Teachable Moments in Clinical Medicine

ABSTRACT

Sir William Osler said, To study the phenomena of disease without books is to sail an unchartered sea, while to study books without patients is not to go to sea at all. This quote is a bleak reminder of the state of clinical teaching after nearly two years of Covid disrupting the implementation of our curriculums across the country given the recent roll out of a Competency-based Curriculum. We cannot allow the undergraduate course to slip into a distant online mode for fear of losses of competences mandated to perform professional roles as physicians of first contact. The focus of this brief lecture is on Undergraduate Teaching-Learning in Clinical Medicine though post-graduate education is not necessarily exempt from these ideas. It will attempt to suggest possibilities given the existing context of the transformation towards the new Competency-based Curriculum and the facts of faculty-student ratios that challenge us. Assumptions must be stated at the beginning that faculty are not only motivated but also enthusiastic and interested in their task to educate their undergraduates to learn and the vice versa exists especially in dealing with students in their clinical phase of studentship. If the patient needs to return to the centre of our education, then moving very moment of teaching to the bedside, Outpatient clinic, Emergency and even Operation Theatre are the needs of the hour. Key elements towards achieving competences and outcomes require us to insist on small groups (usually not more than 15-20 per unit) and formative assessments ongoing throughout phases of teaching clinical medicine. To force multiply we need to include Senior Residents and Postgraduates (even the special Intern) into the pool of 'Faculty' and more importantly use every opportunity to provide experiences in the clinical settings mentioned above not restricted to 'nine to five work hours'. Outpatient (Ambulatory) clinic has great potential to teach small groups of clinical students assigned to shadow faculty and residents/interns working up patients in regular outpatient clinics even participating actively in the actual care and treatment of patients. Since clinical postings occur usually through three semesters leading up to final examinations, judicious involvement in 'work ups' documented in case notes or logbooks as students under supervision of faculty/residents makes fabulous learning. Initial postings begin with history and anthropometric measurements and growth charting leading to physical examination both General and Systems finally even deciding on differentials with investigation plan and writing then counselling regards prescriptions. All this is after it is present to the faculty/resident in the presence of the parents for confirmation or clarifications. Undergraduates enjoys a single patient work up by every student assigned to a faculty/resident is enjoyed by undergraduates simply because it is realistic. Of course, informing the patient or attender of the patient and appropriate allocation even of healthy or follow up patients for this exercise makes this a possibility. It is rare that such an informed patient or attender disallows such an exercise. Depending upon outpatient space, the clinical exercise may occur while sitting opposite the faculty/resident in the same consult room or in a nearby room to return to the faculty/resident's room for presentation in front of the parents. One may hasten the process by focusing on a one patient-one key learning system and various models have been described by John Dent and Ronald Harden classified on Student - Faculty ratios. As an example, in the case of Paediatrics, focusing on growth charting, practical immunisation, nutrition counselling, discussing most likely differentials, investigation approaches, form filling, rational therapeutic choices, optimal prescriptions, education and counselling may be chosen as learning points for different students seeing different patients. Initially, case notes of history and examination are allowed onto outpatient charts followed by assisting by investigation requests, discussing results when relevant and finally actually writing prescriptions to be scrutinised and signed off by faculty/residents. The obvious disadvantage is that it does slow down patient clearance but while students work up their patient's one can continue to clear other patients and every patient does not need to be handed over to students to work up. Their involvement in actual patient care makes great inspiration to learn more. Ambulatory settings also allow one to direct students to the immunisation room or pharmacy to observe and under supervision begin to even administer common vaccines while recognising components of the many prescriptions we dispense. We all know that to do is the best way to strengthen the learning experience. Teaching in the wards at the bedside of patients is also rather fulfilling and motivational for students to understand and want to learn the art and science of medicine. The bedside clinic has been the cornerstone of clinical education only to disintegrate as one 'Bakra' works up and presents the chosen allocated patient to the faculty while the remaining clinical batch of students passively stand by hopefully learning. Allocating patients or beds to individual students or a pair of students, the latter in early postings, with mandatory responsibility of working up and seeing 'their' patients every morning of the clinical posting with details entered in the logbook book is the first step. The faculty assigned for the bedside that day, does not reveal the patient to be discussed but may randomly pick up one of the patients asking the student(s) 'responsible' to present. This mandates that all students posted have to be up to date with history, examination, investigation results and treatment if not daily assessments and care plan. Another successful involving method is to walk up to the batch allocated patients from the parent unit after they have seen their patients for the day and conducting teaching rounds mimicking realistic patient service rounds. Each student or pair of students presents updates of their patients and discussions occur similar to one has on regular rounds. Differentials are argued, Investigation results analysed and Treatment options even choice of antibiotics with doses and duration justified. This clerkship exercise is an early extension of internship and we all know that most learning occurs during Internship at least in our times. Documentation may occur in student logbooks but one may make provisions that patient progress notes be clearly identified as student learning notes and documented as such. The student-doctor then needs to not only interact with patients, practice examining patients, documenting the same, to chase results and cross consults. Common non-medical issues faced in care and treatment are then experienced by students. It is only in the ward that feeding, introducing intravenous cannula, performing phlebotomy, medications administration, infusions, monitoring transfusions, transportation within hospital, changing diapers and even bed making is experienced. It is in the wards that opportunities to participate in procedures like LPs, biopsies, etc. occur making sure that documentation occurs in logbooks. To enable more excitement in learning, the mandating evening duties as observers from 6-8 pm assigned to report to duty residents/postgraduates as they deal with emergencies and regular work documenting what they observe during such duties. Observation in Operation Theatres or in areas where procedures occur only makes good learning if there is a structured system in place, where the teacher briefs the students preparing them for what they are to witness and observe followed by the actual witnessing of the procedure/intervention ending with debriefing of the steps involved and findings. The continuum of learning must continue into the postoperative period to complete the learning by student participation in post-operative rounds. In later postings, the occasional opportunity to scrub up to 'participate' in the intervent on adds to the inspiration to learn. In all these encounters, students must adhere to norms expected of professional behaviour And patient consent by the primary care provider essential. Patients if informed do understand the need and accept reasonable student interaction during their stay in medical college settings. Involving them in providing feedback of students who interviewed and examined them also makes great learning points right from dress code to demonstrating respect. This brief lecture shares ideas to recognise and optimise utilisation of possible teachable moments in clinical medicine thus opening up possibilities of many other ideas from participants.