Respirology

I spent the day yesterday in Respirology clinic. I found it to be great practice at reviewing how to approach PFTs, as I hadn't read one in quite some time. We saw a variety of patients with COPD, asthma, and also a1-antitrypsin deficiency. I learned that in these patients they are often left undiagnosed for quite some time since they may present like someone with COPD. However, they are generally younger when they first present with symptoms. We saw a 54-year-old patient yesterdays with PFTs that would suggest emphysema but in fact he had undiagnosed a1-antitrypsin deficiency. I think this was an important learning point to keep in mind, and to remember to always keep a broad differential.

- JD

Teaching Session

As part of my medical education selective, today I had the opportunity to hold a teaching session for third year clerks. I decided to hold my teaching session on acute burn management as it's an important and relevant topic to know, but also one that I find interesting.

I decided to structure my lesson using a combination of both didactic and interactive activities. I first presented general background on burns etiology, diagnosis and management (specifically trauma ABCs). Throughout the didactic session I also asked the clerks questions to get them involved in the lesson. For the interactive component, I presented patient cases to allow the students to apply the content they had just learned. Using burn assessment sheets that are often used in the trauma bay, the students applied the Rule of 9's and calculated fluid resuscitation for the patient cases.

As a previous teacher, I find the opportunity to teach others very rewarding and exciting. I found this to be a great activity that allowed me to review my knowledge and also find an fun way to share that with others. I hope that I will be able to continue teaching medical students in the future.

- JD

Ambulatory Medicine

Ambulatory settings are a great place for medical education, and tons of potential to facilitate teaching. However, it does require some preparations in advance to ensure that learners get the best experience and patient care isn't disrupted.

When preceptors aren't aware of incoming learners, many issues can arise. The clinic may be too busy for the preceptor to balance teaching vs. service, causing a lot of tension. There may not be enough space for the student to use to perform their own examinations. Patients may be less than welcoming of the sudden learner, especially if they're in a hurry and weren't informed. Other staff may be disoriented because of the extra personnel, and not being familiar with their roles as part of the team. Likely, the preceptor and student would not have had a chance to go through learning objectives and determine expectations for the experience.

However, when proper preparations can be made, students can have a great learning experience. Health care is moving away from hospitals and towards ambulatory and community settings, so it will be helpful for students to learn within the setting to better reflect what they'll be practicing. Ambulatory settings also provide a broad range of patients for students to see, and often undifferentiated symptoms to challenge problem solving and medical knowledge. If a preceptor can be informed in advance of a learner they will be taking on, along with their medical background, they can ensure that there is adequate space for the learner to see patients and research medical information. By informing staff of the student and their roles on the team, the student may be able to have more experiences working with different team members, and find themselves in a more welcoming environment. Having staff gain patient consent to have a medical learner ahead of time, or having informational sheets in the waiting areas, can allow the learner to have a more productive encounter with patients. Clinic days with a learner can also be scheduled so that time will be available for case discussions and teaching, as well as regular feedback.

These are not the only ways, but just a few ways in which ambulatory learning experiences can be optimized for learners. Hopefully, ambulatory teaching settings can be continuously improved to help learners become competent physicians.

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Complication

Yesterday in dermatology clinic I was able to see an interesting patient case of alopecia. The patient experienced some alopecia previously that resolved a few years ago with topicals . Now, she has started to notice loss of hair on her bilateral temples. She has no PMH or FHx of autoimmune or dermatological conditions.

On examination, the initial location of alopecia on her crown had resolved with good hair growth. On her temples, however, there was evidence of scarring alopecia. Interestingly, the patient also had two symmetrical scars in the same area where she had a previous facelift in another country. Our plan for this patient was to schedule a biopsy to confirm whether or not she had any remaining hair follicles in the area that would be amenable to treatment.

I found this case especially interesting because of the mixed presentation of both scarring and non scarring alopecia. Also the incidental finding of a 10-year-old scar in the same area as her new symptoms seems strange given the length of time between surgery and symptoms.

