Blog | Friday, September 9, 2011

Medical students need to get comfortable with uncertainty


Medical students are usually taught a rather comprehensive approach to history and physical exam. They appear to go through a mental check list of all the things that need to be asked and examined. They start off by following this check list regardless of presentation. They may also think that a test is needed to rule in or rule out each condition on the differential. It takes them a while to realize that a good history and physical can diagnose almost 70-80% of unknown cases presenting in the out-patient clinic and that even when one is not sure of the diagnosis, one does not always have to order tests.

When they first show up in clinics students tend to be quite confused that the clinical world is very different from the one they were training for. The experienced doctor seems to ask questions in a very different order than what they expected and seems to be quite comfortable with uncertainty, tending to order far fewer tests than they would have thought.

What can we do to ease the transition to the clinical years?
Some techniques I have tried are:
1) I teach a mantra that "Time is a diagnostic tool." This is particularly true in outpatient medicine. Some conditions can best diagnosed by waiting and watching. Either they will go away or they will show new features which will help diagnose them.
2) Empiric treatment is also a diagnostic tool. Sometimes a short course of medication can help. If the condition gets better (or it does not) it can point to the diagnosis.
3) I give them a framework and ask them to try and place the patients' possible diagnoses (from the differential) into one of three buckets (categories):
--Potentially serious (e.g. life threatening) and urgent (needs to be diagnosed or ruled out quickly).
--Potentially serious but not (very) urgent. This is on a scale.
--Likely not serious and not urgent.

I then ask them to see if they can eliminate any condition on their differential that falls into category 1. If that cannot be done, they need to absolutely do something right away including ordering a test. If they can, then they have time and then they can try still order a test or try empiric treatment or wait and watch.

Forcing a student to try and place the likely possible conditions in these categories helps them ask the questions that matter, rather than go down a checklist of history of present illness, review of symptoms and past medical history that are often irrelevant.

They students are often confused that they spend a long time with the patient asking questions and doing a head to toe exam and then when the preceptors talk to the patient, they ask one or two pointed questions or check a couple of physical exam findings that change the management completely. Discussing this with the student early in their clinical rotation can help smooth their transition and reduce their frustration.


Syndrome: Low back pain
Category 1: epidural metastases (history of cancer), abscess (systemic features of infection), (spine tenderness), (nocturnal pain)
Category 2: sciatica (straight leg raise test)
Category 3 muscle strain (paraspinal tenderness, history of unusual exertion)

Syndrome: Chest pain
Category 1: Acute coronary syndrome (previous stress test/cath,), aortic dissection features of affected arteries or nerves (e.g horner/recc, laryngeal etc.)
Category 2: gastroesophageal reflux disease, viral pericarditis (systemic features, rub, EKG findings)
Category 3: Rib/muscle strain (reproducible tenderness)

Syndrome: Headache
category 1: aneurysm (neuro findings check the pupils disc), temporal arteritis (age, jaw claudication, eye symptoms, scalp tenderness)
category 2: migraine (photophonophobia, triggers, caffeine)
category 3: scalp hematoma from minor injury

The items in parentheses are just examples of types of questions or exam findings that may not be part of the standard check list that a student my use. These not meant to be inclusive of all such questions. Also there are several guidelines that students can be directed to e.g. the guidelines regarding which head injuries should get a CT scan.

This is not to say that there is no role for the comprehensive history and physical. Often the students will discover something important about a patient that their primary care provider was unaware of. This is especially important in someone who has an unresolved symptom/s even after being seen by multiple providers/consultants. A fresh look at the case with a systematic approach can reveal clues to the answer.

Clinicians will sometimes miss a diagnosis but if the patient is appropriately instructed regarding any red flags and followed closely, the prognosis will usually not be any different.

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.