The Art and Science of Medicine

It has come up as a recurring theme in the clinics we have been attending that medicine has two parts that are equally important. The science is the knowledge and technology behind investigations, diagnoses and treatment. The art is all of the nuances that are involved in the human interactions that accompany clinical encounters.  Without the science, we would simply have social interactions and without the art many health problems would remain a mystery or would not receive adequate treatment. 

   From what I have witnessed the perfect blend of art and science in medicine is often seen in interactions with more senior physicians who have had time to develop these skills in unison.  They enjoy learning about their patients’ families, having a personal connection, reminiscing about past appointments and will be seen smiling and laughing during clinic appointments despite the busy schedule.  You can see in the patient’s that it makes a difference to them that their health care practitioner takes the time to really get to know them.  It also allows you to put people’s illness in the context of their life and not the other way around and I think patients really appreciate that. 

  In my own experiences during medical school, we move from one extreme to the other.  We start with no knowledge and getting the chance to simply talk to patients is a privilege most of us have waited a long time to get.  In clerkship, the focus is on gaining skills and knowledge.  I have found myself dreading that 4am failure to cope consult and thinking, what could this possibly add to my knowledge.  Then being reminded when I step into the room, that there is an elderly lady who fell at home and is scared and confused, that needs my help.  It’s very easy to ignore the art because I think that’s the part of medicine that requires more of a personal investment but I can say the art of medicine had a lot to do with why I chose it for my career.  Internal medicine in particular for me couples the opportunity for that perfect mix of art and science, with the clinical medicine I find fascinating and the opportunity to get to know my patients more fully and have an ongoing relationship with them.  I have been reminded of that in the past few weeks, and although starting as PGY1 in July is a frightening thought, it is also exciting to think I’ll be starting my own journey very soon. 

Ashlay

Learner vs Teacher

In discussing our presentation for the end of the selective, my colleague had the idea that maybe instead of focussing on a  clinical skill, maybe we should teach about teaching and learning as a resident.    I thought that as an interesting topic since it has been the area of much of our conversation so far on the selective and the focus of our readings.  It is also a more "soft" skill that students don't necessarily get teaching on before residency when we are much more focussed on passing our board exams!
      With the aim of being able to teach our peers something useful next thursday we have begun our research with help from Dr. Cavalcanti and Dr. Panisko and once again I am astonished by the amount of research available in the area.  Not only is there a whole realm of information about the theories behind medical education but there are books and journals with whole sections devoted to this topic. It has been very eye-opening to begin to explore this realm of research and realize how many tools and structured interaction guidelines there are out there.  There has been more than one time in the past couple weeks where I thought, hey I would have liked to have known that as a third year clerk!  At the same time, I can begin to recognize how knowing about these tools will help me as a resident.  The line between teacher and learner becomes blurry when thinking about implementing many of them.  In that nature my colleague and I have decided to spend some time thinking less about separating our presentation into info about a learner and a student, and more about using the tools effectively as both at the same time.  This will be a valuable skill I think we will best learn on the wards but it never hurts to have some background knowledge!!

Ashlay
   

Interprofessional Learning (#4)

Tina Zhu

Today, as per Dr. HPK's weekly tradition, we spent the afternoon visiting our radiology colleagues on the third floor.  Dr. HPK wrote the names and MRN numbers of the patients for whom he needed a radiological opinion and off we went.  At the neuro-radiologist's office, we learned about mesial temporal sclerosis as a cause of refractory seizures, and after explaining the case, the radiologist offered to perform brain MRI on our patient within the next week.  Then in the musculoskeletal-radiologist suite we reviewed ankle edema NYD.  Finally we saw a strange and rare case of intra-abdominal pulmonary sequestration in abdominal radiology.  During the case discussions, it was clear that Dr. HPK had excellent relationship with all of his radiological colleagues.

During this rotation, I have really come to appreciated the art of learning through case discussions with colleagues, residents, and staffs.  I have found that our different experiences and viewpoints contribute to interesting discussions, and having more than one brain working on the same issue makes the experience more stimulating.  Most of all, I remember the cases that we discussed better than ones that I was lectured on or read on Uptodate.  Maybe there is merit to a medical education curriculum that is composed of mainly small group problem-based learning (PBL) such as the at McMaster University.  I believe that our own undergraduate medical education curriculum will benefit from the implementation of similar case-based discussions.  

