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I recently read several articles suggesting that interns order a
significantly higher number of tests before reaching a diagnosis
than experienced attending physicians. Many have written articles
on this subject and attribute this to inexperience and lack of
exposure, and ultimately suggest that this issue will resolve
itself as interns gain experience. This made me think: When will I
become capable of reaching a diagnosis without using an excessive
number of diagnostic exams? When are students or residents expected
to learn how to streamline? Will there be an enlightened moment
when we realize we have developed enough clinical confidence to
confirm a diagnosis while being efficient with hospital funding?
There are so many questions for which I do not have answers.
During my recent internal medicine core clerkship, I found one
teaching activity to be especially helpful in this matter. One of
the many educational activities we were scheduled to participate in
was biweekly teaching rounds with Dr. L, a knowledgeable attending
physician. He was a practicing internist in several area hospitals,
including our teaching facility. As a result, Dr. L had not
necessarily seen the patients we would present to him during these
teaching rounds. Having to present a patient to a "consulting"
physician meant that as a student, we had to gather all pertinent
patient information under the assumption that he would be
unfamiliar with minute details. This was a stark contrast to our
usual rounds, which were presented to the physician caring for our
patients who were thoroughly familiar with their history. This
exercise taught us what information was essential to present and in
what order the facts should be presented.
As each student presented their patient, the attending internist
interjected to teach us how to think critically along the way.
After Dr. L heard our brief patient introduction, he gave us time
to reflect on differential diagnoses and guided in systematic
thinking. What should our next step be? What is essential to test
versus what is superfluous? Using his extensive experience, he
taught us to focus on history and physical findings before
transitioning to costly testing. This was the first time in medical
school when I truly understood the importance of physical findings
in guiding my decisions about a patient. In our first year of
medical school, a problem-based learning group had attempted to
teach us this very same thing; however, it was not until I had a
live patient in front of me that I was truly able to comprehend the
As we continued presenting our patient, the astute physician
taught us several pathognomonic findings for diseases. He also
taught us a basic approach to order studies in the most
cost-effective and least-invasive way, all while gaining the
maximum amount of information. As the weeks wore on, it was obvious
that all the students were beginning to discuss patients like a
group of young physicians. We became eager to have the most
precise, concise presentation to guide our fellow medical students
to reach our target diagnosis. With Dr. L's guidance, we developed
the ability to present a patient to any physician in a logical
manner, which would allow them to have the same clinical suspicion
we did and help them reach a similar diagnosis.
My experience in my internal medicine core clerkship has been a
sort of breakthrough in my medical education. Being guided by
several attending physicians has finally led me to begin to feel as
though I have the potential of using all of my theoretical
knowledge, so I can apply it to a live patient. These teaching
rounds became an exercise in refining my ability to practice
medicine in the manner of an experienced physician. With further
education, I hope to emulate such model behaviors as I continue on
my path toward truly learning medicine.
Natasha Desjardins, MS-IV
Ross University School of Medicine
Class of 2013
March 2013 Issue of IMpact
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