A course of survival for interns and last year medical students. Chapter two: How Can I Start Practicing Medicine?

ADVICE: These recommendations are the personal opinion of the author.  In the medical literature, there are many good textbooks with a practical information. Comments are welcome.

I am here, in front of the patient. What am I supposed to do?

The physician is a person qualified  to take care of a person with a health problem, to identify the cause through a process of reasoning with the help of diagnostic tools, in a safe, accurate and compassionate way.

The first step in this process has been always to obtain a correct information from the patient and the family.  This is an important and key moment in the clinical process, because there are multiple opportunities to achieve  a wrong conclusion under the influence of a cognitive bias that introduces a distortion in the final representation of the problem of the patient (see  a list of cognitive biases in Medicine here).

Practical Clinical Scenarios

A new medical intern may develop his or her work in three basic scenarios (not mentioning pediatrics and gynecology):

  1. Emergency Department (ED) area

This is a place with a lot of pressure for a doctor, because the decisions have to be implemented against time with uncertainty.

I would like to give some recommendations to approach the clinical practice in this difficult environment:

  • Even with the lack of  time that a doctor has in this area, you should establish a clinical judgment and a differential.
  • Try to select a key sign or symptom and think in terms of a syndrome/s.
  • In the ED I recommend two actions: follow the “worst-case scenario strategy” , in other words, you must think in serious processes in relation to the  anatomical area. A summary list is exposed below.
  • In the second place, you have to  think  in the most  probable  diseases  associated with the sign or symptom referred by the patient.  As a final step, stop for one minute and think “what else could it be”.
  • One practical aspect is to comment the case with colleagues even during lunchtime.
  • I recommend to elaborate a list of clinical situations that you can see in the ED, with a subtle presentation, but with a very bad prognosis , such as if they are not detected in time they can be deleterous to the patient These are called the “atypical presentation” of common cases, for instance a retrocecal appendicitis, a myocardial infarction in a woman, metabolic disorders, pulmonary embolus, sepsis in an old person. If you train your brain to think in the possibility of an encounter with one of these situations, maybe you can detect them on time.

2. Health Center: General Practitioner (GP)  Clinic

The main characteristic of diagnosis in General Medicine is to detect a serious or urgent case within a group of patients with similar symptoms, but with a non-serious process.  This is not an easy task, but I would like to recommend some strategies:

. Even in the crowded environment of a GP  clinic ,try to select the cases that you think have some clinical details that made them worthy to discuss later.

. If you don´t feel comfortable with your first decision, give  a second opportunity and set a second visit with the patient.

. Give advices to the patient about the alarm signs or symptoms to ask for a second visit or when to go to the hospital.

. If you ask for an appointment with a specialist, be sure that the time for the visit is appropriate.

. Break the rules: use the phone to reach the patient if you have an important message, without wait un5til a “formal” visit.

3. Working in the Hospital

The clinical practice in a hospital combines situations similar to the two previous scenarios. Here, you have time to study the clinical conditions of the patient, and your medical decisions can be implemented with  less uncertainty. There are some particular aspects of this environment that need to be considered:

. Inside a hospital, in a ward, there are multiple microsystems interacting among each other, and the possibility of an error increases significantly.

. The most important step working with patients in a ward is to set a differential diagnosis, something that you can always adapt when new clinical information is achieved.

.Another important recommendation, in my opinion, is to ask  the patients everyday about the normal function of the respiratory and digestive organs. Also, you need to have a discipline to examine every day the head, neck, thorax, abdomen and the legs. With this attitude you will discover important data that you could miss in a first examination.

.You need a strong mind: when you see that the clinical evolution or the data doesn´t fit with the diagnosis promoted for another colleague, you should stop and re-start again in your reasoning process.

Author:  Dr. Lorenzo Alonso. Medical Oncology. FORO  OSLER

Professor of Medicine. Málaga. Spain. 2021