-JD

SNAPPS

SNAPPS is an approach for medical trainees to present a case to their preceptors, in a way that helps them learn and be concise. This would've been a very useful tool for me to have known about earlier in my medical school career as I always struggled to give concise presentation.

S - summarize your case by presenting only pertinent information
N - narrow your differential to the top 3 or less
A - analyze your differential with evidence that supports and doesn't support it from your encounter
P - probe your preceptor (your time to ask questions!)
P - plan your management
S - self-directed learning topic (what steps can you take to improve?)

As I feel this is a very useful tool, and I didn't come across it until this selective, I've decided to teach CC3 students how to practice using this tool by going through cases with them.

Hopefully they find it helpful as well!

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What IS the guideline?

The Canadian Task Force's recommendations on diseases screening has been taught to my class throughout our medical school. Especially for me, as I'll be pursuing family medicine, it has been a very commonly referenced resource by me and many physicians I have worked with. Although most of the time, the recommendations are in agreement with what is practiced, there are also suggestions that don't quite sit well with all physicians.

During my endoscopy clinic today, the resident and staff both informed me how their specialty of Gastroenterology still recommends colonoscopy as a screening tool, despite the Canadian Task Force stating otherwise. When I hear conflicting information such as this, I wonder what choices I will end up making when I am practicing independently. I think this is when it's important to try and understand what priorities lie behind the guidelines I am reading. For example, the Canadian Task Force's guidelines are not only based on population studies, but also taking into account, economic efficiencies. Therefore, from its point of view, a colonoscopy is not the most cost-efficient tool for screening purposes, but from a physician's point of view, it is the best method of finding any pathology within the GI tract.

This is something I believe medical students should be taught, to accurately weigh the pros and cons of each recommendation they reference so that they can make choices that are most beneficial to each patient. Since we're taught to know the "guidelines" to pass exams, it should be made clear to us as learners, what really matters in real-life practice.

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Interesting Case

During my time in the TB clinic earlier this week I had the opportunity to see a very interesting case involving a patient at follow-up. Initially, the patient presented with large masses on her ears with no apparent cause. As an immigrant to Canada from a country with cases of leprosy, the patient was worked up for a variety of potential causes including both leprosy and also TB.

I found this to be an incredibly interesting case as I had never seen any cutaneous manifestations of TB before. Cutaneous lesions are relatively uncommon manifestations of TB and occur in only 1-2% of infected patients. The lesion appeared to be large, verrucous nodules, almost similar to keloids. In learning about TB in class, we are taught of extrapulmonary TB. However, I was amazed at how the physicians were able to come to a differential diagnosis including TB based on this appearance. I also found the case interesting as the treatment for potential leprosy would be counterproductive in treating TB, and vice versa. The physician decided to treat the patient empirically (despite all tests for M. tuberculosis being negative) with great improvement of the lesions at her follow-up visit. From this encounter I learned how insidious TB can be and to be reminded to always keep it on my differential.

-JD

Don't Just Refer!

I had the opportunity to work with an amazing dermatologist in his clinic today, and there were several important learning points to take away from the experience.

First, don't make assumptions because you've seen a similar case a hundred times. Just because a patient has what looks like a wart on the bottom of their foot, doesn't mean you can dismiss your other differentials. Make sure to rule out the melanoma or actinic keratosis. Despite having been practicing for so many years and seeing countless numbers of similar cases, the dermatologist still made sure give them conscious thought.

Second, we're here to provide medical advice and treatments to our patients but ultimately, the choice is up to the patient (given capacity is present). Once a patient is sure that they're making an informed decision, they shouldn't feel threatened or so pressured by their physician to start a treatment that they don't feel their concerns are listened to.

