Clinical Reasoning and Communication

Our communication class last week was about ending the doctor-patient relationship. It was insane. I was supposed to be a med student who had just finished my longitudinal clinic from first and second years, and I had to tell the patient that I was leaving to start my third year rotations. My actor was really over the top. He actually started crying with real tears when I told him that I'd be leaving! I wanted to laugh at the absurdity of it all, but I couldn't, because that would not be professional. Don't get me wrong. There are several patients whom I've seen multiple times, and we've built up some kind of relationship. But it's not like any of these people are going to throw a total hissy-fit like this guy did when I move on. Can we talk about dependence issues here? If this guy had been a real patient, I don't think I'd have worked nearly as hard to smooth things over. But when you're in a room with five people evaluating you, of course you have to see the whole thing through.

Friday was the last time we had to do one of those awful small group projects for ARM/POD. I was going out of town for the weekend, so I didn't even go to the presentation part. What a colossal waste these sessions have been. Even worse, what a missed opportunity to have made a series of small group sessions that could have been really interesting and useful. For example, it would have been great if the faculty had us actually go through the process of writing an NIH grant and taught us about different grant awards, how study sections work, etc.

We had another clinical reasoning session today. I had the same group and preceptor as last time, and it went about the same as before. First we each presented a patient and went through the differential as a group. Then we went over to the hospital to interview a real patient. This patient was a character. I'll just say that we heard about her sexual history in exquisite detail. And to think some people claim that you don't learn anything interesting in medical school!

Last week was our last week of GI (liver week), and now this week we have started with renal. Everything is going great. My PBL group still rocks. The renal seminars are as awesome this year as they were last year, interactive with lots of small group sessions. This week, we've been talking about glomeruli, which are the capillary beds that do the filtering in the kidneys. They're really beautiful. Here's a picture of one (the big thing in the middle). The smaller circular things surrounding the glomerulus are parts of the tubules of the nephrons, which are the urine concentrating units of the kidney.

My Last Patient

This week has been much better. We're going over liver pathology. I like the liver because it has so many interesting functions, and it is also capable of regenerating itself. Those are just some of the reasons why it's my favorite GI organ, but I won't bore you by going on and on about how cool the liver is. Suffice it to say that yesterday we went over viral hepatitis, and today we did gall bladder diseases. (The gall bladder is the organ that stores the bile produced by the liver.)

Today was my last day in clinic. Wow, what a way to go out. My very last patient of the afternoon was a guy who came in because a box fell on his hand. His fingers were all black and blue, and he will probably lose some of his nails, but there didn't seem to be any major problems otherwise. I was going through the review of systems (ROS) with him, and when I asked him about chest pain, he said yes. I asked him more about it, and he said that it was a kind of tightness more than a pain. Did it radiate? Yeah, to his left arm. When did it start? About half an hour ago. Had this ever happened before? A few times within the past month. At this point, I excused myself and went to get my preceptor. We personally walked the patient over to the ED so that he could be worked up for an MI (myocardial infarction, popularly known as a heart attack).

I was most struck by the fact that if I had not asked this man about whether he had chest pain, he would not have ever told us about it. He didn’t fit the normal demographic for a patient with coronary artery disease (CAD) that I had learned about in school. He didn’t think his chest pain was important enough to mention to the doctor. I've gone through the ROS so many times over the past two years that it's practically perfunctory and mechanical by now. This experience re-emphasized to me how important it is to not take shortcuts, to ask every patient about life-threatening symptoms like chest pain. You will never have the opportunity to save a person’s life with one simple question unless you ask it.

Shifting Dullness

This week we have been learning about the effects of radiation on the GI tract (not good) and congenital diseases of the GI tract. There are a surprisingly large number of babies who are born with some kind of GI malformation or malrotation. During embryology, the GI tract has to turn twice so that all of the intestines end up where they're supposed to be in the adult. If that doesn't happen correctly, it causes a malrotation. There can also be problems where the intestines don't return to the abdomen after they normally herniate out into the yolk sac during the second month of gestation, or where the neurons of the enteric nervous system don't migrate where they need to go. I hadn't realized that GI embryo was so complex.

