WHAT DOES THE DOCTOR THINK THIS MONTH?

Dr Ian gives an insight into the training given to new doctors

Tomorrow's doctors: One of my roles in retirement is to carry out some of the examinations of medical students, assessing their knowledge, not examining them physically! This all take place at The Norfolk and Norwich University Hospital Faculty of Medicine and, to be honest, I find the experience very stimulating and my knowledge levels benefit as I have to study hard beforehand to keep one step ahead of the students I am examining. We had a couple of sessions before Christmas, one of which was hilarious and well worth sharing with you.

The course in Norwich differs from many others. The students do not spend the first two years isolated from live patients studying Anatomy and Physiology. They are exposed to patients from Day1 of their training, meeting patients on the wards and in general practice. Each term, they will study a different subject, such as gastroenterology, neurology, the respiratory system, etc. Last term, they had been studying the cardiovascular system and my role in the examination was to supervise each student while they examined a real live patient's cardiovascular system, discussing their findings, the diagnosis and the possible treatments. We also were experimenting with a dummy which, at the touch of a button, could have any one of 30 problems with his heart for the student to discover.

I arrived at 8am to discover that Harvey, the dummy, was dead. It would not breathe and its heart would not beat. An engineer was summoned and the cabinet underneath was opened to reveal a vast array of tubes, pumps and electronics which were soon coaxed into life and, once again, Harvey could breathe and have a heartbeat, together with 30 assorted cardiological problems! Harvey is an American dummy, bolted motionless to his table, staring at the ceiling with the worst pair of thyroid pop-eyes I have ever seen. His hands cannot be moved for examination and he cannot be sat up to listen to the back of his chest so his use is somewhat limited. Whatever you do or say to him, he just lies there, staring pop-eyed at the ceiling.

In the morning session, I had live patients for the students to examine and, in the afternoon, I had Harvey as the "patient". Because Harvey is experimental, the students had the option of whether or not to take that part of the exam. If they did, the results of the live and dummy sessions would be amalgamated. Unfortunately for them, most students opted to avoid Harvey.

The morning session was a disaster. The students go through their entire course in groups of six or eight, encouraging each other, sharing study, testing each other and so on. It is a good idea and it works well until some student leads all the others down a wrong path. The cardiovascular examination carries 26 marks, 1 of which is awarded for talking to the patient and keeping them informed of what is happening. The students had placed vast overemphasis on this and the examination, for which the student is allowed only 10 minutes, would go something as follows:

"Good Morning, Mr Peabody. I am a second year medical student and I have been asked to examine your cardiovascular system today. Would that be all right?" Patient, being paid to lie on the bed with his shirt off, grunts in the affirmative. "Would it be OK to call you by your Christian name?" Patient, primed by me, tells them that this would not be acceptable. "I have to tell you that everything I find during the examination will be treated with total confidence but I would be grateful for your permission for me to share my findings with the examiner" Patient grunts OK and I wonder when the student will get on with the examination. "I need to look at your hands to check for splinter haemorrhages ......... would that be OK? Grunt Yes. "I need to take your pulse - do you have a problem with your shoulder?" Student then checks pulse and raises the arm to feel for a collapsing pulse. "I need to look at your neck to check what we call the JVP - this tells us whether you have heart failure or not" Patient, who knows more about his clinical condition than any of us, starts to look alarmed. This goes on and, before the student has even lifted their stethoscope, the time has run out. So, they get their one mark for talking to the patient but lose 12 by not finding the diagnosis and all that would follow from that.

The afternoon was different. Those students who did brave the dummy came in one at a time, "Good afternoon, Mr Harvey, I am a second year medical student........." and so it went on. However, with the best will in the world, the students could not talk to the unresponding, ceiling staring exophthalmic dummy as much as they talked to the human patient. As a result, they all completed the examination, got the diagnosis correct because Harvey had cardiac murmurs you could hear from the end of the bed, and managed to obtain between 22 and 24 marks out of 26. As Del Boy says, "He who dares wins".

As they were only second year students, they have time to sort themselves out and modern statistical methods ensure that nobody fails overall, so that's all right then!

Here is your homework for the month: When a doctor has his stethoscope in his ears, all conversation is completely muffled and it is impossible to hear what anyone is saying. Keep an eye on the medical soaps and see how many doctors carry on a conversation with ears full of stethoscope while listening to the patient's chest.

Best wishes to you all.

Ian G. Nisbet