Web Site Design by Jan Thompson, Program Representative, UCSD School of Medicine.
A Practical Guide to Clinical Medicine
A comprehensive physical examination and clinical education site for medical students
and other health care professionals
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.
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):
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.
- 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.
- 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.
- 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.
- 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.
- 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
- 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.
- 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.
- 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.
- 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.
- 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.
- 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... ?"
- 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.
- Become comfortable with the phrases, "I don't know" and "I need help."
- 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.
- 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.
- 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.
- 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
- Be kind... to others and yourself.
- 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.
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