Today I had my meeting with Dr. I about the OSCE. He had printed out all of my evals and read through them before I got there, and I got the impression he was kind of surprised that I had requested this meeting. I explained that I didn't feel I had done as well as I should have for the amount of time and effort that I spent preparing. He apparently didn't realize that my classmates and I were studying for the OSCE, because it was supposed to be something where you just kind of walked in and took it. He didn't think I had done badly at all, and he even wrote an email for me to put in my portfolio saying that I wasn't underperforming in clinical skills. Maybe part of the point of the exercise was to see how we'd adapt after we bumbled through the first station. But all I can say is that from a student perspective, it was a very frustrating experience.

My clinical correlation today was on performing abdominal exams. The GI fellow who was helping my group turned out to be one of my classmates from my Clinical Trials course last semester. We saw some interesting patients. One was so jaundiced that she was literally bright neon yellow. We also saw a patient who was positive for shifting dullness, which occurs when the patient has ascites (fluid in the abdomen). To test for shifting dullness, you percuss the patient's abdomen while he is lying on his back, then have him turn on his side and percuss his abdomen again. If the border between the dull and tympanic regions move, the test is positive. On an amusing side note, one of the attendings told us that when he was in med school, he and his classmates had to sit through boring lectures all day, five days per week. They used to call the lecturers "shifting dullness." :-D

Besieged by Reviews

We had a couple of GI path seminars on Wednesday and a really cool pancreatic surgery seminar today. I think I am about the only sucker in my whole class who is still doing the assigned readings for seminars. I brought up something in PBL that I had read in the articles for today's seminar, and I swear the rest of my group was looking at me like I had two heads. It turned out to be good that I had read that article though, because it helped us understand the case. We also had a domestic violence screening communication class on Wednesday. It wasn't bad, but I thought they should have done it about a year ago. I've been doing domestic violence screening on my clinic preceptor's patients since about halfway through last year.

We were supposed to have a Dean's Dinner on Wednesday, but it got cancelled since most of my classmates couldn't go. The first years had their Dean's Dinner last week though, and I got permission to go. As it turns out, my research preceptor was the speaker, so I was glad that I got to be there. I had seen part of his talk before last fall at the conference, but some of it was new.

Today was also the first pathology review session for Step 1. I went to this one, but I don't think I am going to go to any more review sessions. I really didn't get very much out of it, mainly because I have not started studying at all for the boards yet. Being suddenly bombarded by so many review sessions is making me feel a little stressed out and overwhelmed. There are reviews being set up for everything: path, pharm, micro, anatomy, embryo. But right now, I am more worried about getting my summative portfolio done than I am about studying for Step 1. This is the portfolio that will be used by the promotions committee to decide if I am promoted to third year. I feel a little bad about not attending the review sessions, because the faculty are really going out of their way to try to help us prepare for Step 1. I don't want to seem ungrateful. It's just that I am not ready to start studying for Step 1 yet!

Observed H & P

We had a really terrific pharm seminar on Friday about drugs for inflammatory bowel disease. The two pharmacists gave us some cases to work through and then went over them with us. Our POD/ARM seminar, on the other hand, was a disaster. I guess whoever was supposed to give the talk on diarrhea cancelled, because instead we wound up getting a talk by someone from the Innovations Center here at CCF. (They take care of patents for inventions made by people associated with the Cleveland Clinic.) What annoyed me the most about this talk was not that it was awful and had nothing to do with research. No, what really annoyed me is that the only reason I skipped the second look students' lunch and went to this talk at all is that Dean Franco asked me not to skip class when I told her about the schedule conflict. Once again, the faculty for the class didn't show up, and most of my classmates didn't, either. I think skipping it would have been completely justified, but I didn't feel right about leaving after I promised her that I would go. On a happier note, in the evening, one of my friends and I went for dinner at a Thai restaurant I had never been to before, and it was amazing. We are definitely going to go back.

