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.

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