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Read Part 1 here
Lesson 3: Making mistakes means we are doing something new.
I have made countless mistakes which might have costed something from the patient’s side, be it dignity, pain or tears. Dignity: I did not cover a young female’s body with a blanket while doing an ECG test on her. Pain: I failed to insert the cannula into the vein of a patient with suspected appendicitis, thus inflicting additional unnecessary pain. Tears: I enquired a patient on her appetite, not noticing she was on nasogastric tube.
With each mistake, my reflex was to reason my way out. I was too engrossed with getting the position of the ECG leads right, as it was my first time doing it by myself without the assistance of a nurse or colleague. It was my first cannulation on a real patient. It was my first patient whom I approached to interview on the first day of my clinical year. However, the more I thought of these mistakes, the more I was convinced that I was making up excuses as words of consolation to myself. The more I came to blaming myself and thinking that I was incompetent.
If you ever find yourself in such situation, you are not alone. Ask any doctors and they will tell you their personal experience of making a grave mistake, which could or actually did end up badly. Mistakes are inevitable no matter how much we try to prevent them. And they stay with us forever no matter how much we try to shake them off. What we could do is to learn from them. Suck out as many learning points we could from the mistake we did. And remember to never repeat it again.
Sounds like common sense right, the cliché advice to learn from our mistakes? Trust me, this thought will not make its way into your jumbled-up mind full of self-blame and regret, unless you force yourself to rationalize your thoughts. Self-criticism will be your reflex at such a time instead of rational reflection. My advice is to give yourself time for your emotions to take over your mind, to let yourself feel the extent of the impact that the mistake has on you and your patient. Share this experience with a friend together with your mixed-up emotions. Do not let them eat you inside-out. Only then do you reflect and make an oath to not repeat the same mistake again.
Do not let them cloud over you and affect your duty in saving a person’s life tomorrow.
Lesson 4: Reward yourself.
As much as you blame yourself for making mistakes, remember to give yourself a pat at the back for your small victories. First successful venipuncture, first successful ECG, first intramuscular injection, first successful pap smear, being able to help a highly tensed houseman in performing a pleural tap even though it was just holding the little containers of fluid. Of course, victories are not only found in clinical procedures. Little glimmers of fun and happiness could also be found in successfully talking back to the unprofessional groupmate who is a jerk, making a good impression in front of a good-looking doctor you have been eyeing for some time, and even learning the Mandarin term for liver. Reward yourself with nice lunches and dinners other than the usual economical rice with your friends. It doesn’t have to be fancy, even a RM1 ice cream counts as long as you are happy. Medical school has too many downs to account for our heaping stress. Make up for them by not letting the small victories slip away unrewarded.
Lesson 5: Professionalism over emotions.
One month into the start of my clinical year, I was taking the history from a young man who was warded in the medical ward with a chest complaint. Armed with a load of questions related to the complaint and its association with the heart, I marched into the conversation with confidence, feeling sure that I will not miss out any questions this time. The conversation flowed smoothly as he was friendly and more than willing to answer the list of questions I asked, which should be able to cover two to three differential diagnoses I had in mind. Or so I thought.
Now, there are a few questions in the standard history that are deemed “sensitive” in the Malaysian context. Do you drink alcohol? Do you take drugs? Are you sexually active? We are constantly reminded to signpost these sensitive questions before delving into them so that the patient will be prepared and thus, not withhold any important information related to the condition. A certain technique in signposting is also necessary to avoid the impression as if we were imposing a certain stereotype in a patient of a particular race or lifestyle. Communication skills matter.
For this patient, I signposted with as much delicacy and care I could muster to make this young man feel at ease. He looked a little hesitant at first but, seeing that his willingness to open up had not waned, I grabbed the opportunity to ask the first question on my list, which I thought had the highest association with a heart condition. “Do you drink alcohol?” Looking relieved that it was an easy question, he immediately said with a smile, “No.”
