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Students, this one is for you. The rest of you, feel free to read along and reminisce.
It's early August here at the Western University College of Podiatric Medicine. Boards are finished, and our third year students are on their clinical rotations full time. I work in the Foot and Ankle Center on campus, so I usually have a good number of students working with me. Since these students are new to actually seeing real patients with real pathology, they're working hard to acquire the intellectual skills to make them effective clinicians. To that end, my trainee colleagues, let's talk about some clinical information topics that will help you become successful fully functioning clinicians.
Surgery
First, let me climb up onto my soapbox and talk about surgery. Students love to do surgery. They're enthusiastic and desirous of participating in surgical cases and often complain when they don't do as much surgery as their counterparts. From this educator's standpoint, let me say this:
Students assisting in surgery is a privilege and not a right.
This is true for all providers, but doubly so for students. Let me explain. Having a student participate in a complex and high-risk process like surgery adds another level of complexity and increases the complication risk. For example, I recently had a third medical student scrub into an incision and drainage procedure, only to have him contaminate himself twice during the procedure. Having a new trainee forces me as an attending to split my attention even more than I usually do. As a result, I and your other trainers must be willing to put the extra energy into this operative situation.
Additionally, it is a prerequisite for a student scrubbing a surgery to have a good fund of knowledge before doing the case. Students must understand the indications for procedures, the general flow (not necessarily the specific details) and have a firm grasp of podiatric medical and surgical principles. Essentially you need to...
Know the medicine before doing the surgery.
Finally, a strong student must demonstrate a stellar attitude and be willing to pay his or her dues. If you can't demonstrate to your attending physicians a desire to learn and a professional demeanor, in addition to a strong fund of knowledge, why would they want to bring you to the OR? Show them you deserve this privilege.
Surgery experience is earned and not given freely.
It may be important to keep one piece of perspective in mind. Unless you do surgery repeatedly and make a conscious effort to learn, then you're highly unlikely to recall exactly what occurred during a procedure. When I was a third year student, I scrubbed in for an ankle fracture case. Of course, the only thing I can remember from that case was the point when I was allowed to put a couple of screws into the plate. That's it. I basically got nothing out of the case other than practicing my basic OR skills like scrubbing, gowning and very basic assisting.
My suggestion for each of you is to write down everything about the case immediately following completion. What kind of tourniquet was used? Where was the incision? What anatomy did you see? What were the steps of the procedure? The list goes on. When it comes to surgery a good assistant (and eventually surgeon) will anticipate the upcoming steps in the procedure. This allows for an easy flow to the case.
How Clinicians Think
Let me now climb off my soapbox and talk about clinical thinking. As I mentioned before, this is much more important for the student to master before doing surgery. If you as a student do a clerkship where you do zero surgery, but you learn you how to think, then you've received some strong education.
Let's talk about the thought process of a clinician. There are two primary ways that clinicians think. We use clinicodeductive reasoning and scripts.
When a clinician begins to take history from a patient, they walk into the room with a pre-existing picture of how a particular pathologic entity looks. This is a script. The simplest script for a podiatrist would be plantarmedial heel pain that is worse on first rise. Within about two seconds, most podiatrists have already thought, "That sounds like plantar fasciitis." If I describe medial ankle pain in a 40-year-old overweight female with flat feet, the first thought is usually adult acquired flatfoot secondary to posterior tibial tendon dysfunction.
This isn't magic. With study and experience, we create these scripts that allow us to rapidly make diagnoses and begin clinical decisions. If I instead describe a patient with plantarmedial heel pain that is burning in quality and worse at night, the clinician might start thinking of Baxter's neuritis or tarsal tunnel syndrome and begin the workup. As the details of the history are added, we adjust our thinking according to the script in our minds.
Now, in some instances, the story doesn't fit our disease script and the clinician falls back on clinicodeductive reasoning. They acquire as much data as possible, asking increasingly detailed questions and incorporating the physical examination and other laboratory and imaging data to deduce the diagnosis.
This takes logical reasoning and thoughtful consideration of all the details. It also takes asking the correct follow-up questions. For example, if a patient says, "My heel hurts", the next logical question is, "What part of the heel hurts." One of the most common errors my students make is not asking the follow-up questions. Recently, one of my students was seeing a 35-year-old patient taking Warfarin. When the student presented the patient to me, I asked the question that is obvious to anyone with experience: "Why is the patient on Warfarin?" If a patient states she drinks socially, the follow-up question is, "What is social drinking?" Is that an occasional drink or is it binge drinking on the weekends? It takes practice, experience, and logical thinking to build this skill.
Finally, one last piece of advice is to ask questions, take notes and read. A lot. When I say a lot, I mean A LOT. Students should be reading about everything they see every night. If you work an 8 AM-5 PM podiatric shift, that should leave about four hours of solid study before 10 PM (an early night). Obviously, this excludes driving home and eating. Reading should not be passive, as if reading a book for pleasure. Instead, it should be active, with heavy note taking and repetition to burn the knowledge into the brain.
Understanding how experienced clinicians think and how they got to that point should help students focus their clinical work and studies to help become the future colleagues that we all need.
Best wishes,
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
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