This week seems to be a bit of a hodgepodge of different gastrointestinal (GI) problems. Yesterday we had a seminar on infections, and today we talked about diabetic neuropathy. You may not have known that the GI system has its own nervous system that functions semi-independently. This is one of those facts about the human body that I had no clue about before I began medical school, and that I find just fascinating.

My preceptor was back in clinic today, so I did my observed history and physical (H & P). It went really well. The patient was a very interesting woman who was involved in a variety of charities. I didn't do a Pap smear on her, but I did do a breast exam and instruct her about how to do them herself. I am amazed by how many women do not do breast self-exams. Whenever I ask them why, nearly all of them say that they know they should do self-exams, but that they have never been taught how to do them. This patient was no different. The good news is that patients seem to be getting the message about the importance of monthly breast self-exams. But of course, telling women to do these exams is not terribly helpful unless they also know when and how to do them! Instead of asking patients whether they do monthly self-exams, it is probably better to ask them if they know how to do monthly self-exams. Then if they say no, the provider can show them.

Spring OSCE

On Monday, I participated in the feedback session for our Heme/Onc block. The students are supposedly asked randomly to participate in these feedback sessions, but somehow I sure seem to end up participating in an awful lot of them!

This week is the beginning of our GI block, and the seminars have been on the oh-so-appealing topic of diarrhea. I can't really complain, though. We've had a relatively light schedule so far because we're taking the spring OSCE this week. Yesterday, I had all day to study for the OSCE after the seminar was over at 10 AM, because we don't have clinic this week. Then I took the OSCE today.

It was worth spending the time to review all the exams, but in the end, it wasn't enough. This OSCE was much harder than the one we did last year, and I felt like I was really floundering around for a large portion of it. Like last year, we had to examine standardized patients, and there was a preceptor in the room with a checklist of skills we were supposed to demonstrate. But there were a bunch of new features as well. First, there were more stations (four in all), and they were much more ambiguous. We weren't told anything more than something along the lines that Mrs. Smith was here for a check-up. At the first station, I did a focused history and physical for a patient who had a sore shoulder. Afterward, I was getting feedback from the preceptor, who told me that I was supposed to do a complete history. He said that I did a good job on the parts of the history that I completed. But I still wound up flunking the station because I missed so many of the objectives.

Ok, well, now that I knew I was supposed to do a complete history, I could handle that. I went in to the second station, which involved counseling a patient on smoking cessation. That one went well and I got very good feedback from the preceptor. The next station was for an abdominal exam, and that one went well too. I had to write a SOAP note at the end, and I just barely got it done in time. But I totally missed the point of the last station. That patient had right sided abdominal pain and a cold, so I did the ENT (ear, nose, and throat) and abdominal exams on him. Then I gave an oral presentation to the preceptor. But it turns out that this patient's flank pain was supposed to be chest pain, and the preceptor said that I should have done a complete cardiac exam. I still don't really get how right flank pain was supposed to scream "cardiac problem!" at me. But I guess the lesson to take away from this is that anyone with pain below the neck and above the pubis is going to get a full cardiac exam AND a full abdominal exam from now on.

I am pretty disappointed about how I performed on this OSCE. Considering how much time I spent preparing, it's frustrating that I failed two out of the four stations. I have already emailed Dr. I, who runs our clinical course, to set up a meeting to discuss my performance. Don't get me wrong--I'm glad that I screwed up now and not on the clinical portion of Step 2 that I will be taking at the end of next year. But at the same time, this OSCE is supposed to be a demonstration of our current level of clinical and communication skills, and I know that my performance was not nearly up to the level of which I'm capable.