The Art of Clinical Medicine

My career in family medicine will be predominately clinic based.  Through my time at Toronto Western Hospital I have been exposed to many unique and interesting patients in the ambulatory clinic environment that, along with the helpful teaching and guidance of my preceptors, have taught me a lot about medicine.  However the strongest message that I will take away from these experiences is the true art that medicine can (and should) be.

Our clinical skills course in first and second year medical school was entitled “The Art and Science of Clinical Medicine”, nicknamed “ASCM”.  Although the inclusion of “art” in the name tried to encompass the true nature of the physical examination being partially rooted in experience and clinic judgement, the vast majority of our teaching focused on the science.  Our sessions focused on interview techniques and patient care sometimes seemed half-hearted compared to the then excitement of learning a new and complex physical examination maneuver.  I spent significant time during my selective working closely with Dr. Ho Ping Kong, who in my opinion truly embodies the art of medicine.  Through working with him I have seen that the physical examination can be both informative and therapeutic.  Even when patients were present for long-term follow-up appointments and had no current somatic complaints, we would examine them (as appropriate) for signs and symptoms of disease.  As a clerk, I found that in many of my rotations, we would focus on the imaging results, blood tests, and other investigations before we would focus on the physical findings of the patient.  I have even been told that the physical examination is “dying” and that in general findings on physical examination are no more specific than flipping a coin.  But here I saw that a hand, a touch, a look can been more reassuring than simply affirming that the blood tests are normal.  After all, patients come to SEE a doctor, not their testing results.  They value our opinion, which includes the way that we look at them carefully, and the way that we lay our hands and our eyes.  I was impressed in the ways that Dr. Ho Ping Kong remembered important social aspects of his patient’s lives; he would specifically ask me if I had asked one patient about her husband’s health, and another if I had asked how her current financial situation was.  To me, this is an imperative part of caring for a patient: understanding who they are as a person and where they are coming from.   Physical health is only one part of this piece, the rest is fleshed out in the art of medicine.

I will be starting my residency training in rural family medicine on July 1^st.  I know that a strong physical exam will be necessary for me going forward as the hospitals and clinics that I envision working at do not have the sophisticated technology and imaging capabilities of many urban sites.  I know that the “science” of medicine and how I apply it will be different from many of the things I have seen training in Toronto.  However I think that having the opportunity to work closely with Dr. Ho Ping Kong is an excellent conclusion to my clinical training in medical school as it has reinforced the necessity of focusing on the art of medicine in addition to the science.  This is one of Dr. Ho Ping Kong’s strengths that he brings to every patient interaction and is something that I will make every effort to prioritize in my residency training when I start caring for my own patients.  I started medical  school with the goal of providing comprehensive care to all of my patients and my time in ambulatory internal medicine at Toronto Western has provided me with the tools to approach each and every patient with the art and science of clinical medicine.   

Reinforcing Outpatient Care

Today a preceptor shared with me an innovation at Toronto Western Hospital that I was previously completely unaware of.  One of the internists spends a half day per week on “consult” service in the family health team aiding primary care physicians who have questions about puzzling or complex patients.  This doctor is modifying his availability to these primary care physicians in order to work around the constraints of our current medical system which puts much pressure on primary care physicians to manage complexity in an out-patient setting.

As anybody working in healthcare knows, hospital admissions are shorter now (sometimes drastically so) than when my preceptors were medical students and residents.  A logical extension of this is that patients are leaving the hospital in a more fragile state and needing close and effective follow-up with their regular primary care physician to maintain and improve their health status post-discharge.  Furthermore patients are also living longer with more medical conditions that need to be managed both in and out of hospital.  Consequently complex patients are often being managed in the out-patient setting, often by family physicians that have little support from specialists, except through formal consultation.  You can’t just meander down to the doctor’s lounge or to the specialist’s office to ask a question when you are out in the community. 

You can learn lots of medicine on any inpatient rotation, but one of the more interesting things I observed throughout my clerkship is how good, available primary care is essential to discharge planning and managing complex patients in an outpatient setting.  It is surprising how much better you can feel about discharging a patient with multiple active issues when you are sure that they have good follow-up and that the care plan enacted during a hospitalization will be able to be followed to completion.  Team-based care works great on an inpatient unit but is much harder to orchestrate and enact in the community.  It can also be difficult to rapidly access the same services that a patient can rapidly access within hospital.  We expect so much from primary care physicians when we discharge our patients and we are giving them very little support in many cases.  