The Art of Navigating the Gray Zone (#3)

Tina Zhu

Today, as my colleague and I worked together on our upcoming teaching session, she brought up an interesting case that we saw recently along with the "think tank". Although this particular patient had a very striking cutaneous presentation, we were more perplexed by the art of disclosure that we observed during this encounter. The physical findings of this particular patient strongly (80-90%) suggested underlying malignancy to all of the medical professionals who were present. However, it was clear that the patient was unaware of these implications since the patient did not feel otherwise unwell except for the cutaneous findings. Although we did explain to the patient that there was likely an "underlying cause" for the presentation, there was no explicit mention of the C word during the physician-patient interaction. Instead, a full body CT scan was arranged urgently and the patient was told to return to clinic after the investigations.

I must admit, I initially agreed with the extent of disclosure that the team had chosen. I reasoned that if we had told the patient that there was a high possibility of malignancy without any concrete proof, such as imaging, we would just be causing undue anxiety for them.  However my colleague disagreed. She maintained that we should have been more explicit when explaining the potential "underlying cause" to the patient so that the patient is not disillusioned into thinking that we were looking for something benign. After some back-and-forth discussion, I must agree with my colleague in that if I were this patient, I would have wanted a little more clarity regarding the medical significance of my symptoms. Although it is unclear whether this particular patient shared my views, since some patients do prefer to not know their diagnosis, potential or otherwise.  In hindsight, there were probably moments during the conversation when we could have segwayed into a discussion regarding the sinister nature of the findings, but instead, we all tip-toed around the subject.

In the past, when we discussed the topic of disclosure in the classroom, it had always been a relatively black and white case of whether or not to disclose when a patient's family member requested to withhold the information. However, this particular case represented a much more gray area of disclosure in the face of diagnostic uncertainty. At what point, do we tell our patients that we suspect cancer even though further work-ups are still pending before we can be certain of the diagnosis? Is there a cut-off point depending on the strength of our suspicion? And how does the patients' wish for clarity factor into the equation? How do we even gauge what the patients' wishes are in the cases of diagnostic uncertainty? Should I begin each new patient consult with "How high should my diagnostic certainty be before I disclose that you may have cancer? Rank from 0%-100% certainty"? Ok, maybe I'm being a bit fastidious here, but you get my drift. Unless the diagnostic certainty is 0 or 100%, everything in between represent a massive area of gray regarding best practice in disclosure and there are definitely no evidence-based guidelines to help us navigate this unfamiliar arena.  I guess this is what they refer to as the "art of medicine".

Thus far in my education, much of the learning focused on the science of medicine with lectures, readings, and exams.  It is only recently, during clerkship, that I have started learning the art of patient interaction, through observation of staffs and residents, as well as reflective discussions with colleagues, both through structured educational activities and in informal settings.  Personally, I have found the informal discussions, such as the one today, most enlightening and I must thank my colleague for sparking this particular reflection.

Microskills: Putting power to form ambulatory experiences into students' hands

To further our reading about medical education, we fittingly focussed on articles this week relating to ambulatory internal medicine teaching.  Being honest, the articles themselves didn’t really reveal any ground-breaking new ideas to me but I think they highlighted some points from the many conversations I have had with my colleagues about our clinic experiences in the past two years.  Many of the suggestions would be things any resident or medical students could tell you first hand if asked. 

