By Walter Wiggins
In Luke’s recent post, he gave a personal account of one of the more difficult situations you will overcome as a 3rd year medical student in your first few months on the wards – the presentation. In many, if not most, med schools in the US, you’ve likely had some sort of clinical experience during your first two years. At my institution, we had a series of three courses: Doctor-Patient Relationship (DPR) and Physical Examination during 1st year and Bedside Teaching (BST) during 2nd year. These courses taught us the basics of interacting with patients and taking a history (DPR), conducting a comprehensive physical exam, and putting those two things together and formulating a problem list and differential diagnosis (BST). We also had 1-to-2-week “community practice experiences,” during which we worked with a primary care physician out in the community to put these skills into practice.
These types of courses provide an introduction to the clinical skills you’ll need to succeed on the wards, but for most of us, they come a little too early in the game for us to really get as much out of them as we’d like. I certainly didn’t appreciate all of the subtle techniques I learned in DPR to maneuver through a patient interview to get the information I need while still letting the patient tell the story. And I definitely didn’t know which components of the review-of-systems were going to be the most relevant for a particular problem. (To be perfectly honest, I still don’t always know or remember the most salient questions to ask.)
So…we’re given an advantage, but we still walk onto the wards or into the clinic on our first day feeling a little (or a lot) overwhelmed.
In his post, Luke described a scenario that is all-too-familiar to those of us who have been there. He described his inability to generate a reasonable differential for back pain when queried by his attending. Personally, I had the good fortune of having a friend who was a 4th year at the time tell me to “just go for it” when I hit the wards. I was wrong a lot more often than I was right, at first, but I got better quickly because I put myself and my knowledge to the test.
Here are three major points from my experience that may help you put your mind at ease about your first few months on the wards…
- You know a lot more than you think. You’re just not used to using that knowledge in this way.
- What you don’t know, you’re usually not expected to know yet.
- If you don’t try, you’ll have more difficulty learning. So…just go for it! Be wrong! It’s OK to be wrong. You’re still a student, after all.
And two more points that should help you with the dreaded differential…
- In the first 2 years, you learn a lot about zebras. On the wards, you need to remind yourself that horses are way more common.
- Attendings get excited when a patient has a “textbook” presentation of a particular disease. Attendings don’t get excited about things that happen every day. Therefore, don’t expect “textbook” presentations of diseases, whether they’re horses or zebras.