For the past 4 months I have been tutoring medical students in both Year 1 clinical skills and Year 3 case based learning. Before this, colleagues had always said that you learn so much from students. I have found this to be very true. It has also been a great way to look my own consulting and examination skills and find areas for improvement. Here is a short list (that will hopefully grow) of things that I have taught, I have learnt and that bring a smile to my face. If you are a clinician, I highly recommend doing teaching of some sort.
- Avoid negative leading questions “you havent been febrile have you?” It leads the patient to an answer, I’m guilty of it sometimes too!
- If after your beautiful open question the patient says “I have a cough.” Instead of jumping in to closed questions, ask another open question like “tell me more about the cough…”
- Explain examination procedures to patients in simple terms. So instead of saying “I’m going to percuss the lower lung fields,” you can say “Im just going to tap on your chest quickly.”
- If you state the absence of esoteric signs (Janeway lesions), be prepared to explain what they are a sign of
- To save you time listening to the chest say to the patient “take a big deep breath in and out through your mouth everytime you feel the stethoscope on your back
- Its called a ‘tongue depressor’ not ‘suppressor’!
- Avoid saying “cool” or “excellent” when asking history. It’s good that you have got the information, but it doesn’t sound great if they’ve just told you about their bowel cancer. Say “ok” or “mmhm.’
- Don’t pronounce the ‘p’ in ptosis
- Pt: “I havent seen a GP in 35 years.” Student: “Well its good that you came to see us today.” Great line
- Recap your history at the end. It gives yourself some time to remember any points you might have forgotten, the patient might remember something and it shows you’ve been listening!
- If a patient says they are not smoking, make sure you ask if they have every smoked.
- Similarly if you ask about recreational drugs, it’s a good idea to list some common examples.
- Be non-judgmental about any answer that comes back.
- Don’t be afraid of silence. In fact if there is a large pause, let the patient break it.
A few weeks ago, my uni students were given a scenario similar to this one:
Mr Hugh Jass, 65 year old lawyer presents with headache, nausea and sweatiness. Cough, non productive. Muscle aches, dysuria and urinary frequency. No symptoms of meningism. 25 year pack history. No other relevant family or past history.
O/E: Temp 40C, HR 90, BP 110/90, RR 18. Crackles in right base. Abdo tender suprpubically, no loin tenderness. BS normal.
In the case, Hugh is referred to a tertiary ED where he has some tests. CXR shows some COPD but no consolidation and urine grows E.coli. He is evenutally seen by a urology consultant who gets a better LUTS history and does the PR and PSA test.
The question was asked, quite fairly, should we have done a PR earlier? And if so, when? GP room, first ED work up? It made me wonder “would I have done a PR in the GP room for this man?”
I also put myself out on a limb during the case conference with the other tutors and said that I probably wouldn’t have sent this man to ED. Was almost shouted down! I thought that a reasonable action (even in the peri-urban setting) may have been to check for UTI with dipstick and commence on oral antibiotics. Given his high fever and symptoms perhaps even a shot of IV antibiotics as a stat dose? Although I understand that a UTI in a male is a concern, I thought immediate referral to ED was a tad overzealous. Of course more detailed history about urinary symptoms, DRE, PSA (if symptomatic) and a referral to urology would be on the cards, but within a week or so. It seemed from the other tutors that this would be too gung-ho….
Interested for your thoughts.
Delivered on the 24th May to the 2013 RDWA Conference. First time I had to speak for 30 mins!
[soundcloud url="http://api.soundcloud.com/tracks/93919033" iframe="true" /]
“Gerry grew up for 22 years in the outer suburbs of a small Victorian town called Melbourne. So how was it that this ‘city boy’ ended up undertaking GP training and wanting to work in rural South Australia? Was it family heritage in the bush, inspiring placements, the lure of aviation or all three? Surely they will find out he barracks for Collingwood sooner or later….”
Having difficulty remembering what the lesions look like, what antibiotics to use or what else to education patients? No fear, in 3 minutes your problems will be solved. Apologies for poor singing/pitch and subliminal pro general practice messages…
Towards the RA-Aus Pilot Certificate: @ruralflyingdoc
So I had my recreational aviation certificate in hand. Where to now? Firstly, the RA-Aus certificate only permits you to fly yourself 25 nautical miles from your origin airfield. This also means no landing. It’s obvious that this is kind of limiting. But not to worry, there were two endorsements I had to gain that could extend my flying. First up was the cross-country (XC) endorsement that allows you to fly anywhere in Class G airspace. Class G airspace is anywhere outside of controlled airspace (typically around capital city airports and general aviation ones such as Parafield in SA. The second endorsement was for passenger carriage that then lets you take a single passenger skyward….and back again. To gain the latter, a total of 10 hours solo flying was needed. But to start, it was time to get stuck into navigation exercises and finish the XC endorsement to be able to fly somewhere other than Wirrabara, Port Germein and Gladstone.
