Harvey

February 29
by Alison

We got to spend this morning working on our own with Harvey, the cardiopulmonary patient simulator.  Our supervisor gave us a set of six clinical scenarios and we took turns working through them.  One person acted as the facilitator while the other examined Harvey and proposed a diagnosis based on the information in the case and the physical exam. 

This was the first time I’ve had a chance to spend so much time with a simulator in a small group.  It was a great way to learn.  The scenarios provided some structure, but we were able to maximize our learning by working at our own pace.  When it was my turn to examine Harvey, I spent a lot of time auscultating the heart sounds.  I was able to detect some fairly subtle murmurs, and characterize the various sounds.  From this, I was generally able to determine the pathology.  I liked being able to work through things slowly.  It gave me time to think and allowed me to re-check some findings for confirmation.  It was also helpful to watch my colleague examine Harvey and to note how she approached each case.  The session was very informal, and we would ask each other questions as we went.  We made a list of questions that we were unable to answer so that we can follow-up with our supervisor.  At the end of each case, we reviewed the diagnosis and findings.

After the session we were discussing how helpful it was to work with a simulator.  In a patient encounter, you won’t necessarily be in a quiet, well-lit room in which it is possible to pick up some of the more subtle findings.  There is also generally more time pressure when working with patients.  We were both remarking that it would have been helpful to spend more time with Harvey earlier in medical training so that we could become comfortable with characterizing murmurs.  I realize that Harvey is a valuable and limited resource and I’m grateful we got so much with him today. 

Establishing rapport

Blog #4
by Nishani

The CanMEDS roles emphasize the importance of a physician as a skilled communicator, advocate, manager, scholar, professional, medical expert, and collaborator.   In our curriculum, these skills are continuously evaluated in every clerkship rotation.  We are also expected to reflect on these roles through our portfolio submissions.  Occasionally, the roles are taught formally through lectures and small group clinical sessions based on themes such as ethics, breaking bad news, and dealing with a difficult patient. However, I believe I learned the most about these roles through observing my preceptors and residents.  To that end, I did not realize just how much I learned about establishing rapport and working with patients with addictions until today.

I saw Mr. X in clinic for follow up 1 month after discharge from hospital for a condition related to his high alcohol consumption.  He came with his caseworker and the first thing he stated was that he did not have a lot of time and did not want to wait around for the attending staff.   I told him that it would take a bit of time to be able to provide him with the best care possible, and he seemed agreeable to this.  I made a conscious effort to build rapport during the history taking and physical examination using various techniques that I picked up over time from many of my preceptors and residents.  I then left to review his case.  Shortly after, I was informed that he wanted to leave. My preceptor and I met him outside the clinic and he stated that he felt anxious and wanted to step outside to smoke.  I asked him if he would consider returning after he was done. I told him that we might be able to provide him with some suggestions to help relieve his symptoms that he stated were bothering him so much.  He declined and left.  I was slightly disappointed, but hopeful that he might return.  Through my experience working at an inner city hospital for most of my core rotations and dealing with many patients with addictions, I had almost a “sixth sense,” as my staff called it, that the patient would return.  Indeed, he did.  We were able to complete his assessment, and determine the necessary management and follow up for his condition.  

This encounter reminded me that there are many skills taught in medical school that are not presented through formal teaching sessions.  Having good role models and mentors to teach students significantly adds to this part of the curriculum.  Although no preceptor prefaced this kind of teaching with, “now you will learn about how to establish rapport with someone who does not want to see you,” and I cannot name one specific encounter where I learned “how to reason with a patient who wants to leave against medical advice,” I have learned several strategies to work with these kinds of situations over time through careful observation.  

See one, do one, teach one

February 27

by Alison

Today we were in the dermatology clinic.  With the new clerkship curriculum, I have had limited clinical exposure to dermatology.  I have tried to learn dermatology from textbooks and online modules, but it is sometimes hard to appreciate the subtleties, and certainly the texture, of skin lesions from books.  I am therefore very happy to have the opportunity to gain more clinical dermatology experience. 