Lastly, no matter the resources that are available around us, we should continue to develop our own medical knowledge and skills and provide as much service as we can to our own patients before deferring them to someone else's expertise. We had seen many patients today coming in for simple cases such as acne or warts, where their family physician had not recommended a single treatment to them before referring them to the dermatologist. Even if specialists are much more accessible in more urban cities, generalists should remember that we're also equipped with the knowledge and tools to assist our patients with many of their concerns.

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Morning Report Reflection

During today's morning report, I enjoyed the staff's use of personal reflection on the patient cases and one's self. The resident on-call chose a few interesting patients to discuss. This allowed each of us in the room to use the chief complaint to construct our own differential diagnoses followed by a discussion of the pertinent teaching points.

One of the most interesting aspects that I found was the staff's use of a summary table in discussing each of the patients. The headings were the following: ID, CC/summary, confidence about diagnosis (1-7), diagnosis (if confidence > 4) and area of difficulty surrounding the case. I really enjoyed the opportunity to reflect on one's own level of confidence in their differential as well as the difficulties in managing the case that may have contributed to this doubt. I think that this allows a lot of opportunity  to learn from very difficult cases and perhaps change your thought process in the future when encountering a potential "zebra".

At the end of the morning report, the staff also asked everyone to take away a learning point from the discussion or an area in which you may want to review. Overall, I found it to be an insightful and interesting approach to morning report and I hope to incorporate some of these reflections in my future practice.

- JD

Differences in Medical School Structure

I recently returned to Toronto after an international selective in Argentina. One of the most noticeable differences between medical education in Canada and Argentina lies in the structure of the undergraduate medical program.

In Argentina, similar to the European system, students enter medical school directly from high school. The program is 6 years in length and involves solely theory and clinical observation. Medical students get no practical, hands-on experience until they graduate. After graduation, students are required to complete 1 year of "practical" work in a variety of specialties (similar to our clerkship years). After this, students begin residency.

In observing the first year residents on my surgical rotation I found it hard to believe that their involvement in the OR was similar to that of a clerk in Canada. Residents were shocked to hear that in our program we are assisting in surgeries and delivering babies from 3rd year. However, I think that the clinical knowledge of residents in Argentina was well above ours. They also seem to have an incredible amount of responsibility, even as a PGY1.

For myself, I enjoyed the opportunity to explore other areas of interest in university prior to medical school to ensure that I was making the right decision in pursuing Medicine. As a hands-on learner, I also enjoy the opportunity to have extensive practical experience in our final years of medical school. Nevertheless, I think that both structures have their pros and cons and perhaps a student's success would depend on his/her learning style.

-JD

The Future of Canadian Healthcare

The grand rounds today was a very inspiring talk regarding the change Canada's healthcare needs.

Although Canada has a "universal healthcare", it's the worst "universal healthcare" that exists currently and we, as Canadians, need to recognize this and promote change. We can't just let ourselves be identified by our current medical system but push for an improvement because it's sub-optimal right now.

We need to help the politicians to not be too scared to implement change and make mistakes because these are necessary in change.

Change from the current healthcare system to one that's more community-based can also take power away from hospitals and physicians, but that's what revolution is and for the sake of truly patient-centered healthcare, we need to make steps toward it.

Of course, there's much more to improving our healthcare than what I've mentioned above, but this was a great time for me to think more about the future direction of our healthcare system and how I could contribute to it in the future.

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Unneeded Fear

As a student of the Mississauga Academy of Medicine, I've done all of my core rotations in the Mississauga Hospitals. As a small community site, both hospitals provided collegiality and great learning by passionate preceptors. It also helped that often the preceptor to student ratio was 1:1.

I really enjoyed my time at the Mississauga hospitals, but I'd also developed a fear of the sites located downtown, mostly fueled by rumours and word of mouth. Talk of the strict hierarchy that's present at most hospitals and how us, medical students, were at the bottom of the ladder, scared me. I imagined very hectic environments with preceptors too busy to give a mere medical student any time, and being the bottom of a food chain where you're in a vulnerable position.

