Reformer
 Icons and Fundraisers
 In Spite of All Odds
 Circling the Dome
 Medical Rounds
 Annals of Hopkins
 Learning Curve
Johns Hopkins Medicine

© The Johns Hopkins University 2005