Medical Students Experience Life on the Other Side of the Bed
“Our goal is to increase physician/nurse collaboration by helping medical students understand the role of nursing and the skills that nurses bring to healthcare,” says Cecilia McVey, MHA, RN, FAAN, associate director of nursing and patient care services at VA Boston Healthcare.
Vascular Access Nurse Kassidy Dias, RN, gently tapped her forefinger on the blue vein in the crook of the arm of Vietnam War Veteran David Preston.
“Feel the bounce? That’s perfect,” Dias told second-year medical student Juan Guerrero as he prepared to draw blood from Preston, a former sergeant in the U.S. Army 101st Airborne.
Guerrero is one of five second-year medical students from BU, along with a student from Harvard and another from Tulane, who worked on wards at the West Roxbury VA Medical Center this summer, training in an innovative program known as The Other Side of the Bed. The six-week program, now in its 15th year, has medical students undertaking many of the routine patient care tasks typically performed by the nursing staff.
“Our goal is to increase physician/nurse collaboration by helping medical students understand the role of nursing and the skills that nurses bring to health care,” said Cecilia McVey RN, MHA, FAAN, associate director for nursing and patient care services at VA Boston Healthcare System.
Thirty years ago, McVey suggested the Jamaica Plain VA Medical Center employ medical students to address a temporary nursing shortage. In 2009, recalling the positive experience of nurses and medical students working together, McVey proposed a permanent program, and VA Boston Chief of Staff Michael Charness, MD, agreed, adding an educational component to the clinical work.
The program addresses what numerous studies have found: that an uneven power dynamic and issues around professional respect between doctors and nurses hinder collaboration, teamwork and patient care.
Charness believes the increased use of technology has exacerbated the problem.
“I think that as healthcare and medical education have evolved it’s harder for the different members of the team to understand and appreciate the skills each profession brings,” he said. “And I think patient care can suffer from insufficient collaboration and communication.”
“The nurses understand this. They see themselves as participating in an effort to improve teamwork and interdisciplinary collaboration one trainee at a time,” said McVey. She estimates that more than 200 medical students have participated over the past 15 years.
The experience benefits both parties, said McVey.
“This is the most hands-on care and the most sustained patient time I have ever had in any of my pre-medical school experiences or my first year of medical school,” said medical student Rachel Kim. “I think it’s just a really valuable experience in learning how to talk with patients, how to interact with them at their bedside, beyond diagnosis and planning.”
“For those of us who work in academic medical centers, a big part of what keeps us here is the energy and enthusiasm that learners bring to the health care environment,” said McVey. “It’s very infectious, and I think the nurses really feel this is an incredible opportunity to be able to interact with people who are so excited about what they are doing.”
Working alongside nursing assistants and nurses for eight- and 12-hour shifts, the medical students perform the most basic, but vital of tasks: bathroom assists, help with daily activities like getting dressed, showered and fed, changing linens, doing simple tests like glucose monitoring and responding to patient requests. Students shadow and learn skills from various teams, including vascular access, EKG and respiratory therapy. There are weekly lunchtime lectures by VA staff.
The son of Colombian immigrants, Guerrero moved from Miami to New York City at 18 to pursue an acting career. He started his undergraduate education relatively late at 26. Now 33, he is among the oldest of second-year medical students at Boston University’s Chobanian & Avedisian School of Medicine.
His first exposure to a hospital was at 17 when his grandmother was diagnosed with cancer. Guerrero was impressed by the combined effort of nurses and physicians working to heal people.
“I felt oddly safe with her being there…I was really inspired by that,” he said. “Health care is teamwork. It’s never just one person. I hope to be part of a team where everyone understands where the others are coming from.”
By the end of her first week, medical student Rachel Kim was able to distinguish between the various beeps and alarms that make up the soundscape of her ward. When the urgent high-pitched chirp of a motion detector went off, she set off quickly down the hall to assist a patient who was not supposed to move unaided.
The Princeton graduate is from Denver, Colorado, and spent a year working as a hospital scribe, taking notes during physician/patient sessions. Kim also has done research, but found she really wanted to work with patients.
“This is the most hands-on care and the most sustained patient time I have ever had in any of my pre-medical school experiences or in my first year of medical school,” said Kim. “I think it’s a really valuable experience in learning how to talk with patients, how to interact with them at their bedside, beyond diagnosis and planning.”
Kim is drawn to an interdisciplinary approach to medicine. Her time on the wards showed her that nurses were foundational to a care plan, expanding their responsibilities to fill in for others. During her first week at the VA, she watched a busy nurse with a full patient load take the time to walk the halls alongside a patient desperate to get out of his room, but who was a fall risk, with a walker and trailing IV pole.
“I was immediately struck by how much she was giving to him that day,” said Kim.
“The perspective I gained over the summer is really unique and I hope I’ll be a better team player and less of a doctor-on-a-pedestal,” she added.
Charness said medical students participating in the program come to understand that what a nurse learns by being in the room with the patient for hours each day is very different from what a physician learns when they walk in for a few minutes.