The healthcare system has started to change around us, with a heavier role on outpatient management than on inpatient. I think it behooves us to consider ways that we can change our outpatient management to provide the best outcomes for our patients.  I believe that more integration between general internists and family physicians, such as the initiative at TWH, is one way to reinforce our healthcare system for outpatient complexity in the present and in the future.

-Julia

Continuity in Education

In clinic this week:

Preceptor: Where does U of T incorporate longitudinal outpatient experiences?

Me: Do you mean in which rotations did I see patients more than once?

Preceptor: No.  Did you ever follow patients longitudinally in an outpatient setting?

Me: Never.

I believe this to be a true deficit of my medical education here.  Of course I occasionally saw patients repeatedly as outpatients (never more than twice) but it was always by fluke and not by design.  I recently matched into a rural Family Medicine residency program in BC.  My future career as a rural family physician will be heavily centered on longitudinal patient care, mainly in an outpatient setting.  Yet, despite what I said in my residency interviews, I don’t know what this feels like.  Maybe I don’t even like it.  My current academic understanding and processing of longitudinal patient care may turn out to be quite contrary to my experience.

This reflection has inspired me to read around longitudinal clerkship experiences.  The first references to these types of clerkship training experiences for medical students date back to the University of Minnesota in 1971, who initialed rural longitudinal clerkship to increase training of rural physicians.  Famously Harvard started their own longitudinal clerkship in 1997 and has provided much research to support that both students and patients benefit from longitudinal interactions.  The goal of these longitudinal clerkship experiences is to make medical students responsible for the longitudinal primary care of a panel of patients thereby integrating the diagnosis, care, and treatment of disease while building and maintaining an appropriate therapeutic relationship with a patient. 

I worked alongside three clinical clerks during my 4 week rural family medicine elective in Dryden who were doing a longitudinal clerkship through their medical school, the Northern Ontario School of Medicine.  Currently NOSM is the only medical school in Canada which requires all of its students to participate in a longitudinal clerkship, which they all do in their third year.  (By comparison, I spent my third year doing discrete rotations in various specialty and primary care areas of medicine).  The NOSM clerks’ time and my time in Dryden was not that different: we all did family medicine clinics, primary care obstetrics, hospitalist medicine, and ER shifts (normal family physician duties in Dryden).  The difference was that their experience was 7 months longer than mine.  Longitudinal clerkship experiences were easy to come by in Dryden, as the family doctors all operate comprehensive family practices including hospitalist care.  The NOSM clerks were also exposed to specialty clinics and surgical specialties on the days when they were present in Dryden.      

The University of Toronto is initiating a 10 student pilot of longitudinal integrated clerkship at St. Michael’s Hospital starting September 2015.  I will be interested to see the feasibility and organization of this, especially in the heart of Toronto, where most family physicians do not practice comprehensive care.  I feel that the logistics of having medical students provide longitudinal care are much more complex in the tangled web of hospitals and specialists in Toronto, yet I am excited to see this initiative.  I think that this will truly give students the oppourtunity to experience primary care while learning how to build relationships and care for patients’ overtime.  Communication, empathy, and professional boundaries are all skills that can be optimally developed in longitudinal experiences where students see themselves as the point person responsible for orchestrating the healthcare needs of their patients.

Will this longitudinal exposure to patients in a primary care model increase medical student interest in pursuing a career in primary care OR will it decrease exposure to specialty disciplines leading to more students pursuing primary care by default?  The answer will likely depend on the organization and the details of Toronto’s first longitudinal integrated clerkship.  My only hope is that longitudinal clerkship will set students up to be competent and caring physicians in any and all medical specialties. 

Effective Case Based Teaching

The end of medical school is an interesting time.  Although I am still technically (and intellectually) a medical student, preceptors are beginning to expect me to be more responsible and know how to approach and manage patients.  During a particularly vigorous pimping session with my preceptor this week I was praised with the interesting sentiment “see, you’re not as stupid as you think”.   However, despite how stupid I sometimes feel, I am on the precipice of becoming a resident who will be responsible on some level for imparting knowledge to the next generations of medical students.  At times I still feel woefully unprepared to leave the comforting label of “student” myself and have been focused on my own learning during these last few weeks of medical school, the final chapter of my medical education. 

