Teacher, teacher

21 11 2011

At this stage of the game, I am starting my second week of cardiology (the subspecialty dealt randomly by the clerkship coordinator) at the VA.  It’s kind of  lame so far, and so I’ll wait until next week to post about the experience.

Today, it’s all about the teaching styles.  During night shift, I was assigned to work with three different intern/senior combos, and each operated differently when it came to actually teaching.

The first team liked to have the student team go in to interview and examine on our own and then report back with findings.  The other student and I then presented the patient to the residents in front of the patient, they asked more questions, then generated their own differential diagnosis and plan.  These guys were pretty cool, though I didn’t learn much from them.  They were big on watching the TV in the lounge while they were doing their notes, so we almost always had Family Guy or Storage Wars or Seinfeld on throughout the evening.  While they did their notes, I researched the patient, looked up their treatments, asked whatever questions I could think of, and then mostly hung out and read.  I was asked once or twice to write an HPI (history of present illness) for the resident to copy and paste into his note, but that was really it.  Oh, and this group had us do a lot of rectal exams, which was super.

The second team had us all go in together and they did all of the interviewing and examining (the students hung back in the corner and watched.  Sometimes.  The first day working with them, they sat us in the resident’s lounge all. night. long.  A 12-hour shift.  Just us and our books.  Thankfully the next night with that team they let us out of our cage.  Maybe they were afraid we’d maul the patients or make them too inefficient to take a nap later in the night.  Short of the long, they ignored us, start to finish.  Thankfully they were only with us for 2 days, and they let us sleep in the med student on-call room.  Pretty much learned zilch there .

The third team went in together, assigned one student to take charge and ask all of the questions, and examined together.  These guys were my favorite.  I interviewed the patients pretty much on my own, and the rest of the team was there in case something was missed.  Still didn’t do much, but I learned a LOT of very useful information.

Why? Because the senior resident pimped the you-know-what out of me.  Legit.  Example: I was in “charge” of interviewing a patient with several days of intractable nausea, vomiting, and belly pain with a history of Crohn’s and IBS, and right away:

“What do you want to do with this patient?”  uhhhh…

“From the history and physical, it sounds like a Crohn’s exacerbation.  Let’s admit her, rehydrate her, and give her steroids to calm the Crohn’s.”   I liked my answer.  The resident did not.  The ensuing series of questions sounded something like this:

“Why?”  “What about anti-emetics?” “which steroid do you want to use? What dose? PO, IM, or IV?”  “Do you want to give her normal saline, isotonic saline? Half-normal? Lactate ringers?  With how much dextrose? How do you want to give it?” (and IV was not a good enough answer) “Should we get scans?” “Could it be adhesions? IBS? Ectopic pregnancy? Constipation? Psychiatric? Gastroenteritis?” “Name 15 other things that could be causing this pain.”

Whew.  And that was just the walk back to the resident’s lounge.

Later, he had me analyze an EKG while he, the intern, and another medical student watched.  They latter were asked not to help.  And since before I started internal medicine my EKG skills were not great, I floundered.  While it would be awesome for me to say that I kept my cool and did what I could with confidence, the truth is that I sounded more like the rain man.  It sucked.

Later in the evening, it was like a twisted game of ‘popcorn’ with me and the other student, where the resident would say something like “Name the Ottowa ankle rules” or “Tell me the arteries that come off of the aorta (and not just the proximal ones)” or “What are 15 causes of systolic heart failure” or “Name the equipment used in putting in a chest tube.”

After a couple of days of this, my tolerance for feeling like a moron skyrocketed and it was easier to relax enough to learn something.  Which is why this team was my favorite to work with: they actually took the time to sit down and really teach us.  And it wasn’t just pimp questions, they actually put together a few lectures for us  on ventilators and acid-base disturbance.

While this is often part of their job, very few residents take the time to help out.  The more senior they are, the less they care, and the ones that want to teach are less experienced.  Obviously, there are exceptions to that rule, and they are gems.  I’ve thus far worked with 2 dozen residents, and only 5 stick out as being great teachers.  Like I said, gems.

I’ve said it before, and I’m sure I’ll say it many more times:  Who you’re with  in terms of resident team assignments is way more important than where you are and, sometimes, what you’re doing.  Fact.  That’s just the value of good teaching.




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