Sarah (fictitious name to protect the innocent) is a second year medical student attending my Cardiology clinic for an “observership”. Like her peers, Sarah had an outstanding academic career prior to entering medical school, as well as a variety of personal experiences that demonstrated an interest in the human condition and commitment to public service. Since entering medical school, she has continued to excel academically, easily passing all her courses. She participates in a number of extracurricular activities, is well liked by her classmates and well regarded by faculty.
She is now exploring career interests, which is what brings her to my clinic. Sarah requested this observership because she feels she may be well suited to Internal Medicine, and Cardiology in particular, and would like to explore that interest in greater depth.
As we chat before clinic, she tells me that she hopes to both increase her knowledge and learn more about the practice of Cardiology. It’s obvious that she’s prepared herself for the clinic by reviewing course content from the previous term, and arrives in her crisp white clinical jacket with stethoscope in hand.
My approach with second year students in clinic is to introduce them to a few selected patients and give them about 30 minutes alone to take a history of the presenting issue and carry out a directed physical examination, including vital signs and cardiovascular and respiratory components. The student then presents their findings to me in a separate room, and we then see the patient together.
Sarah sees three patients.
The first is a 79 year old gentleman who underwent aortic valve replacement and coronary bypass grafting about 6 weeks previously having been followed with gradually increasing symptoms over the previous year. He is a retired construction worker of Portuguese background who speaks no English, but is accompanied by his wife (who also speaks no English) and their devoted daughter who translates for them both. In fact, the daughter doesn’t translate so much as respond directly to questions on behalf of both parents. Although he’s doing well, they have a number of questions and concerns. Sarah has difficulty because she feels she needs to pay attention to three anxious people simultaneously, and isn’t sure the responses she’s getting from the daughter are valid. In discussion afterward, she has missed a number of key issues, and feels somewhat frustrated by the encounter.
Sarah’s second patient is a 60 year old adult who has been followed for over 10 years because of Hypertrophic Cardiomyopathy. The patient is developmentally handicapped and, although very pleasant and cooperative, responds to every enquiry in the same polite manner, affirming how well she feels without elaboration or apparent depth of thought. This is in distinction to the results of the recent echocardiogram that indicate the condition is getting progressively more severe, to an extent that treatment would usually be indicated. The case worker who accompanies our patient and knows her well, tells us that she’s “slowing down”, but never complains of any of the symptoms about which we have enquired. Sarah is aware of a number of treatment options that are known to improve symptoms and prognosis in this condition, but isn’t sure how they should be applied given her patient’s apparent lack of symptoms and inability to understand the indications and possible side effects reliably enough to participate in the decision.
The third patient is a 21 year old native woman who lives in lives near Moose Factory and works in the local hospital. She is referred by her Family Physician because she’s experienced two syncopal episodes within the past month. Sarah takes a complete history, and uncovers a number of issues that might suggest a cause, including a history of drug and alcohol abuse, and a family history of sudden cardiac death at young ages. We discuss a plan for investigations, as well as the need to inform the patient that her driver’s license must be suspended until we’ve resolved the problem. The patient is angry and upset, and doesn’t know how she’ll be able to carry out further investigations, since she was expecting to return home on the first flight early the next morning.
After clinic, Sarah and I take some time to “debrief”. She’s clearly a bit shaken by these encounters. We agree that her level of knowledge about the medical conditions she’s encountered (aortic stenosis, coronary artery disease, syncope, cardiomyopathy) is excellent, entirely in line with her level of training. However, she felt very limited in her ability to obtain a complete history and to apply accepted management strategies to these patients. In addition, she found the experience of encountering a person close to her own age with so many issues complicating her care particularly troubling on a personal level.
We were able to identify the various physician competencies that were required to effectively manage these patients. Sarah found, somewhat to her surprise, that the “Medical Expert” components, which she’d always assumed were the most important in her learning were, in fact, not much of a problem for her. It became obvious as we reviewed the cases that the Portuguese family and disabled adult challenged her communicator skills. The young lady with so many social issues required advocacy and highlighted her professional role to enforce public policy. Deciding what managements were applicable to the cardiomyopathy patient required an exercise of the scholar role, and coordinating all these aspects of care was a manager challenge, as was dealing with her personal responses to the young woman’s social situation. Some of the recommendations we made required collaboration with community physicians, therapists, pharmacists and other health providers. Even more importantly Sarah was able to see that providing comprehensive patient care requires these roles to be integrated rather seamlessly. They simply don’t segregate conveniently for us, as early medical education would suggest.
It also became apparent that these aspects of the learning experience had little to do with the cardiology-specific content but are relevant to any discipline. The “career exploration” element that Sarah was initially seeking certainly took place, but in a much broader and likely more effective way than she had imagined.
So, in summary, what did Sarah gain from her clinic experience:
- A deeper understanding of the pathophysiology, clinical presentation, physical examination and fundamental management of four specific medical conditions.
- An appreciation of the importance, complexity and subtlety of communication as a key physician skill.
- The relevance of all physician roles, and how they come together in every patient encounter as integrated, “intrinsic” competencies.
- Considerable self-awareness regarding her own level of professional development, personal strengths and preferences.
- Something about how different medical specialties differ, and how her particular strengths and preferences might fit those choices.
For my part, I was again impressed with the value of providing patient-centred opportunities that allow our students to experience the real life application of the knowledge and skills they are acquiring. Beginning early in their medical education, these experiences provide a framework and relevance that invigorates their learning process, and informs their career choices. Guiding our students through these formative experiences, and watching the immediate impact they can have, is also one of the most powerful and satisfying roles for any clinician-educator.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education