Here come the two most awkward questions in history taking. I paused. Is it really necessary to ask these questions in this case? How do drugs and his sexual lifestyle affect his chest pain? I did not want to lose the rapport that we had built thus far by making him feel uncomfortable. Not to mention his more than adequate eye contact was making me feel slightly squirmish to even begin asking the questions. Therefore, I came up with Plan B. “Are you married?” With a grin, he gave a firm “no”. Assuming that meant he was not sexually active, I moved on to the next sensitive question. And I decided to skip it, thinking that it is not related to the heart. Plus, I had yet to meet anyone in the hospital setting who has taken recreational drugs, and his friendly manner did not seem to fit into the picture of one. I asked a few more questions before ending the conversation with good wishes to his health.
I was about to leave when he stopped me. In a softer voice, he said with obvious uneasiness: “I have something else to add.”
What did I miss? “What is it?”
“I take drugs.”
I was dumbfounded. How could his looks betray his lifestyle? How did I let myself assume so easily? I had a million other questions in my head, but I hid them with an expression which I tried so hard to maintain as neutral and professional. I mechanically wrote down the new piece of information on my notes, and politely thanked him. I turned to leave and again, I was stopped.
“One more thing.”
“Yes?” My voice cracked from not having recovered from his answer just now.
“I am a virgin.”
I was taken aback, this time by his frankness. He still looked uncomfortable and he said it almost in a whisper. Not wanting to stay in the sticky situation for long, I thanked him and left in a professional pace. Luckily he did not stop me this time.
Moral of the story is, never let your emotions get in the way of asking questions which could be vital in saving the patient’s life. This patient had endocarditis, which could be due to the drugs he took. If I were straightforward and professional in asking the “sensitive” questions in the first place, I would have gotten the answers I needed in less than one minute without having to get into an awkward situation, both for the patient and I. Plus, it also taught me to never assume anything based on a patient’s looks. It is probably safe to say that after this enriching encounter, I never again intentionally forget to ask the drug history from any patients that I meet.
Lesson 6: General practitioner? Think twice.
This is a common question thrown into the way of every medical student. What specialty are you planning to undertake? One may add with a snicker: You want to be a GP? Defensively, we will answer with pride: “Heh, no. I want to be more specialized than that. I did not spend 5 years of sweat and tears just to end up sitting in an 8am to 5pm clinic”. And as a young, adventurous and rambunctious medical student, we want to be the best cardiologist, neurosurgeon, obstetrician or psychiatrist in town. Some might choose to be the rare gem of a podiatrist or ophthalmologist.
Now, this has got to be the biggest misconception among medical students. My primary care rotation, if not the best, was nothing short of eye-opening. The general practitioners as we like to call them, are sometimes family medicine specialists whose knowledge on the infinite expanse of paediatrics (child health) and internal medicine (adult health) overflows in rich abundance. They seem to know every condition, from the common cakes like diabetes to the rare gems like pterygium, listed in the Oxford medical handbook with precise detail and no stones left unturned. They know exactly what condition you present with, no matter how vague and disperse the symptoms appear to unknowing minds like us. They know how serious your symptoms are, even when you think it’s nothing, and to decide the urgency in which to refer you to a specialist for further investigation. They have to deal with your initial worries and coax your paranoia into rationality. Most importantly, they have to face the ridiculous wrath of “patients” who drop by to obtain an MC backed by “a serious touch of cold”, but reasonably denied. In short, you have to be the smartest dog with the sharpest olfactory sense to sniff out something is seriously wrong in a sea of vague smells to join the K9 forces of the general practitioner.
Speaking of MC, it is an undeniable truth that we are plagued by the tendency to dismiss certain patients with an MC, especially those of the working class with vague “body aches” or “unspeakable fatigue” accompanied by no other symptoms. Here is a real-life example: A gentleman in his 50s visited the GP of a community clinic complaining of backache. He was a manual laborer. Assuming that it was due to his age and work condition, the GP gave a diagnosis of mechanical backpain without any further probing. The patient was dismissed with an MC and advised to have adequate bedrest. 2 weeks later, the gentleman returned to the same clinic but was assigned to a different GP. This time around, the pain had worsened to the point that it affected his sleep, an indication that the pain is beginning to get out of hand. He described it as a bony pain, not of a muscular origin. Unfortunately, he was given the same diagnosis and MC, with an additional calcium supplement and analgesic to relieve the pain. A month later, the pain escalated to the point that the gentleman could not walk without his son’s assistance. The pain had become so unbearable that he was literally crying for help. This time, an X-ray was done which suggested osteopenia. He was dismissed with more calcium supplement and a referral for occupational therapy.
