March 01, 2009

"Too much time."

I've been criticized multiple times by various preceptors that I spend "too much time" with my patients.  "FOCUS!  LIKE A LASER BEAM!"  and "C'mon C'mon C'mon!" are the mantras one of my docs enters before all of my patient visits.


Admittedly, even some of my patients are exhausted by the end of the interview and I've had a few that needed to take a bathroom break before I started the physical examination.  (In one case, it led to chuckles and jokes by the nursing staff who assumed that the patient left in a huff because I overextended their patience.)


I laugh along with them and I understand WHY it can be a bad thing to spend too much time with my patients.  There's other people in the waiting room and the schedule gets backed up.  I get it.


My take?  I'm a friggin' MEDICAL STUDENT.  I'm still learning!  The best way I learn is by spending time with my patients, thinking through their problem in real time under real pressures, deciding what questions to ask, clarifying parts of the story I'm confused about, which pieces of medical advice to dole out, which path of management I would engage in if I were the doctor (so they can see where I'm coming from before the real doc comes in and says something completely different.  ;)


One of my more critical preceptors gave me a lecture this past week: "Look... I'm not saying you shouldn't know all of those things you're sharing with me.  But we are trusting other docs to do their job before they come and see me.  That's the point of this.  You need to get some perspective."


I feel that this is the crux of the issue.  There's different philosophies in medicine.  One of the "Laws of the House of God" is


In other words, if you intentionally don't ask the right questions, you won't need to follow up on them.


Some will gloss over parts of the history that are not pertinent to their particular field or interest at the time.  Perhaps they have the data readily available on a computer.  Perhaps they've seen the patient in the past and have addressed it already, or maybe they've made a referral to a specialist.


As the ignorant medical student seeing a patient for the first time with nothing more than a blank sheet of paper on a clipboard, I don't have those luxuries or assurances.  I only have one tool -- the brute force of the consistently thorough history and physical.  In many cases, it can take 30+ minutes.  But I find all the fevers.  And the headaches.  And the chest pains.  And the dizziness.  And I need to talk about them with the patient to learn more. 


The law that follows #10 is:

11) SHOW ME A BMS (Best Medical Student, a student at the Best Medical School) WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.

Even though I feel harried all of the time (and perhaps rightly so in most cases,) I'm glad that these docs have volunteered half a day out of their week to teach me -- because I don't really add much to their practice.  I just make their work harder.  I'm the one that takes "too much time."


  1. Hello Clinton

    Keep taking the time. This really is how you learn. A medical student in my practice a few weeks ago had a consultation with a patient for a 'medication review'. Sometimes when students start talking to patients and they hear this they tend to just stop and think that there is nothing for them to ask or learn about. But this student did ask. He asked about what she was prescribed and whether they were controlling her symptoms or had side effects. He found out that she was had been having more problems with dyspepsia in the past few months.
    When we talked together about it afterwards she said she probably wouldn't have mentioned this to me as it has been a problem for quite a while. But because the student picked this up I organised to check a stool sample for H pylori faecal antigen. When the result came back the student had finished his 6 weeks in our practice so he doesn't know that the test came back positive and she has now had eradication therapy.
    He helped me and the patient that day.
    Keep asking questions and reflecting on why things aren't always as they first appear.

    PS Thanks for checking out my blog!

  2. I agree keep asking questions.

    I have two questions for you. Feel free to move this, I wanted to ask it on your blog, considering the content might be interesting for future blog use.

    The first, what do you think about soy as an estrogen mimic. I'm currently in China, and there is a very common drink here called DouJiang, and it's "soymilk" boiled soybeans blended into hot water, with sugar added. I love it, and it cleared up my face. Then I did some reading in an article on Web MD, for effects of estrogen mimics (they were talking about herbal supplements) and they advised for women with a history of different cancers (breast cancer was sited) to avoid estrogen mimics. Other article, perhaps because of other good qualities of soy, say that it can prevent cancer. I was just curious about what you think.

    Second, is the main reason I'm writing. I was on my way back to the school, after a student's parents had asked me to lunch and something terrible happened. A woman was hit (hard) by a truck about 50 feet from where we were getting into the car. She had a child (about 2 years old) who she had been carrying who landed maybe 15 or so feet away from her. I was appalled, as I have never seen anything like that. A bystander went and picked up the child. I seriously doubt there is much I could have done to helped, but of course it tortures me that she picked up the child. I feel like maybe if I had gone into the road to help I might have been able to stop her. I kept thinking of what I would have done ("help call 911" and realizing that wouldn't work at all, and I don't even know the number). I thought... I remember stuff from first aid and the army. I could have checked for a head wound, with my hands first then checked for breathing, then... wait. I realized if I had done anything, and my hands come back with blood on them, that creates a whole new problem. I am not a medical professional, and I'm not even in my own country. I don't have gloves, or one of those safety masks for giving CPR. I've heard lots of horror stories about getting tested, and re-tested for HIV because of touching someone else's blood as a teacher. How do you (as a soon to be professional, and yet not an EMT yourself) reconcile the two, the safety of the individual, and potentially comprising your own health by doing so.

    I've got good friends here who made me immediately snap out of any bad feelings that I had after seeing that, but I am curious about what you think would be an appropriate response by someone like me (with a little relevant medical knowledge)... or what you would do if faced with a similar situation outside of the hospital.