Reality has no manual

Every now and again, you wonder what you know for sure about your job. Right now, all I know for sure is that this evening, I must mark the coursework and write this column.

I know that part of my day job is to teach undergraduates, some of whom are going to be tomorrow’s junior doctors. It is a strange thing, teaching medical students and trying to work out what they might one day need to know. At the best of times, it feels as though we are not fully up to the task. At the worst of times, it feels less like a professional traineeship and more like Timothy Q. Mouse giving Dumbo the elephant a feather, shortly before he shoves him off a cliff.

Unlike those teaching the “proper” science students, you know something of what lies in store for them. You are getting them ready for something real. You are preparing them for the reality of the job, for the days when it is something other than swanning around wards sporting white coats and wearing stethoscopes like feather boas.

We do the naming of parts thing. Foist upon them a Haynes manual for the human body. And we are getting better, I guess. These days, we go beyond rote, beyond the simple remembering and regurgitation of facts. We prepare them in our classrooms to snipe confidently at someone else’s study, to query the quality of the case mix or the randomisation of the trial. We prepare them to see the wood from the trees in the evidence, to be cynical about the hard sell from some corners of the pharmaceutical industry. We help them to understand the difference between what they know and what they think they know.

Of all the things you should prepare your students for, it is days like this. The stuff that isn’t art or science. Only you know there are no courses for this

This we can do. We even teach them something of the softer skills that doctors need: the breaking of bad news and the ethical dilemmas; the questions for which there are no right answers. These days, it seems that there are courses for everything.

They are better students than we ever were. They should be. They have a thousand different teachers available, literally at the push of a button, waiting patiently 24/7 on the end of a URL. They are awash with knowledge, given in good faith, sloshing down digital pipes, spilling off the pages of e-journals. Everything the independent-minded, gifted autodidact needs to be a doctor.

Except that there are other days. Days when the job is not about paperwork or the evidence or the grade you got in your final exam. When there is no intellectualising the challenge, when having a telephone book’s worth of facts in your head makes no difference.

When things start badly and get worse. When you face stuff that isn’t in the books, when you have to run, when you leave a mess of bloody footprints trailing along the corridor, when you finish the case with your gloves wet and dripping crimson. When, in a state of something near panic, you deliver into the hands of a more capable and better equipped team, your sickest patient, and you stumble over the words as you urgently spit out a stream of what you consider essential information, but which, to the people who have just gathered around, is little more than a set of slick phrases and impenetrable jargon that together simply mean “help me”.

On those days, your colleagues later stand beside you, asking if you are OK over and over again, without your understanding precisely why. Until you look at your feet and your hands and then the patient and yourself. And later, when it is over and you are filling in the paperwork, they tell you that everything that could have been done was done. That nothing would have made any difference.

Of all the things that you should prepare your students for, it is days like this. The stuff that isn’t art or science. Only you know for sure that you can’t. There are no courses for this.

And on days like this you ask yourself again if everything that could have been done was done. You rake over it with colleagues, combing over the detail, the timings, the decisions, the interventions. You do the “whys” and the “whens” and the “what ifs”. You ask yourself if you could perhaps have done something that would have made a difference, if there was a chance to escape to a better outcome. Finally, you realise that you don’t know and never will. And you ask yourself again what you know for sure about the day. And all I know for sure is this: that tonight, I have to mark the coursework and write this column.