You are reading 1 of 2 free-access articles allowed for 30 days
When I was a student, I did my medical attachment in final year at the Mercy Hospital in Cork. There was a consultant there who was in his final few weeks before retirement. Every morning we would assemble in his office at 7:45am to be grilled mercilessly for 45 minutes on all aspects of clinical medicine by a man whose countenance and demeanour when you got something wrong, was akin to that of a hungry Jeremy Clarkson.
This man was a staunch evangelist of the merits of clinical examination. If you were smart, you could predict the order in which he would give the tutorials and put in some much-needed reading on the topic of the day before hand.
One day I had correctly calculated that it would be about the respiratory exam, so I resolved to know everything about it. I stood up to a 10-to-15 minute barrage about the various findings of consolidation, effusions and pneumothorax. I knew my vocal resonance from my tactile fremitus. My thenar wasting from my bleating aegophony. I was ready, or at least I thought I was, until I was bitterly admonished for not knowing some old trick where you put one coin on the chest wall and tap it with another to hear the sound generated. I have never seen this done before or since, and I still don’t know if it’s actually ‘a thing’. But I felt like a complete moron for not knowing it on the day.
However at this remove, I reflect with pride at the realisation that I had obviously tested him to the limit of his ‘learning by interrogation’ that day.
After the ordeal was over, you would gather up what sliver of remaining confidence you had off the floor and repair to the hospital canteen, where you’d need a few cups of tea. For others, a crafty smoke was required to settle the nerves for the rest of the day.
Looking back on it, I can’t believe how much we took it for granted. Much as we dreaded these sessions, we bloody well learned a tremendous amount from them that I still apply today.
This consultant was, at a time when most people in his position would’ve been winding down their services towards retirement, giving up four hours of his week to come in to work an hour early and teach us. In today’s context, this is extraordinary. Medical schools in the UK and Ireland have now, for the most part, outsourced the clinical teaching of our own students to nurses and paramedics.
Although many of these teachers from the allied professions are truly outstanding, I can’t help but feel this is an enormous dereliction of duty on our part to our neophyte colleagues. Back in the days when there were far fewer senior clinicians, they still found the time to teach us and made it a priority.
When I was unpacking my box in my first consultant office I took out a tuning fork, much to the merriment of my gastroenterology colleagues, who wondered how this would help me to discern the presence or absence of bowel sounds. The humble instrument had its day in the sun in early autumn, when a guy came in with diarrhoea and turned out to have cord compression.
When I was in the States, myself and most of the Irish docs I knew were frequently complimented on the quality of our physical examination. And to be fair, in my experience we can be more than a little bit smug about it while in exile.
This makes it all the more criminal that we show so little interest in ‘paying it forward’ and paints our generation in a very negative light, compared to the efforts of the man I described above. Similarly, in the assessment of students there is a seemingly unstoppable momentum behind the use of ersatz OSCE-type examinations, often on actors rather than real patients, and a movement away from the more traditional long and short cases. Here in the UK, a young doctor can pass his or her medical exams and membership without ever having been formally assessed on their ability to go into a room with a patient, take a history, perform an examination and come up with a list of reasonable things to do for them. I find this remarkable. Sort of like giving a fella a driving licence because he won a race on Formula 1 on the PlayStation.
A cynic would say it’s part of a creeping tide of deprofessionalisation. I hope not, but as long as I have two coins in my pocket to rub together, I’ll know at the very least I could use them to define consolidated lung.
What a pity it would be for such skills and knowledge to vanish.