30 September 2007

Some Perspectives from Teaching students

I have been teaching some Physical Diagnosis skills over the past semester and I have learned many things. First, I learned that I was taught by some extremely skilled preceptors back when I took this course in medical school. My preceptors' sole objective was for me and my classmates to become excellent diagnosticians and observers. The better we looked, the better they looked and to this end, they taught us well. In short, I have great examples to emulate and I strive every day to live up to those examples.

It is no accident that when one attempts to teach something, one becomes stronger and more secure in their own personal knowledge. I distinctly remember when I was learning how to appreciate heart sounds. It seemed like I would never get the "hang" of figuring out if a murmur was systolic or diastolic. Now, years later, heart murmurs are as familiar as my favorite songs. This came with loads of practice in addition to integrating what I hear with what I know about heart pathology. This integration is one of the great joys of medicine. Every piece of experience can be added to one's knowledge base in some manner.

Every time I hear a murmur, I appreciate more and more. My uncle, a cardiologist always expounded about "auralizing" a heart sound. His lectures coupled with my harmony and ear training in music has come in quite handy. I distinctly remember back in my music courses, I learned to recognize a chord pattern by sound and experience. Listening to a heart murmur is no different. As I move my stethoscope from place to place, subtle differences in the first and second heart sounds are evident. The shape of the patient's chest also plays a role in what one hears too. Auscultation is truly an art that takes both experience and excellent training.

I play loads of recordings over and over for my students accentuating every heart sound and correlating each sound with the physiology of what is going on the the chest. By listening over and over, they gain experience. My own experience began when I would lie in bed at night listening to my own normal heart sounds. Next, I listened to the chest of one of my classmates who had mitral valve prolapse. She has a very thin body habitus and had the classical heart sounds of this very common condition. Again, more experience for me.

No good professor ever compromises their teaching methods to "torment" students. We do joke about making our students miserable but I can tell you from experience that recently, one of my students was able to see the vessels in my retina and nothing made me prouder. I was proud of her because she was determined to learn to use her opthalmoscope properly and she kept practicing until she could. I especially do not want any of my students to feel "tormented" by learning the techniques of physical diagnosis because these skills will stay with each student for the rest of their career.

I once heard the chairman of a department of internal medicine speak about how many medical students have an "under-appreciation" for the skills of physical diagnosis. I kept thinking how much I love walking into a room; taking a patient history; performing a physical examination and putting everything together into a solid clinical plan that is useful for getting to the root of the patient's problem. My feelings about physical diagnosis is far from an under-appreciation but more of a reverence for a fine art just like a reverence for find song.

I have been busy this weekend working on exam questions for my student. Since Physical Diagnosis is mostly a practical type of course, I am striving to make my questions test the practical aspects of performing the physical exam. Until you have been charged with the task of exam question writing, you cannot appreciate how difficult this task can become. My questions don't come from exactly what I give in lecture but from reading and actual performance of the the skills of examination of each system covered. The questions are not designed to "trick" students but to make sure that they know how to perform each task.

Physical Diagnosis requires that every aspect of a patient is examined. The demeanor, the speech, the gait and other general aspects of a patient's behavior and actions are all important clues to what underlying pathology may be present. A person who has a perforated peptic ulcer has a distinct demeanor and position on a stretcher/bed in the emergency department versus a patient who is passing a renal calculus (stone). One quickly learns to do a very quick assessment of the entire general appearance of any patient.

A very critical aspect to writing the report of a history and physical exam is making sure that your notes and evaluation are as accurate as possible. I have learned to record my findings and impressions such that any clinician picking up the patient record ten years from now can understand and appreciate what I observed at the time and why I treated the patient in the manner that I did. In short, a trained clinician should be able to follow my clinical thinking. This doesn't mean that I have every answer at the moment but it does mean that I followed a logical plan to arrive at a correct diagnosis and that I developed a coherent treatment plan.

Finally, a note about writing in a medical record. It may look wonderful to have a fancy signature and penmanship but I print everything as my cursive writing is not always clear. My signature is distinct but under that signature is my name, title and pager number in clear block letters. I pay very close attention to every letter when I write a prescription and dosage. I don't use too many abbreviations and Latin pharmacy phrases. I simply write four times daily instead of QID or I write out nothing by mouth instead of NPO. By doing this, it simply saves phone calls later in the evening. I am as pressed for time as anyone but some things save a bit of time if you take the time to do them correctly in the first place.

28 September 2007

Getting Through the Semester

By now, many students have had their first block of exams in medical school. Some people have done very well and some people have "breathed a sigh of relief" that they passed and some people have not passed one or or more of their exams. To fail an exam at this stage can be a huge personal blow but your actions after discovering that you have not passed (I am going to avoid the word "failure" here) are critical to figuring out what you need to do to get "above the yellow line". Sure you NEED to do a bit or mourning in terms of the loss of those wonderful feelings that infused during orientation week but don't let the mourning phase go on longer than a couple of minutes. Replace mourning with a very objective strategical look at what might have gone wrong and how you are going to fix the situation.

