Learning to get it right
Diagnoses & bedside manners, it’s not all fun & games as the journey continues with Molly Brazil in the quest to achieve her MD dream
To better prepare medical students like me for their residencies we have clinical experience early on in our studies at Oregon Health & Science University (OHSU). We start seeing patients during our first term in supervised “simulated” interactions. So far, this is the most entertaining part of medical school but also the hardest to explain. We do what are called Clinical Skills Assessments (CSAs) every other Friday. They’re graded exams but not in the traditional sense.
We show up in our best business casual, white coats and stethoscopes. An instructor gives a brief overview of what pertinent physical exams we must perform, such as abdominal or lung. Then an overhead announcement tells us to line up outside the exam rooms where we get a “patient scenario” that reads something like “Pat Smith presents with night sweats, fever and fatigue. Take a history and do a physical exam.”
With a deep breath and a knock on the door you enter and get to “play a doctor” (yes, at this point in my education it still feels like make-believe). For the next 20 minutes you try and ask the right questions and do the proper exam to come up with the correct diagnosis.
A good imagination is helpful because the patients are really “healthy actors” who don’t have a heart murmur or punctured lung. Instead you listen to their healthy lungs and heart and a slip of paper tells you what you’re supposed to hear or feel, such as “crackles in the right inferior lobe and absence of breath sounds over the left inferior lobe.” Based on these “clue cards” and whatever you learn from what the patient says, you should be able to make a diagnosis; sometimes more successfully than others.
The exam rooms are exactly what you’d expect to find in your own provider’s office but with one distinct difference; these rooms have video cameras recording the entire interaction for the medical students to watch later. I do and then turn them off within minutes because I can’t bear to watch my slip ups and awkward questions!
The “patient actor” is from the community and supposed to be standardized. But after a few CSAs I quickly realize they’re not so typical. We always debrief afterwards for feedback on what worked, what was awkward or seemingly rude and how best to improve your bedside manner. Sometimes patient feedback is contradictory. One says always re-tie the gown after an exam; another says let the patient do it themselves.
I’m learning to review all the advice and find what works best for everyone concerned for greetings, comfortably and confidently draping patients to maintain their modesty, and everything in between.
In some CSAs we must take an in depth sexual history, in others we have to tell a patient who came in for a cold that they have advanced stage cancer. It’s not easy. I’ve been told I have an excellent bedside manner and good energy but also that I smiled when I told a patient they had a terminal disease. Needless to say it takes practice and training.
Our instructor views CSAs as a safe place to fail; no human lives are at stake and the only consequence is a medical student’s bruised ego! Luckily these CSAs are graded with the understanding that it’s a learning experience so medical students can try new approaches for improvement’s sake, instead of focusing on protecting their grades.
Sometimes I nail the diagnosis and other times I sit there with absolutely no idea what is going on with my patient. More often than not I say awkward things like “do you have any plans for the weekend?” when a patient comes in for acute chest pain following a car accident. Or I forget to adjust the table for a patient, which leads to a difficult abdomen exam.
As much as I hate to crash and burn in these CSAs, I’m grateful for them. CSAs are humbling and uncomfortable. But I look forward to them and honestly believe learning to “get it right” while putting the patient at ease is one of the most important things we’re doing in medical school.
Stay tuned for more Molly blog in the coming weeks…