The purpose of this entry is twofold: first, to help any medical students who may read this blog in their transition from preclinical to clinical years and second, to fulfill my need to rant.
In medical school, we are taught the myth of The Complete History and Physical. Myths are fun and good to know about. The problem is that we are taught to believe this myth. Like Theseus and the Minotaur or The Abominable Snowman, the Complete H and P does not exist. There is no such thing. It is a fictional construct used by medical educators to teach those without very much medical knowledge how to approach a patient. It serves the same purpose as the story about Apollo pulling the sun across the sky in a chariot every day. The truth is that the type of questions you ask a patient and the type of physical exam maneuvers you perform completely dependent on a) the patient's chief complaint and b) the context in which you are seeing them (i.e. inpatient already seen and evaluated by ER doc vs ER not yet evaluated by any doc vs outpatient vs OB vs pediatrics vs nursing home vs hospice etc.) There is no such thing as a "complete" set of elements that must be present. To be complete, you need only whatever elements are relevant to whatever objective you are trying to achieve.
Of course, this presents at least one huge problem for medical students and physicians in training. Since your knowledge is less complete than that of the person who will be making the final clinical decisions, you may not always know which information is relevant and which is not. Not only that, but you as a learner may not even be sure exactly what objective you are trying to achieve since this is based on a) your medical knowledge, b) the patient's wishes, c) whatever overarching principles guide you in your beliefs about how medicine should be practiced. Therefore, with all of these unknowns, the diligent learner is obliged to gather more data that what he believes to be strictly relevant in the event that his supervisor wants to know some detail that the learner had no reason to think important.
Which brings me to what I now perceive to be the point of this post: rather than subjecting medical students to this highly inefficient process of gathering mountains of data and only later helping them to understand which data they needed to gather, why not first teach them which data are important before throwing them in a data-gathering situation? Seems only reasonable, doesn't it? Yet, we continue to teach medicine by putting students in situations in which they are expected to perform without first giving them the opportunity to learn how best to proceed. Do not misunderstand me, the current process does work...eventually. Spend long enough in France and you will eventually speak French pretty well. But it seems to me that we could make the path from learner to skilled clinician many times more efficient.
4 Comments
This is poor advice. Like you, most students will realize that an H&PE only include relevant components. The problem is a first year medical student likely doesn't understand what is relevant. On top of that, it is important to know all the components of the exam as each is used for different patients. If you honestly believed that you had to do a full H&PE on every patient, regardless of their chief complaint, then you're a bit slow on the uptake.
Your final "point" undermines medical education and logic. How long do you think it would take for someone to understand what signs are important before learning about physical exams? What about patients with ambiguous symptoms, or those malingering? The complexity of patient complaints is vast. Knowing the components of an H&PE in general is simple to learn.
Yes, spend enough time in France and you'll pick up the language. But who is to say that is the CORRECT form of the language. Maybe you learned mispronunciation, wrong word context, etc. That would get you laughed at in France, but in medicine it would get you sued.
Apparently Anonymous didn't understand my analogy. In case I was unclear, let me be more explicit:
I believe that sending a non-French speaking person to France is to learning French as putting a clinical medicine naive third year medical student on the wards is to teaching them medicine.
Therefore, I agree with Anonymous when he says that this is not the best way to teach medicine.
Which is of course why clerking takes me twice as many pages as the consultant with 20 years ED experience.
Very intriguing article. I would agree that Med students should be taught what info is important and always must have the patients best interests at heart.