What the GPs failed to obtain from the gentleman’s history were his other symptoms of constipation, fatigue and excessive thirst; his past medical history of undergoing chemotherapy; and the medical history of his family members. You might think it is the patient’s responsibility to tell all this information to the GP. In his defense, he did mention about the history but was not taken into serious consideration. Regarding his symptoms, how would he know they were related to his current complaint, but not an unrelated complication of his increasing age and workload? The patient had a missed diagnosis of multiple myeloma. Prescribing calcium supplement to this patient is akin to pouring fuel into a raging fire.
Moral of the story is, do not assume everyone who walks through the door is here for an MC. Never underestimate any presenting complaint given by a patient, no matter how small, common and non-specific it seems. Probe, probe and probe as if every case is a mystery to be solved. Ask specific questions which patients might think are unrelated but to knowing eyes, they are the key to the diagnosis. Of course, to do the latter, make sure you study abundantly before you go into the wards and start shooting random questions in the hope that some will fit into the context.
Lesson 7: Respect the nurses.
As a doctor, you work closely with the nurses, pharmacists, specialists of other fields, therapists, social workers, medical assistants, radiographers, pathologists, and so on. Without them, a holistic treatment will never be achieved. Therefore, it is common sense for us to respect them even as medical students. This is especially true in the case of nurses, whom we will always meet in the wards during our clinical year. Nurses will be the ones who assist us all the way from a student to a successful doctor one day. A senior told me a story on how a nurse coolly offered her hand for him to practice cannulation on, as he confessed that he could not poke the cannula into a vein every time he performed it on patients. With much insistence from the nurse, he performed his first ever successful cannulation. He was a Year 5 student then. Therefore, greet the nurses politely whenever you see them in the ward. Do not trigger their anger by deliberately disobeying them. Being a medical student does not and will never put us above them.
Lesson 8: Use your clinical eye.
What it means is to observe above everything else. Before you talk to the patient, try to obtain clues from the patient’s general appearance and the bedside. A puffy face may be a Cushing syndrome. A protruding forehead might suggest acromegaly. Lack of paraphernalia by the patient’s bedside might suggest estrangement or no family members. Once you form a hypothesis on what the patient might be presenting with, you could direct your history taking in a more specific way to confirm your suspicion. As Sherlock put it, fit facts into theories, not theories into facts. A lecturer once said we inarguably gain more information from observing than history taking.
I am still developing my clinical eye, so there isn’t much to share on this except for embarrassing failures. A patient once told me he was an occasional alcohol drinker. I blindly took his words for it. However, judging by his skinny physique with protruding rib cage and cheekbones, and combined with the diagnosis of chronic pancreatitis, it was an obvious case that the patient was hiding the truth from me. Yet I failed to put two and two together until I went through his medical notes after my feeble attempt of obtaining a history from him. He had been a binge drinker for the past 10 years.
In conclusion, clinical year is fun. I hope you will enjoy it as much as I do. These stories are either shared by clinical lecturers or encountered by me and retained as lessons. Certain aspects of these stories have been changed for obvious reasons. Some people learn best through stories, and I hope you are one.
Glossary
History – A set of questions asked by the medical staff to know the details of the patient’s condition and other relevant information, such as the patient’s social lifestyle, family’s health, etc.
Ho Mei Hui, currently sailing the 4/5th part of her journey in attaining her MBBS degree in Newcastle University Medicine Malaysia. Barely surviving and always occupied with trying to keep her boat from capsizing in the middle of the ferocious sea, she regrets still not having learned how to swim. Single and available.