Love thy patients, or How to pass medical school

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.

Oh, and they shook my hand and said “Well done” at the end. I guess I passed.

 

 

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23 thoughts on “Love thy patients, or How to pass medical school

  1. Congratulations! Love the diagram. In the paleosphere we have Kurt Harris (sane but not hard working and afraid of the light), Emily Deans (crazy with good attention span) and Jack Kruse (surgeon — mean!). Where are you going to fit in?

    My brother-in-law is a gynecologist. I wonder where he fits in.

    • Well, let’s see: sane (I think) -> hardworking? Not so much -> big things -> dermatology. Noooooooo! Gynaecologists are in the league of their own. Let’s leave it at that ;).

  2. Oh Anastasia…..that fluffy old lady just WASTED 10 minutes of my time with her knitting story!!!

    No matter how annoying patients can be, I would have to agree that the I can relate almost every medical condition to one patient or another I have seen during some point in my medical career.

    I think your diagram is flawed….I don’t see myself as a pathologist 🙂

    • I’m sure that experience taught you invaluable skills on how to firmly keep the patient on task :). And I find the annoying ones stay in my memory the longest.
      I reckon you underestimate yourself. You actually DO like patient contact, you just don’t want to admit it!

  3. If only I’d read this 45-50 years ago, I’d have done something with those scholarship offers. Instead, I got married and had a kid, divorced, remarried (miserable), divorced (13 years), remarried (I think this one may last). I’d have been a darn good pathologist.

  4. Congratulations!!! Love your blog too. If health is an ocean, and paleo is a sea, then your blog is an island where things make sense!

  5. My dad’s a 70 year old obgyn who still delivers babies and stays at the hospital overnite…I put him in the ‘crazy’ category, although at some point after he had 3 kids during his med training i’m sure he started out perfectly sane. I love this graphic, and have to show it to him!

  6. Congratulations, Anastasia!

    Can’t wait to show the diagram to a friend in emergency medicine 🙂

  7. What a wonderful Blog! Thanks for sharing with us… I opened a thread about your Blog on my very low carb diabetic forum saying how great I think it is and how easily understood your explanations are. I just hope you are able to continue to Blog as I know that time is a factor for doctors. Y’all do seem to be overworked sometimes! (http://www.diabetes-book.com/) Dr. Richard K. Bernstein is the doctor that has this forum. I think you will probably have a lot of readers from there soon. I know I will be checking your Blog daily, just in case you added something, I wouldn’t want to miss it.

    • Hi Mary, welcome to the blog. I have a lot of respect for Dr Bernstein, he has done amazing things for diabetics and diabetes education. I try to post once weekly, normally on Mondays/Tuesdays. Feel free to check out earlier posts, there are a few touching on blood sugar and diabetes.

  8. Hi Anastasia and thanks for this wonderful Blog site!

    I know doctors are amazingly busy people and the time stress on their lives is terrible, but I hope you never stop this Blog. I am afraid you will, as you become more and more busy with your profession.

    When you consider stopping your Blog or letting it die, I want you to remember something. This is a service to the world.

    Educating the public on health, is a real service and should be considered a charitable act. I hope you can always find time for it and if you can’t, I hope you at least keep what you have already done in here online and available to the public.

    Every doctor wants to be a lifesaver. Well, I think this Blog probably will save a lot of lives by educating ordinary people about real health issues, in a manner they can relate to and understand. You have a real talent for teaching.

    Respectfully,

    Mary

    • Thank you Mary. I really appreciate the support. It is true that blogging definitely cuts into my study (and spending time with my family) time but I see it as an important way to get the information out there. Especially for people like yourself who are prepared to take responsibility for their own health. Teaching is something that I really enjoy and will definitely continue it whether via blogging or another media. Thank you for spreading the word on Dr Bernstein’s site.

  9. There was a clip on CNN’s website here a couple of days ago about how our former president Clinton has gone vegan. I commented on how it’s too bad he cut the wrong things out of his diet and that it surely wasn’t the eggs, meat and cheese in his former diet that gave him heart problems, more likely the sugar and refined starches. Someone–most likely a medical professional–replied something to the effect that “you can’t be serious…the usual nonsense…unless you have medical training, don’t give medical advice.” I didn’t consider what I said medical advice, I considered it nutritional, and reminded him that medical training doesn’t include a lot of nutritional training, and what is given is more than likely wrong, but I am pretty sure I was whistling in the wind. (The site closed it’s comments section so I couldn’t see if he replied to my reply.) So I am infinitely glad that someone (you) who does have medical training is providing accurate information that is not necessarily the same old, same old. Perhaps–perhaps–your degree will force arrogant idiots like him to take this information more seriously and start doing some critical thinking of their own. Anyway, we certainly do appreciate everything you do on this blog and hope against hope that you can continue after you become a busy doctor. Peggy

    • Peggy, I find that people like this only fall back on “you are not a doctor” line when you disagree with their views. Everyone is happy to snigger at obese people or get worked up about their obese children. Because it is much more comfortable to blame obesity on gluttony and sloth. Much harder to admit that you’ve been lied to for the last 30-40 years. Most people (and some doctors) prefer to live in denial.

      • And they’re suffering from the same diseases as the fat people and they don’t even see it. I don’t know why I bother feeling sorry for them, but I do…

  10. Just catching up on some reading here..
    Oh so that’s what HPC stands, somehow i’ve just learned that that’s what they came in with hehehe.

    Congrats you passed!

    I’m glad that you think you are going to change the future of medicine 🙂 go get em gurl! Just don’t be one of them arsewipe interns who think they are god’s gift to the surgical team. And I know you won’t be xxx

    PS I love the flowchart. I wonder if the same applies to nurses. Then i guess that explains why im a surgical nurse hehehe

    • Justin, I’m very aware that hospitals are in fact run by you, the good nurses. Let’s all play nice together for the future of medicine 🙂

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