 There are certainly things, such as more coherence between preceptor and student scheduling, longitudinal clinics and setting aside time for teaching, that have enriched my own ambulatory experiences.  There were also more system based suggestions that I think are lacking in a lot of training programs and would greatly benefit students.  These included making ambulatory training a priority, prioritizing orientation for students in new clinics and having faculty development/training.  These articles seemed to set out a guideline for the ideal, but I think where they were lacking was in providing tangible solutions or suggestions to improving the current state of ambulatory medicine and how medical schools might accomplish these goals.  All of these suggestions are well and good but they are challenging for school curriculums to instate and enforce with large class sizes and widely distributed clinics.  Although I think some fundamental curriculum changes can help with accomplishing these goals, the article we read by Lipsky, Taylor and Schnuth gives some practical tips how students can enhance their own ambulatory experiences.  I think this would be a useful article to provide to medical students at the beginning of their clerkship so that they have an idea what they should be able to expect of a rotation.  By providing it to faculty as well, it could act as an important starting point and guideline to the ambulatory experience in a variety of specialities.  One of the strengths of the article is that is provides easy and straightforward tips to help students know how to go about accomplishing these tasks, putting the power back into the students’ hands.  I think this would also help to alleviate some pressure off institutions regarding evaluations and goal setting and probably generate a more meaningful experience for students if they are initiating the endeavours and know their preceptors are expecting these things of them.  In retrospect I think it would have had an impact on my ambulatory experiences early-on in my clerkship.

Ashlay

A week of CEEP in Review

(I'm posting this now although I wrote it on friday because reviewing the posts it appears it didn't work! Darn blackberry playbook bridge!)

After a week of CEEP and participating in ambulatory clinics I'm happy to say that my experiences have reaffirmed my desire to pursue internal medicine as a career. That is a comforting thought as residency is only a few short months away!

I had always enjoyed the clinics in my clerkship rotations but until this experience have had very few internal medicine ambulatory clinics. My experiences have been limited to four half days during my eight week core training and a few other scattered observership and elective experiences. Although I know the general internal clinic I have been in is very unique, it has given me the exposure to a wide variety of interesting cases and has exposed me to a very unique way of learning!

It has been interesting to read around the vast number of issues that have come up in clinic and it is nice to be reminded of how interesting medicine can be. As a student it can be easy to get caught up in reading only to prepare for the next academic hurtle.  Although board exams are not far away, this sort of reading I think will accomplish a dual purpose!  The scary thing is how much I have forgotten, I can agree with my colleague that a lot of knowledge I remember being easily accessible is buried deep a lot deeper than I had thought.  Dr. HPK also has an interesting way of helping us to recall it! I didn’t used to become as anxious when being pimped but I often found myself grasping for words this week!  Hopefully with all of our discussion about learning and education I can dredge up my own tool kit for learning from the depths of a six month hiatus from internal.

Ashlay

Medical Education in the Ambulatory Setting (#2)

Tina Zhu

While sitting outside of Starbucks on this rare balmy March night, I perused through Dr. Bowen's paper on Changing habits of practice - Transforming internal medicine residency education in ambulatory settings ¹.  The paper reviewed existing studies that focused on curriculum, teaching, and evaluation of internal medicine (IM) residents in the ambulatory setting. 

I must agree with the authors in that IM learners are under-exposed to learning in the ambulatory setting.  This has certainly been my experience thus far during my core IM clerkship rotation.  I spent  a total of 4 half-days in various ambulatory medicine clinics, which is about 3.5% of the time spent during my 8-weeks rotation.  This pattern seems to persist during residency.  At Wednesday's Grand-Rounds on Toronto's new IM residency curriculum, it has been revealed that starting in July 2012, PGY-1 residents will no longer be participating in the AIMGP (Ambulatory Internal Medicine Group Practice) clinics.  The reasons presented for this change are multi-fold and fall outside the scope of this particular blog, but it was proposed that PGY-3 residents may benefit more from the AIMGP experience instead of the PGY-1s.  Here is my question: shouldn't both PGY-1 AND PGY-3 residents participate in AIMGP?  After all, it is one of the only longitudinal ambulatory experience that our residents receive during their training and it should therefore be well emphasized...no?  I am sure there are various barriers to this model that I am ignorant of...maybe this can be a point of discussion with Dr. C during our Monday meeting. 

