logo

A Practical Guide to Clinical Medicine

A comprehensive physical examination and clinical education site for medical students and other health care professionals

Web Site Design by Jan Thompson, Program Representative, UCSD School of Medicine.
Content and Photographs by Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, California 92093-0611.
Send Comments to: Charlie Goldberg, M.D.

Introduction Breast Exam Write Ups
History of Present Illness Male Genital/Rectal Exam The Oral Presentation
The Rest of the History The Upper Extremities Outpatient Clinics
Review of Systems The Lower Extremities Inpatient Medicine
Vital Signs Musculo-Skeletal Exam Clinical Decision Making
The Eye Exam The Mental Status Exam Physical Exam Lecture Series
Head and Neck Exam The Neurological Exam A Few Thoughts
The Lung Exam Physical Exam Check Lists Commonly Used Abbreviations
Cardiovascular Exam Medical Links References
Exam of the Abdomen    

The "daVinci Anatomy Icon" denotes a link to related gross anatomy pictures. DaVinci's Anatomy Symbol

A Few Thoughts Before You Go...

The start of your clinical rotations provides you with an opportunity to finally get involved with patient care and begin in earnest the process of becoming a doctor. You'll be amazed at the speed with which you move from outsider to functioning participant amidst the swirl of activity that is clinical medicine. It is, unfortunately, quite easy to lose your sense of perspective while working in this very intense environment. In fact, you'll recognize this as a common problem among many in the medical field. A few things to think about before you get started (and perhaps refer back to as you make your journey):

  1. Treat patients as you would want yourself or a family member to be cared for. This should cover not only the technical aspects of health care but also the quality and nature of your interpersonal interactions.

  2. Try to avoid viewing the medical training process as a means to an end. As medical education is a life long undertaking, you've got to enjoy the journey. If not, stop and think why.

  3. Do the right thing. This applies to patient care and your dealings with colleagues and other health care workers. If something feels wrong, it probably is! The rules which govern your behavior in the world outside of medicine still apply, regardless of what others say or how they might act! This can be challenging, particularly when you are fatigued, in a subordinate position or working with others who don't have the same interests.

  4. Mistakes will happen. The oft referred to: "Primum Non Nocere (first do no harm)" probably sets an unreasonable expectation. You will all do harm to someone at various points in your careers. Those who claim otherwise have either not taken care of enough patients or are not being truthful. We are all human and thus all fallible. When errors occur, acknowledge them, discuss them with colleagues and the patient, make efforts to correct the fall out, and move on. Above all, try to learn from what happened and don't allow yourself to forget any relevant lessons (without at the same time torturing yourself unnecessarily). This should help you to maintain a healthy dose of humility and become a better doctor. Remember also that anyone can be a genius in retrospect. Using this information in a manner that promotes education and growth requires a sensitive touch.

  5. Never be afraid to ask questions. If those that you are currently working with are unreceptive, make use of other resources (e.g. house staff, students, nurses, health care technicians, staff physicians). You can learn something from anyone.

  6. There is no substitute for being thorough in your efforts to care for patients. Performing a good examination and obtaining an accurate history takes a certain amount of time, regardless of your level of experience or ability. In addition, get in the habit of checking the primary data yourself, obtaining hard copies of outside studies, mining the old records for information, re-questioning patients when the story is unclear, and in general being tenacious in your pursuit of clinically relevant material. While this dogged search for answers is not too sexy, it is the cornerstone of good care.

  7. Learn from your patients. In particular, those with chronic or unusual diseases will likely know more about their illnesses then you. Find out how their diagnosis was made, therapies that have worked or failed, disease progression, reasons for frustration or gratitude with the health care system, etc. Realize also that patients and their stories are frequently more interesting then the diseases that inhabit their bodies.

  8. Become involved (within reason) in all aspects of patient care. Look at the x-ray, examine the sputum, talk with the radiologist, watch the echo being performed. This will allow you to learn more and gain insight into a particular illness/disease state that would not be well conveyed by simply reading the formal report. It will also give you an appreciation for tests and their limitations. Caring for patients is not a spectator sport. As an active participant in the health care process (rather then simply a scribe who documents events as they occur) you will not only help deliver better medical care but will also find the process to be more rewarding and enjoyable.

  9. Follow up on patients that you care for in the ER, are transferred to other services, seen by sub-specialists or discharged from the hospital. If you don't make an effort to learn about what happens to your patients as their situation evolves, you run the risk of convincing yourself that you're a genius every day. That is, without checking back, you can develop the sense that all of your decisions are always correct. Following up (by computer, talking with colleagues who also provided care, etc) will give you a better understanding of the natural history of medical conditions and allow you to confirm (or adjust) your clinical suspicions. This is particularly relevant today as patients are shuttled through the system with great speed, affording us only snap shot views of what may be complex clinical courses.

  10. Keep your eyes open for other interesting things that might be going on elsewhere in the hospital/clinic. If there is a patient on another service with an interesting finding, go over and investigate, assuming it doesn't interfere with your other responsibilities and is OK with the patient and their providers. This will give you the opportunity to expand your internal library of what is both normal and abnormal.

  11. Pay particular attention when things don't seem to add up. Chances are someone (you, the patient, the consultant) is missing something, a clue that the matter needs further investigation. Challege yourself and those around you by continually asking "Why... ?"

  12. Before deciding that another provider is an "idiot" for adopting what seems an unorthodox or inappropriate clinical approach, assume that it is you that are short some important historical data. Give others the benefit of the doubt until you've had an opportunity to fully explore all the relevant information. And in those instances when it becomes apparent that mismanagement has occurred, focus on communication and education rather then derision and condescension.

  13. Become comfortable with the phrases, "I don't know" and "I need help."

  14. Try to read something medical every day. This will help you to stay abreast of new developments and provide an opportunity to become reacquainted with things that you've learned and forgotten. Medicine is less about achieving mastery then it is about reinforcing old lessons. Our individual "knowledge tanks" leak information on a daily basis. There is no way to plug the hole. Instead, you must continually replenish by adding to the top.

  15. Realize that, ultimately, you are responsible for you. The quality of care that you provide is a direct result of the time and effort that you invest in the process. The distinction between good and bad medicine is generally not a function of oversight by the patient, colleagues, or the legal system. For the most part, it's dependent on your willingness to push and police yourself.

  16. You are not automatically endowed with the historical wisdom of a particular institution merely by walking through its doors. Nor does this knowledge necessarily arrive with your white coat, degree or other advanced title. Rather, this is something that's learned and earned, often on a daily basis.

  17. Every once in a while, push yourself to become an expert in something. First hand knowledge is a powerful tool, one that is available to anyone willing to take the time to read through the primary data. Become informed by delving into the original literature pertaining to a particular subject. You may find that the data is robust and the rationale for a clinical approach or treatment well grounded. As frequently, I suspect you'll find instances where the data is rather shaky, and the best path not as clear as guidelines or expert opinion might suggest.

  18. Be kind... to others and yourself.

  19. Have fun! Remember why you went into medicine. Keep this first and foremost in your mind and periodically readjust your course so that this is always in your sites.

There is magic in medicine. It does not, however, derive solely from technology, testing, or diagnostic aptitude. Rather it more often comes from your interactions with patients, a touch on the sleeve, sitting at the bedside and treating them (if only for a few minutes) as a fellow human being and not as, "That guy with Lupus." You are all capable, right now, without additional training, of being magicians. The challenge lies in not losing track of this as you make your way in the coming years.

  Home | Clinical Images | For Our Students | BioMed Library | Next

Copyright © 2015, The Regents of the University of California.
All rights reserved.
Last updated 10/15
.