At one point, the staff dermatologist saw a lesion he wanted biopsied and asked the resident and me to do a punch biopsy.  The resident asked me if I would like to do the biopsy.  Ordinarily, I’m happy to have the chance to practice procedures.  However, I had only seen one punch biopsy performed and that was more than a year ago.  Therefore, I didn’t feel comfortable doing the biopsy today and asked the resident if I could just observe.

This got me thinking about the often-used phrase “see one, do one, teach one”.  When I have recently observed a procedure, I am usually comfortable trying the procedure the next time.  However, when a significant amount of time has passed, I may have forgotten some of the steps and may require a refresher before attempting the procedure myself.  I feel like “see one, do one, teach one” is time-dependent.  I think it's a strategy that could work well in ambulatory teaching since there’s some control over which patients are seen at a given time.  For example, an instructor, having recently demonstrated a particular procedure, could arrange for another patient requiring that procedure to return when the trainee is scheduled to be in the clinic.  Perhaps instructors in ambulatory clinics could look for such opportunities to implement the “see one, do one, teach one” learning strategy.  I certainly hope that I get a chance to do a punch biopsy in the near future to reinforce what I have just observed.

Learning how to teach

Blog #3
by Nishani

Friday’s meeting with our supervisor involved a discussion on the ways information is taught in medical school.  I personally prefer the older method of chalkboard/whiteboard teaching over slide presentations.  I find that I learn better through this former method because it forces the presenter to slow down how he/she describes the information.  This was also the lecture method I was more familiar with through my undergraduate study.  However, I was intrigued to hear from my supervisor that very little is actually learned during a lecture.  Coming from a predominantly math/physics background, I found that I tended to rely on lectures to learn how to solve homework problems.  This changed somewhat in medical school because I knew I had to constantly review the volumes of information presented in lecture in order for it to “stick.” 

We then discussed how teaching techniques change through clerkship.  During this particular week, I realized that I learned a lot of information simply by being tested on the spot in a patient encounter.  One strategy that our preceptor used was to give clues to the questions he asked by connecting them to seemingly unrelated topics.  He made connections that forced us to “think outside the box.”   After the patient encounter, he would bring out his collection of photos showing various physical findings associated with a particular condition. I found both of these methods to be very useful in reinforcing our knowledge.

Leading by Example

February 25

by Alison

I had a great week in clinic and learned a lot over the course of the first four days of this selective.  Our preceptor has been a prominent teacher for a number of years and is known to be a role model to many past and current trainees.  From an education perspective, I believe role models to be very important and I’m far from alone in this.  The literature suggests that role models play an important part in shaping the attributes and career paths of future physicians [1,2]. 

Among the attributes cited in the literature as important qualities in role models are time spent on teaching, emphasizing the doctor-patient relationship, and teaching the psychosocial aspects of medicine [3].  It is perhaps my good fortune that the majority of the preceptors I have encountered on my clinical rotations have possessed these qualities.  They have also all been highly skilled clinicians.  However, there are a few people who have really stood out as the people I would most like to emulate.  Reflecting on why I admire these particular people so much, part of it stems from similarities in approaches to care.  However, I think mostly it relates to them having particular personal qualities, such as altruism and humility, that I find admirable outside of medicine as well.  I sincerely hope that I can follow the example they set.

 1. Paice, E., Heard, S., & Moss, F., How important are role models in making good doctors? BMJ, 2002, 325: 707-10

2. Wright, S., Wong, A., & Newill, C. The impact of role models on medical students, JGIM, 1997, 12: 53-6

3. Wright, S.M., Kern, D.E., Kolodner, K., Howard, D.M., & Brancati, F.L., Attributes of excellent attending-physician role models, NEJM, 1998, 339(27): 1986-93

    

The big C and the art of medicine

February 23, 2012
by Nishani

Today’s theme in the ambulatory internal medicine clinic was focused on the art of medicine.  In particular, we saw two patients who had very different experiences with cancer.   The first patient, let’s call her Ms. X, was told she had cancer before further investigations confirmed that she did not have it.  The other, Ms. Y, worried that “something was wrong”, but instead was told not to worry about it.  Later investigations revealed that she did have cancer, and in fact, it had already spread to distant regions.  Both patients experienced significantly different outcomes.  However, they both continue to wish that things could have been done differently.  

