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Show he is functioning as a physician. He conducts detailed patient histories and physicals, writes progress notes and orders. At this point he is almost totally dependent on his mentors, typically the interns with whom he has been assigned to work. They will teach a style for accomplishing these tasks, a style which the student will frequently continue to use throughout his training and on into his practice. He learns by trial and error which items are important, which are relevant, how to present a case on rounds, what to leave in the presentation, what to leave out. Slowly he begins to feel comfortable in the physician's role. The teacher-clinician is an incredibly powerful figure during this first clinical year. As Pellegrino points out, "One careless action at the bedside will undo hours of lecturing about the dignity of patients. Conversely, one act of kindness and consideration will make compassion a reality and an authentic experience" (Page, 1992d). Stories of jaded residents using black humor to survive their ordeal are common; it is much less common to hear of genuine compassion at the bedside in front of witnesses. Yet the behavior the student observes will usually serve as his model for how a physician should act. The fourth year is the first time that the student has any significant decision-making authority. He chooses his rotations, and the site of those rotations, which is generally used as a staging ground for residency. Students typically choose rotations that they feel will help prepare them for the residency they have chosen, and sites that they think will help them obtain the residency of their choice. For instance, most students will try to do a sub-internship in the field of their choice at the institution they would like to attend for residency. This is their best opportunity to make a favorable impression on the program. A few students are still undecided about their field, and use the fourth year as an opportunity to explore multiple areas. A very small number will use this opportunity to spend time in fields they know they will not encounter again once they are committed to a particular residency. Residency applications must be completed during this time, and are a source of great stress. Just as they did during the process of applying to medical school, applicants must again endure a selection process requiring assessment of objective data such as grades in medical school and board exam scores as well as the subjective data of evaluations from clinical rotations, letters of recommendation, and interviews. The residency "Match" is the culmination of this experience. Each student turns in a list of ten residencies in which he is interested, ranked in order of preference. Each residency also turns in a list of students it is interested in, ranked in order of preference. A computer shuffles the data and matches the students to programs. On Match Day, every fourth year student in the United States receives a letter with his match information simultaneously. Then programs that did not fill all their spots, and residents who were not accepted into a program on their list "scramble" for the remaining positions. Once the Match process is over, students relax, knowing that their future for several years is now determined. Residency is the next major phase of training. Internship, the first year of residency, is the biggest source of stress. At this time, the intern is performing the same tasks he did as a third year student, but now without supervision. He can now write orders independently, where previously a co-signature had to be obtained from a more knowledgeable person. For the first time he is making truly independent assessments and decisions. Backup is available from the upper-level resident, but he is expected to make the final decisions himself. During the subsequent years of residency, more and more responsibility is acquired. Now the resident is approving of the intern's decisions, and generally has little oversight of his own actions. Following completion of internship, most states allow licensure. The physician is now legally empowered to function independently. He can finally write prescriptions, even for Utah's Health: An Annual Review 1993 93 |