“There is a big difference being on the floor and being with patients the whole time,” said Kim.
Kim noticed nurses making careful observations of the changes in a patient as his prognosis rapidly shifted from recovery to palliative care over the span of a weekend. When a resident came onto the ward, she was impressed that he turned first to the nursing staff to ask what they had observed and what they thought should be done.
“It was the first time I saw one of the physicians take the time to get the full story from the nurses,” said Kim. “I saw that, and I said this is what I want to keep with me and emulate as I move forward in my training.”
While second-year medical students are academically gifted, love science and helping people, they are still transitioning from the theoretical world of medical education into the tactile, very real world of patient care.
“One thing that really surprised me is how quickly you can make a valuable connection with a patient,” says second-year med student Douglass Bryant. “They are more than just their medical problems. They matter to so many other people and that’s all the more reason to do a great and respectful job.”
“There are a lot of skills involving patient communication, like how to interact, how to understand their needs and be able to help them. Bringing them (what) they want, or need is a big thing,” said medical student Ariana Rauch.
“It’s surprising to me what little percentage of time the physician is in the picture for any one patient,” said medical student Douglass Bryant, who grew up in a San Francisco suburb and graduated from Harvard before coming to BU’s medical school.
Going into the VA program, Bryant hoped to get a more comprehensive understanding of how treatments, therapies and medicines affected patients. He was surprised by how everyday activities, like taking someone to the bathroom or helping them shower, factor into caring for a patient.
“Those are the in-between parts of a patient’s day that you’re not going to see…in a textbook or in classes,” he said.
Studies show an increasing reliance on technology, even just entering patient information and observations into a laptop, contributes to the estrangement of physicians from patients. Students in The Other Side of the Bed said it was the opportunity to work directly and intensively with patients that drew them to the program.
“One thing that really surprised me is how quickly you can make a valuable connection with a patient,” said Bryant. “They are more than just their medical problems. They matter to so many other people and that’s all the more reason to do a great and respectful job.”
Like most of the students, Guerrero was drawn to the intensive hands-on care experience, but found the reality of that work challenging.
“I thought I knew what I was getting into, but this was a lot more difficult; changing a patient for the first time, understanding how to move around a catheter, dealing with someone who feels really betrayed by the system, and not knowing how to get through to them,” he said.
It was a simple act of kindness, bringing a patient with dementia the Pepsi he enjoyed each time Guerrero visited him on the ward, that established a bond that allowed him to coax cooperation from him when he became combative.
“Throughout my first year [in medical school], I was afraid of having too much physical contact [with patients], too afraid of invading their privacy. It’s a hard line to walk, in how to provide hands-on care while still respecting their privacy and sense of personhood,” says Kim.
Sometimes, it’s the small details of care that make patients’ lives in the hospital more bearable. Glucose testing is a daily ritual on many wards, and it involves pricking the patient’s finger with a needle to raise a drop of blood. No painkiller is used for this test and Kim found herself massaging patients’ hands to warm them and get the blood flowing so that she wouldn’t have to stick them more than once.
“Throughout my first year (in medical school), I was afraid of having too much physical contact (with patients), too afraid of invading their privacy. It’s a hard line to walk, in how to provide hands-on care while still respecting their privacy and sense of personhood,” said Kim. “I learned a lot from (nurses) about how to do these really intimate tasks with dignity.”
Success is measured in achievements most people take for granted – putting on clothes, personal hygiene and ambulating. Patients provide life lessons that are humbling to students accustomed to accolades and success.
Guerrero recalled his surprise when his expression of sympathy was rebuffed by a patient complaining about his condition.
“He was very clear that he just wanted to be listened to. He didn’t want to be fixed; he wanted me to bear witness to his suffering,” said Guerrero.
Medical student Jackson Wallner thought the most underrated aspect of the program was the opportunity to talk with patients and not feel rushed to move on to something else, a luxury he expects he won’t have as a physician. It’s why he knew that a shave was important to retired Army drill sergeant Robert “Rick” James. It’s a remedy that won’t be found in a medical textbook or that he’ll be expected to do on his future clinical rotations and residency, but Wallner grabbed shaving gear and fulfilled James’s request.
“He’s going to make a good doctor. He’s got the heart,” said James, a Vietnam War veteran.
Research has shown that knowing the patient’s life story, what is important to them in their life, can provoke feelings of empathy and compassion in providers and help tailor care to the individual. Students often cited the VA’s “My Life, My Story” initiative as meaningful and most helped record patient stories for the project.
Since 2013, thousands of veterans have been interviewed; their brief life history becomes part of their medical record and helps physicians and care providers know the person behind the patient. Often, it was the patients teaching the students life lessons.
“Hank (not his real name) showed me how humbling it is to require help for daily acts of living,” said Wallner. “He taught me that everything doesn’t need to be so deadly serious and how unconditionally one can love their family.”
“Being there for them (patients) can be actively listening to them with an open heart and that’s what I’ve tried to do. And every day I’ve gotten better at it because of these patients and because of you (the nursing staff),” said Guerrero.