Ms. X reiterated the need for doctors to be cautious and mindful of the patient’s feelings when delivering bad news.  Her doctor had told her that she had cancer after seeing a suspicious lesion on imaging.  In actuality, this lesion did have a very high likelihood of representing a malignancy.  She explained that she would have preferred if the doctor had said something to the effect of: “It looks like there’s something on the imaging that’s not quite right, but we will have to do further investigations to sort it out.”  I wondered, when there is a 90% chance that a lesion could be malignant, do you try to prepare a patient for the worst?  Or, do you withhold that information until you are sure?  According to Ms. X, it is better to let patients direct how much information is delivered.  If Ms. X had probed further to inquire whether there is a chance that the lesion could be malignant, perhaps then her doctor could have offered this information.  Of course, each case and each patient interaction is different.

Ms. Y emphasized the importance of listening to patients and addressing their concerns.  She had been worried about her symptoms for quite some time, and asked repeatedly for further workup and investigations only to be told not to worry.  She said, she “knew [her] body best,” and wishes that her doctor had listened to her requests.  Perhaps her cancer might have been caught earlier and she might have been offered a chance for cure.  Again, I was reminded that even though doctors may have their own agenda of tasks to complete, addressing patient concerns should take precedence.  However, as managers of health care system resources, is it practically feasible to offer investigations to patients every time they ask for them especially when these investigations may not actually be clinically indicated? 

In both of these scenarios, it would be easy to look back on what was done and direct blame.  However, I see that the doctors involved did what they did according to the information they had at the time.  The patient perspectives serve to illustrate that doctors don’t always know what’s best and they really need to be mindful of their patients’ wishes and concerns while carefully balancing the multiple duties of their role. 

Rapport

February 23

by Alison

We saw a number of follow-up patients in clinic today.  Our preceptor’s rapport with the patients was excellent and it was obvious how much the patients trust him.  We were also able to watch our preceptor do a new consult and observe how he establishes such a good rapport.  Our preceptor didn’t jump straight into questioning the patient about her medical issues.  Instead, he asked about her personal history and about her family.  He spent a fair bit of time getting to know her before moving on to her medical issues.  When he sees patients in follow-up, he similarly spends a few minutes chatting before addressing their medical concerns. 

With inpatient medicine, we are often so busy and our patients are usually so sick that we aren’t able to spend much time getting to know them.  In ambulatory medicine, the patients are medically stable and are seen over multiple visits, allowing the establishment of rapport to be a primary focus of their care.  From a learning perspective, I was able to see the importance of this rapport and the value it adds to the patients’ care and wellbeing.  It was helpful to observe an initial consult by our preceptor as I feel he provided me with some useful techniques on establishing rapport quickly in an outpatient setting.

Blink

My first couple days in the ambulatory internal medicine clinic have offered excellent opportunities to review diseases and concepts.  However, what was painfully made clear to me is that even through continuous medical education, I have lost practice in some areas.  Core and elective rotations in Pediatrics, Obstetrics & Gynecology, Radiology, Physiatry, Family Medicine, and Psychiatry presented few occasions to practice and review the diseases and conditions I once knew so well in Internal Medicine about a year ago.  For instance, clinical cases involving monoclonal gammopathy and dermatomyositis simply never came up since then.  I was reminded of the phrase, “use it or lose it.”

Apart from revealing some gaps in knowledge, these first couple days have allowed me to reflect on some of the challenges I’ve faced while learning how to learn through medical school.  Our preceptor brought up Malcolm Gladwell’s book, Blink. It is a book about rapid cognition. Our preceptor used the concept to refer to the rapid decision making that occurs to arrive at a diagnosis in the first few seconds after being presented with a clinical case with a classic textbook presentation.   The only problem is I felt that while many of my colleagues were learning to how to “blink” their way through clerkship, I was trying to catch up.  I would often arrive at the correct answer, but I felt that I needed slightly more time to think about a problem.  These insights led me to begin thinking about the way I think, and how I interpret the volumes of medical information that we are taught in medical school. I am continuously trying to learn new ways to learn and make connections between pieces of information so that I can access them more quickly.  It’s still a work in progress.

By: Nishani