There is something in medical school that will throw every person. It may be that first round of exams, that USMLE score or a patient contact that just did go well. The important thing is that out of every experience, good or bad, you learn something about yourself and what you are capable of achieving. It is out of experience that you will learn to treat your future patients so let your experience become your teacher and move forward from here. Not passing an exam just doesn't feel good and can play with your "head" in terms of how your look at your future. My point here is that nothing except that round of exams is over at this point. You mourn a bit and then you push forward because (and I am not wrong on this), the material for the next round of exams is already upon you.

As soon as you know that anything has not gone well for you academically, ask for help. Your first action should be reviewing the test and trying to figure out where you went wrong. Do you need to rely on more detail? Did you move too fast and not answer the question that was asked? Did you neglect to read every answer choice with a more correct answer further down? Did you not fully understand the material? Were you distracted by something outside of school such as a relationship or illness and not put in enough time studying? In short, try to figure out what went wrong and take steps to make sure that you don't repeat your mistakes.

In some medical schools, class attendance is not mandatory. If this is the case, and you ran out of study time, try figuring out if there is one day a week that you can stay home and study the material using note service/lecture tapes or vids/textbook and syllabus reading. Many students do not attend class and find that home (or away from school study) works best for them. This may work for you but be careful if you have too many distractions at home or find that not attending class puts you behind. (Getting behind in medical school is deadly.)

If your work is not detailed enough, figure out which classes do not require the detail and which ones DO require more detailed study. In short, give each course what it demands. Many schools have integrated courses that definitely demand loads of detailed work coupled with "professional-type" courses like Practice of Medicine that are more performance-based. Try to look at your coursework from this perspective and see if you can give your integrated course a bit more time and your performance course a bit less time.

Another problem is that in many first year courses, the load of information can seem overwhelming. Resist the urge to dwell on what seems overwhelming and nibble away a chunk at a time. I always remember that scene in the movie "Shawshank Redemption" where the protagonist chips away at the prison wall over the course of 17 years with a small rock hammer. Eventually, he gets through the wall and escapes. Extreme but I think you get my drift in terms of divide your work into manageable chunks and stay on course. Keep moving forward because you can only affect what is happening now and use that to impact the future. Weekends are your friend because you can breathe a bit, relax a bit and catch up if you have fallen a bit behind your class. In the middle of the week, go to where the class is and use the weekend to "catch up".

I really discourage students from recopying notes as a means of study. When you have volumes of material and information, you can become more of an excellent clerk in terms of producing a beautiful set of notes that you have not mastered. Organizing your material is good (can be done with a highlighter or in the margins of your notebook) but total recopying of every word may be too time consuming and not as beneficial as when you were an undergraduate student with less volume. You may need to review the material and then constantly question yourself or recite the material back to yourself rather than a complete recopy. If you can recopy your work in an efficient manner while learning and your grades are good, then recopying is working for you and don't change your strategy.

Another problem that can interfere with some freshman medical students is feeling that they "need" to study for boards. You don't need to take time away from your coursework mastery to do board study at this point in your career. If you absolutely feel that you NEED to do some board study, then do it during the summer between your first and second year but the best preparation for boards is to thoroughly master your coursework and then study for boards at the end of your second year. You cannot "review" what you have not "learned" in the first place. Don't take valuable coursework study time to do board study. Board review books are most useful because they summarize material but most medical school courses require the details and not summaries. Beware of the "I am going to use a review book to summarize" method of study because it might work against you in terms of you not getting enough of the details to pass your course. The other extreme is to attempt to memorize the textbook which is most likely too much detail. In short, strike a happy medium that will work for you.

Don't be afraid (0r ashamed) to consult your instructor or your dean if you are struggling. Not to reach out for help (especially because of the amount of money that you are paying for your school tuition) is not wise. It really looks great to a residency program director to see comments from your dean or professor that state that you were able to overcome a deficiency and excel. These types of comments indicate excellent problem-solving skills which are highly prized in a physician.

Finally, tune out the boasting of your classmates who say that they "didn't study" and "aced" their exams. They are lying period. You have to do what you NEED to do for yourself. Congratulate them for being so "brilliant" and don't waste a second of your precious time worrying that you are somehow deficient because you studied like a demon and didn't do so well. There is nothing wrong with you that correcting your study strategy will not solve. Just don't add "questioning your worth" to your list of things to overcome. It isn't necessary and it won't get the job done.

Statistics (and odds) state that if you were accepted to medical school, you will get through the four years successfully. Some people make the adjustment to the rigors of medical school academics faster than others but trust yourself enough to know that you will get the job done. There is very little difference in intellect between the person who graduates first in their medical school class and last in their medical school class. Residency program directors know this which is why the person who graduates last in their class is still called "Doctor". Run your own race and get what you need.