Today, I had my first TB clinic at TWH. It was an amazing working and learning environment, where my preceptor was a very chill, and super nice teacher, walking me step by step through the process of seeing a consult. The nurses were also terrific, being very patient with me as I learned the ropes and the most friendly people I've worked with. Even though I'm quite a reserved person, I immediately felt comfortable among the team and they really helped me to feel like I was a part of it.

Not only did I learn a lot about TB consultations at the clinic today, but I've realized how silly my worries were and what I can look forward to when I start my Family Medicine residency with the University of Toronto.

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Case-Based Learning

In my final blog post, I am reflecting on the exposure that I have had to case-based learning (CBL) during my selective.  Throughout my clinics and the lunch-time rounds, I have had the opportunity to listen in and participate in the discussion as residents prepare for their Royal College examination by going through practice cases.  The scenarios have ranged from topics within the various Internal Medicine subspecialties and the practice questions always include asking the trainee to summarize the case in one to two sentences.  The next step is to create a differential diagnosis (with their leading differential stated upfront) and develop a preliminary management plan.  Follow-up questions from preceptors may surround counseling or altering the scenario to see how management plans may differ under other circumstances.  After the trainee has completed the case, we talk as a group about how the scenario went.

We use this framework in CBL frequently and it stimulates fruitful discussion as it allows group members to contribute and bounce ideas off of each other as to how they would manage certain patient cases.  It is particularly useful as you put yourself in that situation and think about what you would really do if you saw that presentation in the emergency department or an outpatient setting.

CBL has been defined by Thistlewaite et al. in 2012: “The goal of CBL is to prepare students for clinical practice, through the use of authentic clinical cases.  It links theory to practice, through the application of knowledge to the cases, using inquiry-based learning methods.”  (Thistlewaite et al., 2012) CBL allows for the application of lecture material to practical scenarios.  (Brown et al., 2012) In CBL, there may be some advanced preparation and discovery is encouraged in such a way that both students and facilitators share responsibility for coming to closure on key clinical pearls.  (Srinivasan et al., 2007)

CBL is contrasted with problem-based learning (PBL) which operates slightly differently and is more open-ended and self-directed in which students must identify what they need to know.  In PBL, facilitators play a minimal role and allow students to explore different avenues.  (Srinivasan et al., 2007) When students work together for PBL, the group will still be presented with a clinical case, but students are allowed to define and struggle with the problem.  (Srinivasan et al., 2007) PBL focuses on discovery by learners to stimulate problem solving and critical thinking as well as both independent learning and team learning.  (Srinivasan et al., 2007)

The study in 2007 by Srinivasan et al. at the University of California, Los Angeles (UCLA) and the University of California, Davis (UCD) looked at the response of medical students and faculty after a switch was made from PBL towards CBL.  CBL was preferred by both students and faculty, however those that did prefer PBL felt it encouraged self-directed learning.  (Srinivasan et al., 2007).  In PBL though, it can be difficult to cover large amounts of ground given the exploration component.  (McLean, 2016) Whereas, CBL allows more focusing on learning objectives and there is more emphasis on achieving a set outcome by the end of the session.  (McLean, 2016) Both are advantageous to medical education and have unique aspects to offer.

Thanks for reading my posts!

SH

Resources:

1. Srinivasan, M. et al.  (2007).  Comparing Problem-Based Learning with Case-Based Learning: Effects of a Major Curricular Shift at Two Institutions.  Academic Medicine, 82(1): 74 – 82.

2. Thistlewaite, J. E. et al. (2012). The effective of case based learning in health professional education.  A BEME systematic review.  BEME guide number 23. Med Teach, 34: E421 – E444.

3. Mclean. Case-Based learning and its Application in Medical and Health-Care Field: A Review of Worldwide Literature. Journal of Medical Education and Curricular Development 2016:3 39–49 doi:10.4137/JMecd.S20377.

4. Brown, K. et al. (2012). Case Based Learning Teaching Methodology in Undergraduate Health Sciences.  International Journal of Health Sciences, 2(2): 48 – 66.