 Like many medical students, I like case based teaching and learning.  A story is worth something to me; it is memorable.  Case based teaching is commonplace in internal medicine from morning report to lunch time rounds.  Instead of “good morning”, every day of my core internal medicine rotation started with “This is a case of a __ year old ___ presenting with ____”.  I enjoyed that but found these exercises to be more intellectual than real.  There was no real patient in front of me.  I wanted to learn, yes, but I also wanted to know what happened, something that was not always available for these reports.

On my current rotation I am exposed to exclusively outpatient clinics.  Most of the patients are follow-ups.  At the start of my clerkship, I would have been disappointed, thinking that there was little I could learn from follow-up appointments.  At the beginning of clerkship the objective is often to see new things for yourself.  To do the history and physical.  To make the first attempt at diagnosing managing disease on your own.  To see people that were sick.  Now, as I prepare for a career in family medicine, follow-ups are suddenly cast into a different light.  My preceptor has been encouraging me to read the chart first.  He tells me about these patients when they were sick or unwell.  Using his signature style, he often shows me pictures of their condition when he first met them.  He wants me to understand their journey.  He wants me to learn the full story so that I can recognize familiar tales if I come across them again.  He tells me how these patients presented initially and makes me talk through a logical work-up with him before he shows me what tests were done in real life and what they showed.  

This form of case based teaching is extremely valuable to finishing medical students.  My preceptor is allowing me to benefit from the best: the beginning and the end of a particular patient’s medical story.  He encourages me to think about how I would fill in the middle of this story, before showing me what was done to our current patient.  There is no guesswork or hypothesizing.  We go over real stories, real results, real notes, and finally talk to the real patients.  It is some of the most complete case based teaching I have ever been exposed to throughout medical school. 

 

I emphasize that for effective case based teaching, it is helpful to know the end instead of just the beginning.

-Julia

Reflection on Clinical Experiences

Over the past three weeks, I have had the opportunity to experience very unique Internal Medicine clinics. Each one has a particularly salient feature that makes it an ideal learning experience. Whether it was the scope of the practice, or the way in which the clinic itself was run, I have learned several valuable lessons from my outpatient experiences.

First, I will try to put into words the fantastic time spent with Dr. Ho Ping Kong. His clinic is ideal for a medical student to learn from, as he sees patients in follow up for routine, "bread and butter" medical management as well as many very interesting and rare diagnoses. With these "zebras", he spends time in between patients describing the thought process that went into evaluating the patient, and explains how he arrived at his final diagnosis. While knowledge of all these rare conditions is not expected at the medical student level, it is a great opportunity to learn about the deductive skills and diagnostic reasoning that goes into arriving at the final diagnosis. Coupled with abundant teaching (often using his trademark style of showing photos of conditions he's treated), his clinic is an ideal setting for medical education. However, the one lesson he always imparts on his students that I will truly carry with me throughout my career is the role of communication and rapport-building in clinical medicine. He is an exemplary communicator and advocate for his patients, and it shows when every single patient I have seen of his has only the strongest words of praise and gratefulness for him.

The second experience I am reflecting on is the PGY3 Internal Medicine clinic (formerly known as the AIMGP clinic). I first participated in this clinic during my third year core IM rotation, and really enjoyed this clinical style. The afternoon begins with a teaching session with one of the Internists (such as a case scenario, physical exam teaching with a simulator, etc.). Then, the clinic begins in which each of the residents and medical students get one to two patients each over the afternoon. It is purposely not overbooked to ensure that an adequate amount of teaching around the case can occur before and after seeing the patient. From an educational standpoint, this clinic is also very ideal for learning, because there students do not feel rushed to talk to, examine and discuss the patient with the staff. The ample time allotted per patient allows significant reflection on the case, and for one of the staff members to discuss a differential diagnosis and ample teaching about the particular disease or symptom warranting referral to the clinic. It also goes without saying that all of the staff involved in the clinic are eager and willing to teach at any time during the afternoon.

Both of these experiences have been model examples of effective ambulatory medical education. I have learned a great deal about a variety of interesting medical cases, while also feeling reassured knowing that staff are always willing to answer any questions or teach on any topics I may be wondering about. Most importantly, I look forward to being able to apply these methods of education for future medical students in the ambulatory setting or at the bedside.

- Anthony

Practice makes perfect: Physical exam rounds as an education tool

It is a great feeling in ASCM1 to learn the myriad of physical exam maneuvers available for each organ system, and then to practice them with painstaking detail on willing patients every week. I remember poring over the handbook, trying to accurately perform every exam possible for a given system and not missing a single test. Then clerkship happened; it is all too easy to forget the less performed physical exam maneuvers with each passing rotation.

