Medical students taking a job in the hospital during their studies is nothing new. But taking the place of the doctor is something else. A day in the Lithotripsy department at Erasmus MC, where the students seem to rule the roost.

Bang! Bang! Bang! Bang! For the unsuspecting visitor to the Lithotripsy department in Erasmus MC, it comes as quite a surprise to hear such loud noises coming from the operating theatre every other second. But medical student Gyan Ramsingh (24) remains unruffled. A room further down the corridor – appropriately known by doctors and students as the ‘Steenweg’ or the Stone Road – he’s watching calmly and confidently with his colleagues. Just before that, he’d been exploring the patient’s kidneys and urethra with a type of ‘canon’ looking for a large white mark: the kidney stone. Using that same canon, the kidney stone is now being attacked with shock waves. That’s what causes the loud bang. In just thirty minutes, the stone should be history. If you’re waiting for the doctor to appear in this story, you will wait in vain. Because Ramsingh is not just a student, but also ‘a type of doctor.’

It works both ways

Erasmus MC Studententeam 1
Gyan Ramsingh

The fourth year medical student very consciously uses the words ‘type of’. Calling yourself a doctor before you graduate is obviously sacrilege. But for everyone else who comes across him during the course of the day, from patients and their parents to colleagues, Ramsingh is the duty doctor. Patients know that they’re being treated by a medical student, but one who is just as experienced in lithotripsy as the doctor. “I would never say so myself, I’m still very low in the pecking order,” says Ramsingh. “But it does involve quite a lot more work than is expected of the average student here in the hospital. It’s far different from bringing round food and drink.”

Giving students responsibility is exactly the reason why five years ago, urologist Willem Boellaard and his colleagues started employing medical students in the department where patients were treated for their kidney stones. “Residents were given a different rota, which meant they had less time for lithotripsy,” Boellaard explains. “So we had to find a new solution.” That solution came in the form of medical students. “It works both ways. The students learn more about medical practice, meaning they become better doctors faster. It’s better for the hospital too. Residents can be used in other locations, while students often stay around longer, so that you have a more stable base.”

Not afraid of mistakes

‘You have to learn really fast here and you immediately get given a lot of responsibility. So students don’t do this for the money’

Gyan Ramsingh

Ramsingh agrees with his boss. As team leader, he’s not only worked in all the jobs in the department, he’s also responsible for the intake of new students. “You have to learn really fast here and you immediately get given a lot of responsibility. That’s not the case in many other places. So students don’t do this for the money – neither do I. It’s purely for the experience and the challenge.”

Boellaard isn’t worried that Ramsingh or one of his colleagues will make a mistake. “It’s not unusual for students to be involved in the medical process. They get a three month training before they gradually start their first treatments, under the supervision of a urologist. So when they eventually start on their own, they’ve already got a lot of experience. And every treatment is also under the direct supervision of a urologist. As long as they consult the doctors if anything seems out of the ordinary, we never have an undesirable situation. As long as they don’t think: I won’t call the doctor in case I look stupid.”

Keep talking

That’s not a thought that seems to have occurred to Ramsingh at all. As he looks through the files for the rest of the day early in the morning, he’s already put a question mark by one of the patients and he contacts the doctor. “You can’t say in advance how the treatment will go, so you must always be on your toes.”

Erasmus MC Studententeam 2
Tim Offringa (l) and Gyan Ramsingh

Nor does he panic later on when he finds it a bit more difficult than usual to find the kidney stone during a treatment. He calmly consults his colleagues, weighs up the options and finally – like a ‘real’ doctor – takes a decision himself. His predecessor Tim Offringa (now doing his residencies) looks pleased, as Ramsingh turns on the canon again. Offringa: “That’s what I taught him to do and Gyan will later teach other students to do the same. As long as you keep talking to everyone, you’ll be fine.”

Source of inspiration

‘But we’re well prepared so, touch wood, nothing ever goes wrong.’

Gyan Ramsingh

At the end of the day, there are only happy faces on ‘the Steenweg’. The patients can pass the fragmented kidney stones and so Ramsingh can go home feeling satisfied. Does the success of this team mean that students will be doing more operations in future? “No,” he says. “This is the maximum that you can do as a student. Assuming the role of the doctor is one thing, but cutting into someone is quite different. That doesn’t mean that these treatments have no risk, because if I shoot wrong, the patient has a problem. But we’re well prepared so, touch wood, nothing ever goes wrong.”

Boellaard doesn’t think that more responsibilities will be put on the doctors of the future either, but he does hope that Ramsingh and his colleagues will be a source of inspiration for other departments at Erasmus MC. “More departments should do this. You work with young, enthusiastic and fresh people. Why wouldn’t you be positive about that?”

Extracorporeal Shock Wave Lithotripsy (ESWL) is a technique for treating stones in the kidney and ureter from outside the body using shock waves. These target the stone, which creates cracks. Eventually the stone breaks into fragments which the patient can then pass from the body along with the urine. The stones are located using ultrasound or X-rays, depending on the type and composition of the stone. The whole treatment takes around 45 minutes.