Another comment I found interesting was the authors' note that "the heterogeneity of the published studies, and the lack of methodological rigor and multi-center designs significantly limits our ability to draw broad conclusions from this literature" ¹.  This comment struck a chord with a recent series of papers we read on the "epistemological crisis" in medical education.  They consisted of a back-and-forth debate between Glenn Regehr^2,3 and Geoff Norman⁴ on the value of using the traditional physicist's reductionist approach to experimental design to explore the complicated/ complex/ chaotic context of medical education.  While I recognize that there are many components of medical education that can be explored using rigorous methodological design and subsequently applied widely across multiple institutions, the interaction between student, teacher, and learning environment is often so complex and individualized to each institution that the ability to draw broad conclusions need not always be the goal of medical education research.  Rather, it may be equally important to explore education strategies that can be effectively implemented at particular institutions and the factors that engender successes. 

References

1. Bowen, JL et al. Changing habits of practice: Transforming internal medicine residency education in ambulatory settings. J Gen Intern Med 2005; 20:1181-1187.

2. Regehr, G. It's NOT rocket science: rethinking our metaphors for research in health professions education. Medical Education 2010; 44:31-39.

3. Regehr, G. Highway spotters and traffic controllers: further reflections on complexity. Medical Education 2011; 45:542-543.

4. Norman, G. Chaos, complexity and complicatedness: lessons from rocket science. Medical Education 2011; 45:549-559. 

Initial Impressions and General Musings (#1)

Tina Zhu

I have now spent three days on this new selective rotation of Ambulatory Internal Medicine and Medical Education.  This was a rotation that I looked forward to with high anticipation, excited to finish off my 4 years of medical training working alongside educators such as Dr. C, Dr. HPK, and the rest of the "think tank".  So far, Dr. HPK's clinic has lived up to its name.  In the span of two clinic days, I have seen patients with Addison's, dermatomyositis, and Behcet's disease, all of which I have only ever heard of during lectures but never witnessed.  No wonder Dr. HPK had been dubbed as "House, but nicer".


Having been away from General Internal Medicine for over 6 months, I felt somewhat overwhelmed on my first day, for many reasons.  Firstly, I was appalled by the amount of information that I had forgotten.  More than a few times, I opened my mouth to supply the correct diagnosis only to find, belatedly, that the neuronal connections that once led me to that particular bit of knowledge has dissipated, or worse, replaced by some stupid Charlie Sheen factoid. I guess that is one of the many reasons why medicine is a life-long learning, for not only are there always new information to be acquired, there are often more old information that needs to be re-visited.

Secondly, I must admit that Dr. HPK's teaching style took some getting use to initially.  I frequently found myself trying to answer a random question only to realize, much to my embarrassment, that the "random" question was meant to be a well-thought out phonetic hint to the correct answer.  Over the past 2 days, I have become much more adept at deciphering the hints and my efficiency in clinic has improved. When I reflected on the cases I saw in clinic in the evenings, I found that I could most easily recall the cases that were associated with the most outrageous hints. Ultimately, I did find it to be an efficient way of learning during ambulatory clinics.

Throughout my medical training, I have worked with various clinicians in clinic and they each had their own styles of teaching.  Some would delve deeply into the details of pathophysiology and disease manifestations for each case while others may highlight the pertinent points and assign the rest for self-study.  Certain educators liked to employ technology such as the Whiteboard or "Harvey" (the simulator) for further teaching and illustration.  Thus far in my training, I have always been the "receiver" of the knowledge transfer and I personally have benefited most from more interactive teaching styles, but as I enter residency, I will soon have to become the "deliverer", a role that I am not at all comfortable with...yet.  Hopefully this selective rotation will help me mature into this role more quickly.

Chaos vs complicated vs complex vs reductionist??

March 20

by Ashlay

As this is my first blog I'm not 100% sure what I'll be doing will keep in line with the themes of the blog so far, and if I repeat some of the topics and sentiments I apologize but you will have to bare with me as I come to discover things for myself.  Before yesterday, I hadn't given much thought to the theory behind medical education.  I guess because I had always been more focused on the delivery of it.  Partly because that is what I've been immersed in for the past four years and partly because it's what I have thought a lot about lately as I consider incorporating medical education into my career.