Patient-Centred Care

A theme that arose this week during both morning report and my Rapid clinics was patient-centred care.  During morning report, the senior from overnight was summarizing the patients that were admitted.  For each, we reviewed relevant clinical pearls as well as how we could tie in patient-centred care.  One of the patients that was admitted was receiving nutrition via total parenteral nutrition (TPN) at home.  The patient presented to hospital severely dehydrated after missing a few days of TPN.  Rather than assuming the patient was not adherent, it was gathered on history that she did understand the importance of TPN but was having difficulty with it at home.  The solution here that that the team could implement on discharge would be to ensure that the patient had adequate home supports and CCAC to help her with TPN.  In scenarios like this, our role as care providers involves exploring the barriers and obstacles that our patients face in their health care journeys.

Patient-centred care has been defined as a concept that integrates patient interests and the personal contexts of patients’ lives into their care; their wishes are honoured and respected during their experiences with the health care system. (Epstein et al., 2011) Epstein et al. discussed some techniques that can been taken to accomplish this.  For example, communication styles that invite patients early on to ask questions about their conditions promotes this concept.  (Epstein et al., 2011) Patients and health care providers perceptions of an encounter may be different.  A recent study by Montague et al. surveyed various health care professionals and the public to identify factors that contribute to patient-centred care.  (Montague et al., 2017) The public valued “timely and readily accessed care” provided in a “caring respectful context” with decisions made in partnership with patients and providers and with a framework that care should be “based on need and not the ability to pay.”  (Montague et al., 2017) Health care professionals agreed with the above with an additional emphasis on “care influenced by evidence and expert opinion.”  (Montague et al., 2017)

An example of patient-centred care that I encountered was during my Rapid clinic in which we had a patient referred to us from the Emergency Department with some abnormal enzymes on blood work.  Upon further history and inquiring about medications, it was apparent that the patient was consuming a number of additional supplements that could be contributing to the blood work abnormalities.  We went through all them in detail and counseled the patient on our recommendations for what would be safe to take.  While doing this, we kept in mind what he valued in his life, what was important to him, and why he was consuming these supplements in the first place.  This helped navigate the discussion and get to know the patient better.

My preceptors exemplified a number of qualities that were helpful in providing effective patient-centred care, and I hope to emulate them as I moved forward in my career.

SH

Resources:

1. Epstein, R. M. et al. (2011). The Values and Value of Patient-Centered Care. Ann Fam Med, 9(2): 100 – 103.

2. Montague, T.  et al. (2017). Patient-Centred Care in Canada: Key Components and the Path Forward.  Healthcare Quarterly, 20(1): 50 – 56. doi:10.12927/hcq.2017.25136

An exercise in reflection

It seems like only yesterday I wrote my first reflective piece for this selective.

Fast forward a few weeks and here I am, writing my last! As a medical trainee, much of what I do is entrenched in a clinical context. Little of my day-to-day communication is an exercise in reflection.

My reflections these past few weeks have been both enriching and rewarding. They’ve helped me disconnect from the usual hustle and bustle of being a healthcare provider and instead, step back to re-evaluate my life with calm. I can describe my reflections best as a venture into mindfulness meditation: I’m more acutely aware of my daily activities and am able to better tease out the little things which make me frustrated, upset, content, or otherwise.

I hope this is a skill I can continue to cultivate as I move forward in my career. I’m certain it will be an asset, which can help me better recognize and regulate my own emotions amidst the inevitable chaos that will be residency at times. I’m thankful for all the new medical knowledge I’ve accrued over the past few weeks. Even more so, I’m grateful for developing a crucial new life skill.

Alice signing out!