The first part of navigation to get my head around was flight planning. This was a multi-step process that involved:
- Drawing the track from origin to destination on a map
- Working out the compass bearing and track distance
- Finding out the weather on the day (including the wind direction and speed)
- Correcting the bearings and winds to magnetic
- Working out the heading (taking into account the wind)
- Finding out what your speed will be and therefore,
- How long each leg will take and the total fuel used
Having always enjoyed geography and orienteering, the map plotting came easily to me. Prior to starting out for real, Dr. Scott gave me a few practice tracks to plot out at lunchtime in the clinic. Most of the brainwork was aided by using the oddly named ‘flight computer.’ In essence this was a circular slide rule on one side and wind correction calculator on the other. It lets you work out the effect of wind on your ground speed and heading, much like water current can push a boat off course. An additional consideration is the correction from true north to magnetic north. Across the world, there are different magnetic variations from true north to magnetic. To fly accurately, a pilot must convert measured track and wind directions from true to magnetic. The current.
The flight plan from Pirie today would take us from Port Pirie to Crystal Brook to Jamestown to Orroroo to Belton to Quorn and back to Pirie. After plotting the tracks and distances, the heading and actual groundspeed was calculated using the flight computer. To do this, the weather area forecast (ARFOR) was decoded and assessed. Along with an overview of any rain, clouds, temperature and barometric pressure, the ARFOR provides wind at different levels. The hardest part of this task was to interpret the information. The system dates back to faxed reports and are condensed to save characters. In RA-Aus circles, there have been moves to update the weather reports to plain text to better help decoding. For example, here is a short excerpt:
Taking off from Port Pirie, we pointed the Jabiru towards Crystal Brook. Even at circuit height, we could see the silos that denoted our first checkpoint. Unfortunately as we passed over the Brook, the cloud base looked to be getting lower eastwards. To around 3000 feet. It meant that the leg toward Jamestown would be flown at non-standard altitude. Usually when flying, any tracks east, between 0 and 179 degrees, would be flown at an odd thousand plus 500 feet (1500, 3500, 5500 and so on). Tracks west therefore made at even plus 500 (2500, 4500, 6500 etc) in order to maintain separation with other aircraft. Given that our cloud base was below the prescribed cruising altitude we would have to duck below to keep visual reference to the ground. Essential for any visual flight rules (VFR) pilot.
In 12 minutes we arrived over Jamestown and circled the airfield to check the windsock. It was blowing across the only runway. I have heard a few people say “there is always a crosswind at Jamestown” and this day was no exception. It was reminiscent flying the circuit over a town that I’d spent considerable time as a student and junior doctor. Our turn onto final took us over the hospital that I remember one of the oldies saying was “up the hill from the cemetery.” Ah mild dementia. So where were we again, I’ve forgotten…ah yes, after the turn onto final approach, the last stage of flap was extended and carburettor heat pushed off. The strong, gusty left to right crosswind meant that we were crabbing sideways down to the threshold. As we got closer and closer, the gusts were whipping up at the Jabiru and pushing us all over the place. It became harder to wrestle the plane back onto course. Earl made the executive decision at 150 feet to go around. Power full on and away we went, no cow on the runway this time…
The next destination was Orroroo, a small town on the drive from Jamestown to Wilmington (the long way). This would take us over a local attraction called Magnetic Hill. Hopefully this would not interfere with our compass!! As we progressed northwest, the sun started to peak through the clouds that were lifting. This meant that the Jabiru could sit cruising at the correct altitude, much more comforting. However, when the estimated time of arrival ticked over, I still hadn’t seen the airport. Either the headwind was a lot stronger than planned or I had passed the strip. Looking across a few nautical miles to the east I saw it snuggled up against the road from Jamestown. In fact the wind from the west was less than anticipated and our heading had taken us further west than the airfield. There was enough time to descend for a quick circuit pattern and full stop. Luckily the wind gusts had died down we took the time to empty bladders and poke around an old school classroom being used as a terminal building.
After taking off we headed towards an old town called Belton. Along the way I practiced matching up what I saw outside with the map on my lap. Trying to figure out which wiggly creek was the nice blue line on my chart was difficult but rewarding when other features lined up. After passing over the Belton ‘metropolis’ it was time to find Quorn airfield. Again as we neared the destination, I had trouble finding the airport. It seemed that the strip was a lot further away from the town than it appeared on the map. Unfortunately with the recent rain and being a dirt strip, we have to pass on landing there. So we turned back to Pirie and got some good experience in dodging small rain showers and finding a safe clearing to cross back over the southern Flinders Ranges. The landing was uneventful as I had plenty of time to practice approaches during the navigation exercise. Next would be to sit and pass the navigation and build up solo hours to tick off the passenger endorsement.