Our students avail of highly-prized elective opportunities at home and abroad. These electives allow students to explore in further depth topics of relevance to their degree programme. As part of our summer elective series, medicine student Michael Conroy reflects on his time at the Mayo Clinic, Minnesota.
It’s well known that rookie medical students absorb all new information like a parched sponge, in particular any wisdom bestowed by a consultant. Probably the most favoured advice of the medical elders is the solemnly uttered ‘common things are common’ – simple explanations are usually the right ones, and, in general, that headache is probably just a headache.
In America however, doctors prefer the more prosaic ‘if you hear hoof beats in Texas, think horses and not zebras’. Apparently this colourful expression applies equally to almost everywhere except Rochester, Minnesota, where I started my clinical elective in July of this year. The Mayo Clinic is renowned as a magnet for the most unusual, unlikely and challenging cases around, and veterans of the place told me to expect nothing but zebras for four weeks.
Given the fact that our clinical electives are supposed to leave us with a solid grounding in a certain area, was this a bit of a gamble? Would I return an expert in Waterhouse-Friedrichsen syndrome without being able to handle a cough? Luckily, the Mayo Clinic manages to find a happy medium and welcomes all comers, regardless of pathological mundaneness.
Rochester is an isolated town roughly the size of Cork, which has an economy and population based almost entirely around the clinic. The institution itself was started by Dr Mayo (originally English!) in the post-Civil war years and became the first group practice in America.
My first impression on arriving there, two days before my elective began, was similar to my first impression of virtually everything I encounter in America – it was simply too big to be allowed. The clinic skyscrapers soar 21 storeys tall and welcome hundreds of thousands each year. The main hospital, St. Mary’s, is the largest private hospital in the US and has fifty five operating theatres (fifty five!) and my department, infectious disease, had twice as many ID consultants as Ireland does in total.
But like any fancy contraption, what matters most isn’t the appearance but how it functions, and the hospital is unique. Unlike many other hospitals in America, where doctors get paid for giving people more treatment, Mayo doctors are all paid a fixed wage. This means that instead of throwing CT scans at every problem and operating whenever they get the chance, doctors are only incentivised to act in the patient’s best interests.
Paramedical staff, rather than being assigned a multitude of different jobs, are expected to carry out one particular job with great efficiency and expertise. And so there are teams of people whose sole job is to draw blood, or insert catheters, or take bone marrow biopsies. Naturally, given the experience they quickly develop, they become more proficient at their jobs than any doctor.
I was on the infectious disease consult service, and so our work involved managing infections in patients who had been admitted under other teams – a typical example would be a patient who presented with a heart attack but then developed pneumonia.
The initial impressions I got of my team were that they were particularly welcoming – they all seemed genuinely thrilled at the notion that a student would want to join the team – and also absurdly hardworking. All the residents (junior doctors) worked six day weeks and regularly 12 hour days. On the side, they also were carrying out research, working on committees and one even had a patent. It was all a bit intimidating.
While on the team, the disease that I saw was a curious mix of common and not-so-common. I saw plenty of pneumonia, but also regular cases of infective endocarditis (a rare-ish heart infection) – my consultants had a particular interest in it. Other interesting cases included a West Nile Virus brain infection, and most unusually, a patient with severe leprosy (an extraordinary learning case).
My working day had a 7:30 start, when I would check my patients’ charts from the night before and see if there had been any incidents overnight. At 8:30 we had morning rounds, at which I would present my patient to the consultant. If he liked my plan, it would become the plan: for a student this is a great sensation, as you get a chance to determine the course of a patient’s care and a taste of responsibility, even though the senior physician is essentially making the decisions anyway. This would always be followed by consultant teaching – Americans take their dedicated learning time very seriously.
After rounds, I would take on one of the new patients we had been asked to consult for, and read up on their case. This was one of the areas where the hospital was most different to Ireland – an extraordinary amount of time was spent preparing for each consult, and I often spent an hour picking through a patient’s extended history, correspondence and lab results. Due to their elaborate computerised records, I could see every patient note, referral and X-ray for the past 30 years at the click of a button, and they were extremely thorough (including detailed notes from each chaplain visit).
There was a free lunch every day at 12:30. True to the adage, it wasn’t actually free, as we had to attend a lecture at the same time. It seemed a reasonable trade-off for a delicious meal.
Following lunch, I finally got to visit my patient after looking into their details all morning. We followed a routine, where I would be the first to visit the patient, followed by the resident, then the fellow (senior trainee) and eventually the consultant. In this way, we would share what we picked up later on; it also meant that the person most likely to be dismissed angrily by the patient (me) arrived when the patient was least frustrated by repeated interruptions. An ingenious strategy by all accounts.
The day would finish up around six and I would be left return to my hotel for dinner and, more often than not, study. Rochester’s social scene is, unfortunately, not its strongest point. But then again, that’s hardly why people travel there.
Overall, my experience in America was extraordinary. While my team focused on one specialty, I got a good grip on hospital medicine in general and an excellent idea of what the everyday life of a junior doctor is actually like. I was lucky to be working in a non-profit hospital where the doctors seemed to be genuinely interested in teaching ahead of money, and where my team was uniformly friendly, helpful and enthusiastic. Lastly, I was fortunate to receive a scholarship from UCD to make this all possible, which was sincerely appreciated.