Match Day Relief and Grief

On 12 pm March 1st, I matched to my top residency choice in Toronto’s Family Medicine! It was gratifying to be recognized by the program for all the hard work I’ve put in these past few years. I believe it was a culmination of research, community outreach work, and clinical excellence, which helped distinguish my application. It’s humbling to be accepted into a class of hardworking and compassionate future residents. The best part of all this is that many of my good medical school friends are also in my cohort! It’ll be exciting to embark on the next phase of this journey with familiar and friendly faces. I promised to serve my patients with integrity and dedication. I hope to fulfill that promise over the years to come.

Reaching out to current residents, my understanding is that a subsequent internal match will occur over the next few months to determine where my training site will be. I’ve heard positive things about all sites but NYGH has a special place in my heart. It’s where I did many of my rotations in medical school and where I’ve come to familiarize myself with many of the staff in the Family Medicine Teaching Unit. Keeping in mind it’s a very competitive site, I hope to train there during the next 2 years. I’ve also been encouraged by others to apply for my CPSO postgraduate training license and CMPA coverage early on. Many residents have warned me about the mountain of paperwork that is headed my way. Having just endured an arduous match process, I feel the administrative work will be a cakewalk. I feel relief at the prospect of being able to complete it!

On the other hand, I know Match Day is a time filled with grief for those students who went unmatched. Some of those unfortunate few are classmates and friends who I know very well. I’m aware of how hard they worked and recognize that today marks a time when the field they are so keen to join has not validated their efforts. For these students, it must be heartbreaking to hear such news. Even more disturbing is the news that 26 students in my class and 222 students failed to match on a national level. This is an unprecedented number and highlights intrinsic failure in the medical training system to support students in their dreams of becoming practicing physicians. It’s unfathomable that years of hard work to enter and graduate from medical school in addition to thousands of dollars of subsidies from public taxpayers will hang in the balance. As a specialty, we must ensure all Canadian medical grads have an option to continue their education so that our system continues to nurture the growth of caring and compassionate physicians.
- AX

Advocating on behalf of our patients

Patient advocacy is such an integral part of a physician’s work and responsibilities. It is recognized officially as one of the seven CanMED roles and unofficially as a core competency of being a physician. In the past, I had always witnessed or delivered patient advocacy in a way to help fight the inequity in our health care system. Today, I experienced something different.

I had the opportunity to work in the fast-paced Dermatology clinic. Having multiple learners in the packed schedule left the staff little time to catch her breath from one appointment to the next. My last patient was a lady in her late 50s suffering from a recent flare-up of her “old eczema”. She said she had been referred to a Dermatologist previously but only had a “5 minutes appointment” with the specialist and was prescribed some topical steroid creams to use. However, she did not have the chance to talk to the specialist about her concerns regarding steroid side effects, so she only used it sparingly in the past several months. When she did use the topical ointments, she got temporary relief from them but had little improvement in her symptoms overall. She also since had been using her own DIY cream to soothe her skin, which she was quite proud of. Ultimately, she was happy about the topical steroid ointments and wanted to have another prescription since she’d just ran out of them.

When we examined the patient, her rashes resembled the typical eczema presentations in certain areas, but there were also large sections of severely inflamed papulosquamous rashes over her trunk. The most “efficient way” of handling this appointment would be to agree with her previous diagnosis and prescribe more of the steroid creams since the patient was satisfied with her treatment. However, my preceptor didn’t dismiss the patient’s unusual presentation and suggested a punch biopsy to delineate the pathology further. She then spent time addressing the patient’s concerns regarding steroid side effects. At the end of the appointment, the patient agreed to step up her steroid to a higher potency so that her therapy would be more effective and understood that a shorter duration of steroid therapy would translate to fewer side effects.

What my preceptor did today demonstrated a form of health advocacy that rarely gets complimented. She was not happy settling on delivering patient care that would be regarded as “just good enough”. Even when our patient was content with her symptoms being sub-optimally controlled, my preceptor believed that she deserved better care by trying to pursue further investigations and spent the time to address her concerns. It’s worthwhile noting the everyday heroes in our field and celebrating their devotion and dedication to patient care whenever we can.
-AX