Well I told my student I’d write something on short cases.
Before Prof Kamaliah left our current instituition (for personal reasons, husband accepted a job offer in Klang Valley) she suggested we added specific teaching times for short cases into the timetable, as short cases was an accepted part of medical school assessment worldwide, although there is a trend moving more towards OSCE type of exams.
Conducting bed side teaching in internal medicine for short cases is more challenging than the usual ‘long case’ type of approach. One of the reasons why is that it (the short cases approach) is often misunderstood.
I usually tell my students I expect everyone to be prepared to discuss at least one patient each (the more, the better, as was the case with my previous work place a few years back).
See how I chose the word ‘discuss’ and not ‘present’? That’s because it’s different. You don’t give away the information to your friends, at least not yet.
For ‘long cases’, the group has to ‘put up’ with listening to the student present the whole case, history followed by physical examination, then discuss diagnosis and management plan. That is what doctors do on a daily basis.
So how does ‘short cases’ differ?
First, the students are gathered together in a corner (often the doctors room, sometimes the corridor). Then, they are asked very specific questions. This is needed because:
It’s not my patients, so I don’t know the cases inside out. If it were my patients, then we could skip the first step.
I ask the students, how many of them had seen patients today (this morning before the bed side teaching session) because in spite of my instruction to please be prepared, there are always students who come having not seen any patients at all. No excuse is acceptable. I repeat, no excuse is acceptable.
Example of excuses:
- I was clerking this patient and then the patient was discharged.
My answer: Then quickly go and see another patient.
- I was clerking this patient and the patient passed away.
My answer: Then quickly go and see another patient.
We’ll pretend that everyone is prepared with one case each, minimum. Then I ask who examined their patient? I know, it sounds crazy right, who would clerk a patient and not examine them? Well, my students, not all of them but quite a number think this is acceptable. No, it is not acceptable. You must take a history and do a relevant physical examination.
Of course I accept the history and physical will require a lot (well, this may vary) input especially in the beginning, in getting it ‘right’, but please START.
My next question is ‘how many students saw patients with physical signs?’ Now at this moment, the numbers should fall because yes, not all patients have positive physical findings. In fact many of them have none. Sometimes though, they have signs but these are not recognised as such by the students. Some students get over excited at this stage and give the diagnosis or physical findings away. Again, a mistake that is easily corrected. The best thing is to answer yes or no, and if yes, what system.
On average in a group of 20 students, there would be about 3-5 patients with positive physical findings, which means something is abnormal during the examination. These patients are ideal for the short cases.
The short cases approach means you do not have any history to rely on. You are given specific physical examination instructions, such as:
- Examine the cardiovascular system
- Look at this patients hands
- Examine this lady’s neck
And so on. You can not ask the patient any questions other than ask permission to examine them, and before palpating the abdomen or moving a limb, you can ask whether the patient has any pain (that what is normally incorporated into the physical examination system is ok).
So the student has to rely 100% on their physical examination skills.
I will normally select a few potentially good short cases based on what system abnormality the patient has. Then we go on to the wards and approach the patient for permission. If the patient agrees, then the student who knows the patients history is taken aside. The rest of the group stays with the patient (they are supposed to put this time to good use by selecting a candidate for the ‘exam’).
The student gives me a summary of the case and the positive physical findings, which I then decide on the appropriate instruction to give the candidate.
A student volunteers (or is picked, whichever necessary).
The student then examines according while being scrutinized by the lecturer and audience.
Any mistake will encourage a “any comments?” comment from the lecturer, where the lecturer hopes other students have been paying attention and will pick up what needs improvement.
After completing the physical examination, and its best to present findings in stages as you pick them up, rather than leave them at the very end, where a lot of students then struggle to remember what they actually found. The student is asked to summarise the positive findings and come up with a diagnosis or differential. Then discuss management.
Any deviation from the expected answer will normally elicit a response from the lecturer for example “are you sure?” begging a reconsideration.
After the student arrives at the correct diagnosis, usually at the end of the discussion, the lecturer will then invite the student who knows the case to share all the details.