  I have recently spent more time discussing curriculum and its design than ever before but I never really thought about the theory behind its development.  While on selective with Dr. Jenkins we discussed and debated at length the changes we all thought might benefit medical education curriculum and how they could be incorporated.  We spoke about the Canadian, American and European system contrasting their strengths and weaknesses, which at the time seemed wide and "complex" (after reading the Geoff Norman articles I now use the term more cautiously) enough to try and understand.

  After beginning to delve into the literature regarding the debate behind how to conduct research in medical education,  and spending some time thinking and discussing it with my colleague, I’m still not quite sure where I stand.  I do seem to identify more with Glenn Regehr, and his stance that we need to look at the process of how it’s conducted, differently than we are now.  I think re-evaluating one's position after years of doing things seemingly in the same way; can only bring about new view points and hopefully new understanding.  It made sense to me that you lose something important when reducing complex systems to simple deductions.  I didn’t think he was discounting the theories Dr. Norman was embracing but describing a way for them to co-exist with a new way of thinking. 

Before I say much more on my thoughts on this situation I think more reading is in store because it has opened my eyes to a new way of thinking about how and why my education has been delivered to me in the fashion it has been.  All very interesting and new, but something I look forward to doing over the next three weeks!

Ashlay

The end

Blog #9

by Nishani

Today is the last day of my selective in medical education in ambulatory internal medicine. My selective partner and I had the wonderful experience of teaching our fellow students today.  We opted to use a case-based learning method.  We created four cases to be discussed over a period of an hour.  Each case was introduced by showing a student a picture of a particular finding on a patient, and this was followed by asking several questions to guide him through the process of making the diagnosis.  We started by asking him to consider a differential diagnosis based on the photograph we showed him. Then, we focused on the aspects of history, physical exam, and investigations that would lead him to a diagnosis.  My partner and I were quite impressed with the way our medical student subject approached our cases.  He said that he had seen many of our cases in the last couple weeks while doing his ambulatory internal medicine rotation, so the concept of recency bias came up again.  However, we all found the cases helpful in reinforcing our knowledge of the disease processes we covered.  We found it especially helpful to have photographs available to provide a visual representation of the findings we would look for on physical exam.  The interactive component of our teaching session allowed for discussion of topics that were related to our case, but were not ones we had thought about including prior to the session. I think this served to enrich our learning experience and we still managed to keep within our time constraints.  Overall, I personally found it to be a very valuable experience, especially in beginning to study for the LMCC exam!

The entire selective experience has given me a new perspective on medical education.  Reflecting on how to teach and learn has been very helpful to my own learning. I hope to take these lessons with me through residency where I’ll be in a position to teach more medical students.  I am very grateful for this experience.  A special thank you to all those who made it possible!

Thanks for reading!

Teaching

March 9

by Alison

We have spent the past three weeks learning about teaching.  Today, we finally had the opportunity to do some teaching ourselves to a small group of our peers.  We decided to use a case-based approach, with pictures to highlight important findings on physical exam.  We had spent some time preparing in advance, and were amazed by how much we learned in the process.  We went through each other’s cases, asking questions and making suggestions.  It was really helpful to have feedback before the actual teaching session.

Our teaching session went very well.  We were both highly impressed at the level of knowledge of our peers.  Some of the cases actually addressed topics that they and we had covered in our recent clinics, and we all appreciated the opportunity to reinforce these topics by reviewing them.  I think it was a rewarding and fun time for all of us.

Since this is my last post for this selective, I will end by mentioning how much I’ve enjoyed the past few weeks.  It has been a wonderful opportunity to take a different approach to learning, which I think will give me a valuable perspective in the future.  Many thanks to all of our supervisors and the administrators who have ensured this was such a rewarding experience.     