This is why it is always a nice experience to participate in physical exam rounds. Once or twice a month, groups of learners are taken to a patient, and can either observe or be put on the spot and demonstrate a particular set of physical exam maneuvers (such as aortic stenosis, chronic liver disease, etc.). Along the way, the staff or chief resident leading the session adds additional information to ensure a complete examination is performed, and the remaining residents and clerks have a chance to participate or clarify any questions they have.

These sessions of group bedside teaching are a great addition to the medical education experience. It is a chance to learn about the most up-to-date, evidence-based physical exam for a particular disease or organ system. For the residents, it is a good chance to perfect their clinical exam skills in preparation for the Royal College exam (each session has a corresponding Rational Clinical Exam article). For the clerks, it is a good opportunity to re-visit the physical exam, and how to perform it more thoroughly and properly. Not only is it important to re-learn the content of the physical exam, but the finesse involved (proper positioning, smooth transitions between exam maneuvers, learning how to present findings while performing the physical exam, etc.) are vital skills for an OSCE and for gaining more confidence for gaining clinical acumen in the future.

- Anthony

Re-thinking Clerkship: The Longitudinal Integrated Curriculum

The core third year of clerkship is a time when a large part of a medical student's clinical learning takes place. Although there have been relatively recent changes to when all of the rotations occur (all core rotations in third year as opposed to spread out over third and fourth year with electives), the format remained the same: distinct blocks of rotations lasting one to eight weeks, with a written (and sometimes oral) exam at the end of block. The student would then move on and learn an entirely new specialty in the next block.

However, beginning next year, there will be a trial of a new model of clerkship taking place. This model has already been implemented in many universities' satellite or rural programs for years, and has been described in a New England Journal of Medicine article (http://www.ncbi.nlm.nih.gov/pubmed/17314348), but this will be the first time being introduced to Toronto. The model is called the Longitudinal Integrated Curriculum (LIC), and as the name suggests, it is a departure from the classical block-style of clerkship. Instead, clerks will participate in clinics/shifts in various different specialties in a given week. For example, they may have a Medicine clinic on Monday morning, an Obstetrics clinic in the afternoon, and Emerg shift on Tuesday, a Family Medicine clinic on Wednesday, etc. This way, by the end of their third year, they will have had just as much exposure to all rotations, just spread out over the year instead of in discrete blocks.

In addition, there will be "panel patients" assigned to those in the program. These patients are ones who have agreed to participate in the program to have the clerk present at many of their appointments whenever they arise during the year. Some examples may include attending antenatal visits sequentially and then being present when the baby is delivered, or being present pre-operatively for a surgery, scrubbing in during the surgery and then seeing the patient post-operatively. This allows for a more "full" experience of patient encounters. There are other unique features of the program, including dedicated half-days off each week to consolidate learning and to keep with all reading and studying, and dedicated teaching time, in which didactic lectures will be given (to replace the teaching that is normally done in the beginning/middle of each block).

I see this new initiative as a bold new step that challenges the classic format of core clerkship. First, this model allows the clerks to participate in all specialties throughout the year and thus have a more well-balanced knowledge base by the end of the year. It is all too easy in the current model to forget the majority of earlier rotations by the end of the year, simply because the focus is shifted onto the new rotation. By keeping up with each rotation simultaneously throughout the year, it can prevent this issue, and potentially make things such as the iOSCE or even the licensing exam easier to study for. Additionally, the dedicated time set aside each week for teaching and for studying is an excellent time for clerks to rest, catch up and keep on track with the demanding schedule that third-year has to offer. Other advantages include the unique opportunity to follow a panel patient and build rapport with a patient early in clerkship (which is much more reflective of a career in medicine), and the possibility of having call on pre-determined, predictable days throughout the year to best accommodate the LIC schedule.

I think the LIC program can be a very advantageous program for the right cohort of incoming clerks. The addition of more outpatient medicine, and with the introduction of panel patients, this new model can offer a wonderful new perspective on clerkship for very academically conscientious and diligent clerks. The chance to participate in many clinics and to follow a panel patient throughout several specialties and over a year gives a very good glimpse of the diverse roles and case management that may be missed in the current block style of clerkship. As the first cohort of LIC students will be entering clerkship in August 2014, it will be exciting to see their experiences and receive first-hand feedback about this new model of clerkship.

