For physicians of my generation, many additional chapters in our medical careers have been written since chapter one, medical school. That opening chapter is somewhat of a fading vision. Not the knowledge part, thank goodness, but the circumstances under which that information was acquired and retained.
Throughout our medical careers there have been important people who have guided, educated, and sometimes chastised us along the way. Without their contributions to our development it would have been much harder for us to reach our full potential as physicians. The expansion of the UBC medical school to 250 graduates has intensified the need for more physicians to become involved in teaching and mentoring at all levels of medical training. I hope we graduates will respond to this shortage and step forward to participate in teaching the next generation of physicians.
Working in a community hospital does not offer many opportunities to teach students. Last year I accepted a request for tutors for the second-year GI seminars. This involved taking a group of second-year students through a history and physical examination session with real but not currently sick patients. The education was to be limited to one area of the body, so I thought there was a high probability of it being within my limited teaching experience, and I signed up. I had eight students and two patients and together we reviewed the precirculated material and then moved on to the patient contact and physical examination.
As part of the lesson I was to ensure that students could palpate a liver edge when possible and assess for an enlarged spleen. There were two approaches looking for splenomegaly that I was to review: Traube’s space and Castell’s sign. I had to dust the cobwebs off my memory bank to accurately demonstrate locating Traube’s space. Castell’s sign, which I use in my own practice, was easy to demonstrate, except I didn’t remember its proper name. Castell’s sign is dullness with inspiration in the anterior axillary line in the lowest coastal interspace, while Traube’s space is based on finding the resonance of the gastric bubble below the sixth intercostal space. My delivery of the second method was less than smooth. The time I had put in preparing to demonstrate that piece of the examination was, shall we say, less than stellar. In the end I confused the landmarks for Traube’s space and Castell’s sign. Fortunately one of the students set me straight. It was an educational success but less so a teaching one from my perspective.
Following the session the students had a chance to give feedback to instructors. A nice envelope arrived at my home a few weeks later from UBC. “Instructor could have been better prepared for splenic exam points,” wrote one student. Ouch! But it was the correct assessment and excellent feedback. I learned a good lesson that day. I had another GI group the following week and, I can assure you, I could have written the textbook on splenic examination for that one.
At a cadaver course I attended last year everyone had an opportunity to complete procedures. After your turn, each student, with a tutor by their side, had to teach the next student waiting for their hands-on learning. It was an extremely effective way to test your knowledge and cement things in your memory.
Thinking back on critical educators in my life, I recognize that I have used their approaches and teachings for 25 years. Not necessarily the treatment or diagnostic tools, as medicine has changed so much, but the way they managed certain illness or complaints. I remember one physician who showed me a thorough approach to low back pain that allowed me to separate out the serious cases. I used to be very uncomfortable seeing such patients as I wasn’t quite sure how to put it all together. He taught me an invaluable lesson and I have enjoyed these encounters ever since.
Senior trainees are also vital in guaranteeing the prerequisite experience and learning opportunities essential to becoming a good clinician. I remember my senior orthopaedic resident taking the time to teach me how to properly apply a cast on a patient with a Colles’ fracture. “If the cast looks like a kindergarten art project, the physician who is taking it off will think you are a dope, regardless of how good the reduction was.” His words and techniques were burned into my memory and I made sure my casting skills were up to his standard.
Some learning moments are naturally very painful because they are the times you didn’t get it right. During my internship, my diagnosis of right renal colic in a patient with pain, nausea, and percussion tenderness in the right flank never quite hit the mark. I carefully documented the signs of peritonitis; unfortunately, I failed to appreciate the retroperitoneal anatomic location of the kidney and ureter.
“Physical exam was fine, but you can’t get peritoneal signs in renal colic; this is appendicitis.” My surgery resident was an excellent teacher.
All physicians have benefited from mentors and teachers throughout their training and into their medical careers. Without them, our learning experiences, clinical skills, and enjoyment of medicine would not be half of what it is. Teaching others is part of our professional responsibility and payback to those who helped us along the way.
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