Maintaining a blog is not easy, even for someone who writes as a hobby.

A few days have passed since the most recent student seminar and best side teaching for fourth year medical students in internal medicine rotation.

I was inspired to jot down some tips as I find, as the group of students change, they keep making the same mistakes as those students that have come before. No problem, as they are, in fact, medical students, meaning future doctors in progress. Mistakes are allowed, but it would be best if they are learnt from by future generations too. Not just by those who make them.

There were two student seminars. One was titled “dyspnoea” and the other “headaches and facial pain”.

Using Whatsapp Group For Teaching And Learning

I find whatsapp groups extremely convenient for direct communication with medical students. I certainly do not recommend this for others, I’m just saying that over the years I find it very useful. I prefer that its just me with the students, all the students. Other lecturers might find it too troublesome.

I always remind students that:

  • Lecturers phone number is private and not to be given to anyone without permission
  • Do not call unless it is an emergency
  • Use the group to WA, so that everyone else can read the same message and I will not (hopefully) need to repeat myself so many times to the same question being asked by different students

Dyspnoea – Student Seminar

Dyspnoea, I had thought was a pretty straightforward title. But the previous groups seminar proved otherwise.

(Student seminar is when the students act like lecturers, prepare the material and present accordingly. Usually it is done in groups and subtopics divided amongst the students.

I find student seminars are a great way for students to learn. The downside though, I have noticed, is that the students who present are the only ones who really master the particular topic while other students may not have such a good comprehension, and this is obvious when the actual topic happens to come out in the exams.

So, I tell students instead to give me an outline of their presentation beforehand. That way, I can scrutinize any possible potential gaps in the content.

Another thing I often tell students, instead of asking the lecture “What topics do you want us to cover in the seminar?” its actually better to propose a seminar layout, and then ask the lecturer “Are these subtopics for dyspnoea seminar adequate? Did we leave out anything important?” Never ask a question which answer you can easily find in the textbooks or by googling. Instead, look up the answer, if you are not sure which answer is correct because there are conflicting information, or if you want to confirm what you understand is correct, then ask the lecturer.

Be a problem solver, offer solutions. This will serve you well through out medical school and when you start working later.

The problem with the previous groups seminar was that, it began quite well with details so as types of dyspnoea, grading according to severity; using New York Heart Association classes for heart failure patients is more impressive than not using it, associated symptoms, common causes, they failed at the management.

Why? Because the management of dyspnoea depends on the cause. There is no general treatment that fits all apart from supplemental oxygen and sitting the patient up. So of course the students will need to explain briefly management of different conditions that causes dyspnoea.

Which conditions to include? The common ones and the important ones. Everyone should know the management of common causes of SOB (shortness of breath) such as CAP (community acquired pneumonia), COPD (chronic obstructive airway disease), asthma, heart failure. What are the less common but important ones? How about pneumothorax, pulmonary effusion, lung carcinoma, pulmonary tuberculosis, arrythmias, pericardial effusion, and pulmonary embolism. These are just examples.

Obviously, in one hour, students cant spend more than one to two slides per condition, as this is not a seminar on asthma alone.

This is what we mean by ‘clinical approach to diseases’. Select the relevant information from the textbook and present it in a way that best reflects what happens in clinical practice.

Headache – Student Seminar

Headaches as a students seminar topic. Often, students love to give plenty of facts on conditions where the information is simple and easy to understand. This is my observation. Even for dyspnoea, many student groups go into detail for example exercises related to physiotherapy, when really, as the treating doctor, we just refer to physiotherapy and do not need to know so much detail how it is done, because there is so much of internal medicine stuff to do. So leave those details to the other relevant healthcare pressionals. Sure, no harm to mention minor details but don’t waste time on it.

So happens every time, there are detailed explanation of tension headache, migraine etc when the focus should really be the same approach as one would give chest pain: is it cardiac? If one cannot rule out cardiac chest pain, then treat as acute coronary syndrome until proven otherwise.

For headaches, the important causes which must not be missed in internal medicine include:

  • hypertension
  • SAH (subarachnoid hemorrhage)
  • SOL (space occupying lesion)
  • Meningitis

For headaches due to the above reasons, yes, we do admit patients if we suspect something more sinister as the underlying cause. This should be the focus and highlight of the student seminar on headaches.

Continuing on the Bedside Teaching session, which was certainly very interesting.

It was long cases, so everyone had to give a summary of the patients they had seen that morning.

As usual, and somewhat strange, there are some students who did not clerk any patients at all. Don’t give excuses. Give solutions. So present a cases seen the day before or recently.

A lot of students also have trouble summarizing cases. It should be maximum three sentences. Anything more is not a summary. The first sentence should include age, gender, presenting complaint and duration, second sentences, relevant positive and negative physical findings, third sentence, the main working diagnosis and test results that confirm or refute it.

Most students struggle with not knowing which information to leave out in order to shorten the summary.

After everyone has summarised their cases, we choose two-three most interesting ones to see, and that week it was an elderly lady with altered bowel habit and weight loss, the second patient was a young lady with generalised oedema and joint pain.

The first patient was admitted electively to undergo procedures looking for underlying malignancy, as the first attempt to prep for colonoscopy as an outpatient failed due to hypoglycaemia (patient is also diabetic and has several other medical conditions including end stage renal disease requiring haemodialysis).

The second patient had anasarca which caused her to seek medical attention, apart from arthralgia in the shoulder and knees.

So it was a good opportunity to teach the students how to do a rheumatological exam, as the working diagnosis was SLE. The four out of eleven criteria were renal involvement (nephrotic syndrome, there was also 3-4 plus red cells, so also nephritic picture), musculoskeletal involvement (joint pain), haematological involvement (there was pancytopenia) and immunological involvement (I cant recall which of the antibodies was positive).

The other cases were the usual, COPD, ACS, heart failure etc, which we could have seen and learnt from too, but its always good to see the less common cases as well, which otherwise, the opportunity would be missed.

Some points to remember for the rheumatological exam:

  • Use a pillow to place the hands on at the start of the hand exam
  • inspect for swelling and deformity (be specific in the description, don’t use the word deform during the clinical exam if possible), palpate for heat and tenderness of all the small joints in the hands
  • After looking at the palm, ask the patient to flex the elbows and lift them up, look and palpate for nodules
  • Each joint examination should involved the following steps: Look, feel and move, aks the patient to move the joint first, noting any limitation in range of movement and reason, then move the joint to see if you can overcome the limitation (if any).

Non-pitting oedema is quite rare. More likely than not, the student did not palpate long enough for pitting to be appreciated. Especially in cases where the most likely cause of oedema is known, and is known to be pitting.