- Anthony

Other strategies in observing clinical skills: The use of the mini-CEX

Looking back on my year of core clerkship, there were many different strategies used by my preceptors in order to assess my history-taking and physical exam skills. These encounters ranged from a pre-scheduled one-time complete observed hitsory and physical of one patient on the wards, to an impromptu "I will come into the room with you while you do this one". With all of the unique strategies used, it is interesting to reflect on which one I thought ended up being the most effective.

The one method that I found the most rewarding by rotation's end was the use of the mini clinical examination exercise (mini-CEX) in my family medicine rotation. In short, there were 5 scheduled days (once per week) in which one of the patients during that day (pre-determined by the clerk and preceptor) would have the encounter with the clerk observed by the preceptor.

There are several advantages I can see with this system. First, it is a snapshot of the clerk's functioning during a routine and scheduled clinic visit, instead of finding a patient anew and doing an entire history and physical (vis-a-vis ASCM2). In addition, having several opportunities spread out throughout a rotation/block allows for multiple opportunities to be observed. I think this is the biggest strength with the use of multiple mini-CEX's, in that the preceptor can assess for improvement during the rotation, and the clerk can eventually become more comfortable with this style of observation and can perform more naturally. The use of standardized mini-CEX evaluation forms makes the encounters more streamlined for the preceptors as well, who can use pre-defined competencies as a guide to assess the clerk easier and more quickly.

On the other hand, the biggest disadvantage is that of resources. Having multiple observed encounters for one clerk requires the preceptor to spend more time directly observing, which could be time spent on other clinical duties (dictating, seeing another couple of patients, catching up with administrative work, etc.). Patient comfort with having a clerk and preceptor in the room simultaneously would need to be assessed also, and it may make scheduling these observed encounters more difficult if a particular patient ends up not being comfortable with having the mini-CEX done.

Given the postives and the negatives of this strategy, I think the use of the mini-CEX in an Intenal Medicine outpatient or bedisde setting can be a very useful way of providing more and effective feedback to clerks (and potentially lower-year residents, if there is an identified need for more observation and feedback amongst PGY1's). The encounter would "feel more real" to the learner, which would allow for more comfort in performing at their best, and once it becomes an incorporated part of the curriculum, it can become easier for staff to schedule and implement. In fact, it may end up saving the preceptor time if the period spent reviewing the case and re-assessing the patient is saved by having already directly observed the encounter.

It is an interesting alternative, and perhaps a better idea is needed as to learners' perception of the mini-CEX compared to other methods of feedback. If data suggests that this method is well-accepted and implemented well, then this may be an important new step in medical education that can provide very realistic and useful educational guidance for students' clinical and bedside skills.

- Anthony

Direct Observation and Feedback in Medical Education

Looking back on my year of core clerkship, the saying "you learn from your mistakes" has definitely held true. Third year was a time of constantly entering new environments and learning new sets of skills with every new rotation. However, gauging success in a rotation was often quite difficult, since feedback was often received quite infrequently. In addition, the feedback itself often felt quite generic and was difficult to apply in the future (if I had a nickel for each time I was told to "read around my cases"...).

There are a number of different factors at play here, and I will devote a blog post to each issue individually. With the student, barriers include a reluctance to ask for additional feedback from a preceptor, and a lack of familiarity of how to ask. Staff members may be too busy during the day to supervise students at the bedside or in the ambulatory setting in order to give adequate feedback. Likewise, there may be a lack of familiarity of how to give appropriate feedback. Finally, the curriculum itself may lend itself to an inability to obtain appropriate feedback. While there are significant efforts being made to ensure all students are observed once doing a history and physical examination at the bedside during their Internal Medicine rotation, could there be further system-level changes that can foster an environment of more observation and feedback?

My clerkship years have been filled with very diverse experiences. With that, I have had some rotations with a great deal of observation and feedback built into the rotation, while others have very little opportunities. Yet in other rotations I was observed often, but was not receiving appropriate feedback. I firmly believe that a medical student's comfort in being observed and asking for or receiving feedback plays a large role in their perceived performance in a rotation, as well as their perception or enjoyment of that block. Most importantly, I think it causes significant avoidable stress in a medical student's clerkship; it is for this reason that I will be focusing on this topic throughout my CEEP selective. It starts with identifying the issues and barriers, and establishing new practices that make increased observation and feedback the norm.

- Anthony