Macules and papules

Blog #8

by Nishani

During our clerkship years, the rest of my classmates and I received a few hours of experience in a dermatology clinic to cover the learning objectives required for our dermatology block.  The experience also included working through several cases online and reading a dermatology handbook.  Although the teaching resources were very helpful, at the time, I knew the practical experience provided hardly enough time for me to get a good sense of dermatology and feel comfortable assessing skin lesions.  How often are we asked by patients and in many cases, friends and family members, to take a look at a “rash” and make a diagnosis on the spot?  I was always amazed at the rapid diagnostic capabilities of dermatologists when looking at skin conditions.  I recognize that the very refined diagnostic skills of dermatologists take time to develop after years of training the eyes to carefully examine numerous skin lesions and their various presentations.  Today, I had a chance to see these skills in action in the dermatology clinic.  I, myself, became more comfortable looking at skin lesions and appreciating some of the features that make them identifiable.  For instance, after seeing several examples of sebhorreic and actinic keratoses, I became more confident in identifying these lesions on patients.  I learned that being able to touch a skin lesion and assess what it "feels like" adds so much more information, but receives little recognition. Many times, we are expected to learn dermatology through pictures.  Although there are certainly a number of great visual resources available to study dermatology, I do not think they can replace the value of seeing the real thing. My personal goal is to gain more practice in a dermatology setting so that I can become more proficient in my "spot diagnosis" skills.

Things are starting to stick

Blog #7
by Nishani

Yesterday’s morning report on hypertension was a very valuable teaching session. I know that all of the concepts that were covered were taught to me at some point during medical school. However, it was very helpful having them reviewed again, especially now that I have a better frame of reference. I try to place myself in the position of the first person who has to see the patient that is being discussed and think about what I would do. Since I have a base to start from, I find it useful to be able to compare my thoughts with the decisions made by the team working on the case. I have also noticed that it has become easier to learn and consolidate new information. Part of the reason for this could be that I already learned the information at some point, and subsequently forgot. Or, it could also be that I find it less difficult to add new information to the basis of knowledge built over time than start from scratch. I am better able to identify knowledge gaps around specific topics and address them more quickly and effectively. My selective partner and I both agreed that we are getting more out of these teaching sessions than we did while we were on our core internal medicine rotations. We are picking up more of the subtleties in each case. At any rate, it is becoming easier to distinguish between the “need to know,” and the “can look up later if interested.” I think we are both glad things are starting to “stick” better.

Teaching us how to teach patients

March 7

by Alison

On this rotation we have had the opportunity to consider many important aspects of medical education through ambulatory learning.  However, we have not really discussed the topic of patient education, which is often a key component of ambulatory care.  There have been many opportunities for patient education during this selective on topics such as lifestyle, medication adherence, and symptoms requiring medical attention.  These are topics for which I have been well prepared and I am quite comfortable in this aspect of patient education.  However, one area of patient education that I continue to find challenging is responding to patients’ criticisms of their previous care and educating patients about the structure and limitations of the healthcare system.

Yesterday in clinic I saw a patient who was completing treatment for an illness.  During our encounter, she mentioned that she had been misdiagnosed at a community hospital before being diagnosed at one of the teaching hospitals.  It was clear that the patient was frustrated by this and she said something critical about the care she had received at the community hospital in comparison to the care she had received at the teaching hospital. 

I understood why the patient was upset.  However, I think that sometimes patients don’t realize the difference in resources that may be available at an academic centre versus a community hospital.  This can lead to a perception that the care offered in the community is inferior to the care offered at academic centres.  Without wanting to make the patient feel that I was invalidating her concerns, I felt it was important to mention to her that we have access to a lot of excellent resources in teaching hospitals, which provides a diagnostic advantage compared to some settings.  This approach seemed to be well received by the patient.  However, I continue to find such situations to be one of the more challenging aspects of medicine, and I hope that I will receive further education on this in the future. 

Residents as teachers

March 5

by Alison

We spent the morning in the dermatology clinic.  The clinic wasn’t particularly busy and there were a lot of residents, which meant there was plenty of time for teaching.  I have not had much dermatology training in clerkship, so this was a welcome opportunity.  In addition to seeing some patients, we went through the approach to a number of common and important dermatology problems.  We discussed the approach to acne, eczema, and psoriasis, as well as how to counsel patients about sunscreen. 

