Monday, September 18, 2006

On Friday we had our first 'formative' exam (monitored by an invigilator no less). It you don't know what they mean by formative you’re not alone. My favorite definition of formative is - forming or capable of forming or molding or fashioning. I could use some fashioning. Or at least some new shoes.

Anyway, it was a test that was formatted just like our final (or summative) exam with representative questions but doesn't contribute to our mark. It was a good judge of how we are doing so far. Except I already knew that I was very far behind because I have been working on some papers for my lab that have held over from my Masters, so for me it was mostly just a kick in the teeth. Probably a kick in the teeth that will be good for me in the long run but I am still a little bruised right now.

We also had clinical correlation on Friday. As always, it was the best learning experience of the week and provoked issues that I wasn't expecting. Specifically the issue of consent and the doctor - patient - student relationship. We have examined one patient that was alone and had ascites and encephalopathy from chronic liver disease. We practiced shifting dullness, fluid thrill and palpitation. Though we repeatedly asked permission, she was obviously in some pain and was having difficulty talking. I doubt she understood all that was going on even if she did know what she was agreeing to.

Another patient we visited (on a different occasion, with a different preceptor) was an older gentleman that was being visited by his wife. Though there was no issue of reduced capacity, it was clear from the interview that they did not know how the many tests were going and were hoping for some answers, even from us. The wife thanked me for coming and helping. I had to explain that we were students and not in any position to give her information. That we were there to learn. This took me aback because I thought our preceptor had explained this to them. All I could hear coming out of my mouth was 'No, we aren't here to help you. We are here to take from you and give you nothing in return." I know this isn't entirely true; that we have to gain experience and knowledge so that we can help other people later. It just feels a little too easy justifying our actions in the name of education. Maybe I am a too prone to obsessive self reflection but I feel like part of learning to be a doctor is examining how our actions have an effect on the people we are lucky enough to call our patients. The reason that clinical corre. is such a good learning experience is because we get to see actual people, not just study cases. If we can't see them as people and think about how we are affecting them then we are losing out.


Miette said...

I have refused to examine some volunteer patients who were obviously in pain:
-An elderly lady with congestive heart failure and arthritis who only got up when she had to go to the washroom, and with much help from the nurses. I was supposed to record her gait and mobility, and couldn't bear to hurt her so.
-A lady who had undergone a partial mastectomy of the left breast. We were supposed to do a breast exam around the mastectomy scar to learn to feel for any lumps sugnalling a returning cancer. She winced so much that I stopped after 30 seconds.
I may have just had nice preceptors, but when I told them my reasons for not completing the examinations, they were totally fine with it. Those poor people were already poked and prodded during rounds, and I felt bad doing something where there was no benefit for them, just for me.
And I agree with you re: volunteer patients. I'm not certain some of them know that I'm not there to help them, but to learn, no matter how many times I try and articulate it. The interesting corollary to that is that sometimes I have inadvertently helped a volunteer patient, for example by letting them know about homecare, or asking about something that they hadn't mentioned before. So we're not completely useless in that regard!

Anna said...

I also have not examined patients in pain or who were not willing to see a student. What really upsets me is the way some doctors introduce students - 'young doctor' is a favourite of some consultants in birmingham. It is lying, and bulldozes patients into seeing students when they don't really know who/what we are.

But on the upside, you gave me somegreat inspiration for a really ranting post!

Miette said...

We have been taught that we MUST introduce ourselves as "student doctor" so that there is no ambiguity about our role.