The Things That They Don't Teach You In Medicine

In medicine, as in any other specialized field, there are things that you can't help but pick up by way of assimilation. It's kind of incredible that despite not being taught these things explicitly, any medical graduate from any medical program anywhere ends up learning them. Here are a few examples of what I'm talking about:

1. 24-hour time -- A few years ago I saw 24-hour time as an unnecessary bother; maybe I was just lazy, but I found it irritating to have to subtract 12 hours whenever I wanted to know the time. Somewhere in clerkship, after many months of writing the 24-hour time on every hospital form and note I filled out, my brain made the switch. My home clocks are now in 24-hour format and there will be no going back.
2. abbr. -- Somewhere along the line you'll start using abbreviations for everything -- and I don't mean acronyms (you'll learn plenty of those too), but short forms of words like patient (pt), seizure (sz), and shortness of breath (SOB). It's pretty much the secret standardized (well, almost standardized -- I did get asked about DLP (dyslipidemia) the other day) language of health care workers.
3. manners -- Occasionally a visitor will wander up to the nursing station to ask which room "John" is in. I never have any clue who John is. We know all patients by their last names, preceded by a Mr. or Ms. (which some complain is overly formal...I would too).
4. patience -- Working in medicine teaches you patience: patience with your patients, when they are too ill (or intoxicated) to cooperate; patience with family members, who only want what's best for their loved ones; patience with your colleagues when they turf difficult patients onto you; and patience with the staff when your stat bloodwork is not so stat because the phlebotomist is being pulled six different directions. Moreover, you learn to be patient with your learning -- waiting year by year as the knowledge falls into place and you transition from student, to intern, to resident, to fellow, to, finally, staff.
5. the (stupid) hierarchy -- As much as I hate it, the medical hierarchy is ubiquitous -- from the lengths of our white coats to where on the scut-work spectrum our day-to-day duties fall, it's immediately apparent which stage each team member is at in their medical education. The hierarchy I hate even more is that which is perceived to exist between doctors and nurses -- and I say perceived because it is not always present, and in a perfect world would not exist. After all, we're all working together towards a common goal; if anything, nurses are the ones who hold the team together, have our backs, and make sure everything gets done. I've learned to insist that nurses call me by my first name; to always be polite and friendly when asking for favours; and to ask for their advice and teaching whenever I can. The medical school I attended taught me nothing practical -- everything I've learned about putting in iv's, feeding tubes, and catheters has come from patient nurses.
6. pagers -- It amazes me that in a world where Walkmans, VHS, and even CDs have all but disappeared, so many of us still walk around with a piece of the 80s clipped to a white coat pocket (the same pocket that contains a smartphone).
7. dictating -- I remember that occasionally while listening to the CBC program Ideas, my dad would comment on how eloquently the person being interviewed spoke -- "like they're reading grammatically complex sentences", rather than speaking conversationally on the fly. I didn't appreciate how remarkably difficult this was until I started dictating. Dictating consists of phoning a number to dictate a patient's history, progress note, or discharge summary, which is recorded for a transcriptionist to type out and upload onto the patient's electronic chart. Ideally dictations are quick, clear, and eloquent. In reality, dictating involves a painful learning curve that's filled with lots of "um", "oops, I mean", "please go back and add", "please delete the last sentence", and not-so-dramatic pauses, for which I hope the poor transcriptionists are adequately compensated.
8. poker face -- When if comes to healthcare workers, the ones who have been around for a while are the ones who are impossible to phase. In healthcare, you meet patients from all walks of life and all backgrounds. You see gunshot wounds and suicide attempts. You hear histories that would stand up as movie plots. You see life-altering illnesses. And you see (and often end up splattered by) a lot of bodily fluids. You learn to be objective about all things and to, above all, respect each and every patient's privacy.
9. death -- The first dead person I ever saw was the cadaver assigned to our group in anatomy lab. The first death I saw was an at unsuccessful code, on the night of my 22nd birthday. The first death I pronounced was two months ago. Addressing death is not something we are taught to do (our "giving bad news" teaching having consisted of the "SPIKES" mnemonic -- which is honestly one of the most useless common-sense mnemonics I've ever encountered). I had to Google "how to pronounce death" the first time I was paged to do it and proceeded awkwardly to use my phone flashlight to check the patient's pupillary reflexes while her family looked on. I suppose we learn -- by watching our more senior colleagues and simply by exposure -- to deal with death in our own ways, both outwardly in addressing the dying patient and their family, and internally in coping with our own emotions.
10. social skills -- Going through medical school is like exposure therapy for social anxiety. Always having been "quiet", going through medical school with a cohort of extroverts (your typical med students) forced a departure from my introverted tendencies. Over the years I've developed confidence and assertiveness I didn't know I had, and am relieved to find that I can establish rapport fairly easily with the array of personalities seen in patients and colleagues. That may not seem like an impressive feat, but rewind a few years to find me stuttering and flushed whenever I had to say anything in a group, or sweaty and anxious whenever I had to give an injection...things that fortunately now happen no more less often. Although some people have natural advantages when it comes to the social aspect of medicine, it's amazing to see how professional and articulate the majority of medical students have become by the time they reach residency.
11. teaching -- The word "doctor" originates form the Latin verb "to teach" and the Hippocratic Oath includes the line "I will teach them my art without reward or agreement"; clearly, there is plenty of teaching involved in medicine. Staff physicians teach residents; residents teach medical students; and everyone teaches patients. In spite of the emphasis on teaching, teaching doctors how to be teachers is not a priority in medical education. Arguably teaching should come naturally, but realistically there are physicians who teach phenomenally and others who could use a few pointers; I'll have to do my best to emulate the former.

I'm sure there's plenty missing from my list, and I know it's a list that will continue to grow as I progress further in medicine -- and will inevitably come to include many things that I'll have to learn the hard way. No one was kidding about medicine being "lifelong learning"...

For anyone working in the healthcare field, what did you learn on the job that hadn't been taught in your training?