I really enjoy learning from residents.  While there is always great teaching from attending physicians, residents are often more familiar with our level of knowledge simply because medical school is more recent for them.  As a result, they tend to anticipate our specific questions and provide an appropriate level of detail.  I’ve generally had more teaching from residents on inpatient rotations, as ambulatory rotations often involve residents and clerks seeing patients independently, then reviewing directly with the attending.  The opportunity to work with residents in ambulatory clinics on this rotation has been extremely valuable.   

Learning how to teach

Blog #6
by Nishani

This week, my CEEP selective partner and I started working on our teaching exercise for our fellow classmates. When discussing our ideas with our preceptor, the terms base rate fallacy and recency bias came up. Base rate fallacy occurs when available statistical data is ignored in favor of specific data to make a probability judgement. In a medical context, this could be described as what happens if you quickly diagnose a patient with Disease X when you see Symptom Y without taking into account the actual prevalence of Disease X and the constellation of symptoms that would increase the likelihood of this person having this disease. Recency bias is the tendency to form judgements based largely on the most recent observations and not taking into account the whole range of data. An example of this might be being quick to diagnose Disease X in a patient shortly after attending a teaching session on Disease X without perhaps taking into account its prevalence or the whole constellation of symptoms a patient has.

For our teaching exercise, we wanted to use photos of hand findings to work through a series of cases of patients with various diseases. Through our medical training, we were taught specific skills to examine the hands. Most often, these skills were taught on healthy patients. Consequently, my partner agreed with me that although we know to look for certain findings, we are uncertain about whether we would be able to confidently name what we find on examination. We thought including several photographs of positive findings on examination to use in our teaching exercise would be beneficial. However, taking into account the concepts of base rate fallacy and recency bias, we decided to shift our focus slightly to emphasize the investigation of the hand finding rather than the specific disease each finding is associated with. I think we are both beginning to recognize the numerous elements that need to be taken into consideration when delivering a “simple” lesson in clinical skills and medicine.

Prescription for exercise

Blog #5
by Nishani

In noon rounds today, we had a discussion about cardiac rehabilitation.  Through this discussion, the topic of prescribing exercise and a heart healthy diet came up. I did not previously think about exercise as something that is “prescribed,” but I think the concept is a great idea.  In my formal medical training, I was taught the two components of heart disease: pharmacologic and non-pharmacologic.   Most often, more time was spent discussing the pharmacologic treatment of coronary artery disease and little attention was given to exercise and diet.  While I could name off the typical medications and doses normally given to someone with coronary artery disease, I was reminded today that I did not know much about the amount of salt in a low-salt diet or the amount of exercise I should recommend.  Usually, I would hand a pamphlet with dietary recommendations and review basic elements such as, low-salt, high fibre, and low-saturated fat with my patients.  Today’s topic brought up an important point that “prescribing” exercise by stating the frequency, intensity, type, and time (FITT Principle) is just as important as prescribing the other medications we usually prescribe to patients.   Knowing about the various programs available to patients to engage in exercise will be important for me as a physician so that I may make practical recommendations to my patients.  This is something I will be looking into to further my own knowledge.

From simulation to application

March 2

by Alison

Last time I wrote about how helpful our Harvey session was for learning to identify and characterize cardiac pathology.  At the suggestion of our supervisor, today we went to examine real patients for cardiac findings, to see if we could apply the skills we practiced with the simulator. 

With the help of the chief resident we identified two patients with cardiac findings and went to see them on the ward.  With a newfound confidence, I performed a cardiac exam on the first patient.  However, I had an enormous amount of difficulty hearing the patient’s murmur.  He was in a noisy four-bed room and was breathing quite loudly.  I could barely hear the heart sounds, let alone characterize the abnormal findings.  Unlike with Harvey, I couldn’t just turn up the volume to better assess the patient.  The new comfort I had with murmurs from spending time with Harvey was certainly diminished.  The second patient was in a quiet single room and was breathing very comfortably.  With him, it was easy to hear his murmur and to characterize it, providing me with some reassurance.

This experience served to highlight the limitations of simulators in learning.  Simulators generally operate under optimal conditions, and therefore cannot replicate a real patient-care experience.  Ideally learning incorporates elements of both: simulators to help with skill development and confidence, and patient-care experiences to reflect reality.