Today I had the first of many exams coming up in the next 2 months heralding the end of med school. Apart from being extremely nerve-wrecking it is also very exciting because you can literally see the light at the end of a very very long tunnel.
Long case examination is an old tradition in Western medical education. In Australia the long case is used to test both final year medical students and candidates at the FRACP examinations (doctors training to be specialists in internal medicine).
The main challenge and the objective of the LC is to demonstrate your clinical skills, or in other words, how you can apply all that book-learning in real life. Knowledge alone won’t get you far in the long case (or in medicine itself). That is why the long case is said to be a skill and an art form.
The exam itself is normally conducted in a different hospital to prevent students from being familiar with patients. On arrival into this hospital I am allocated a patient who has been previously examined by a senior doctor. This doctor, who will be my examiner, has also been familiarised with the full story of the patient’s diagnosis and treatment. I am to spend 60 mins one-on-one with my patient with no notes, blood results or imaging at my disposal. In an age when we seem to treat numbers rather than patients it seems almost anachronistically refreshing.
My goal is to get the history of presenting complaint (it’s advisable not to frame it in those terms otherwise you might get a lecture on the quality of food in the hospital), past medical history, medications, social history (smoking, alcohol, home situation) and the history of any medical conditions in the family.
At this point I am supposed to have a few ideas in my head as to what is happening. This should in theory guide my examination in the right direction. But if you still have no clue you might as well examine everything, time permitting. Sometimes you get lucky and the patient knows the drill so well they give you advice on what to do next (“Hey, love, docs normally use that funny hammer for my reflexes too”). Although if somebody suggests you do a prostate check for no reason you should probably refrain.
After 60 mins the bell rings and I have to say goodbye to my victim. 20 minutes is then allocated to arrange my thoughts on paper. And then the fun part begins: a 20 min presentation to the examiners which includes a compulsory 10 minute “grilling” time. I am supposed to condense my 60 mins with the patient into a brisk 10 minute recital which includes:
- only the relevant clinical information (missing out on that fascinating story about Aunty Selma and her rash)
- identifying the patient’s main issues which is a lot harder than it sounds. They might be concerned about their wedding ring stuck on the finger while in florid heart failure.
- my feeble attempt at probable diagnoses (or Dr House’s “differentials”)
- my suggestions on how to investigate these issues. Sending bloods off for EVERYTHING will not get me any points. Cost and common sense require justification for every test. At least in the exam.
- my management plan. This has to address every medical and every social issue. It might sound a little interfering but I am expected to come up with strategies to cope with the social isolation in the elderly. I suggested bingo nights.
Long case undoubtedly gives you the skills to cope with most clinical problems. But the best part about this exam is the people. Unlike the impersonal case histories in our written tests, we get to spend a whole hour with a real person. And real people are fun. They may be humourous, aloof, rude, obliging, too talkative, not talkative enough. You feel thrown in the deep end and willy-nilly you have to swim. You can read a whole book on rheumatoid arthritis but until you sit down with a fluffy old lady who had to give up knitting because her fingers are not as nimble as they used to be, you will never appreciate these little details.
In my student life I have done dozens of practice long cases. You learn to be succinct but empathetic, quick but thorough. Sometimes patients say no to students. I can understand that. You have been poked and prodded enough, you might have just received a bad diagnosis and this awkward-looking young person is a bit of a nuisance. But what if you knew that your particular condition will always evoke a memory of YOU in my head? I will not remember that chapter in a medical textbook but I will forever remember my first case of Crohn’s 3 years ago: a lovely 30 year old lawyer who had to bravely describe her bowel habits to a group of 5 students, me the only female.
It’s fashionable to dismiss doctors nowadays. Yeah, I know, we have screwed up. We plug the conventional wisdom, give pills like candy and believe the rubbish from pharmaceutical companies. But whatever your experience with the medical profession, teach me what you want me to know. These annoyingly inquisitive medical students and junior doctors are your chance to change the system for the better.