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“Residents and students want ‘old school'”

February 21, 2014

From db’s Medical Rants, a fascinating article about changes in teaching style in residencies.

Some residents requested “old school” teaching;

They defined old school in three parts: (1) talking to the patient, taking a careful history and explaining what we are doing in understandable terms; (2) relevant physical examination and demonstrate physical findings to the learners; (3) use that information plus laboratory data and imaging studies to develop a differential diagnosis, with a clear explication of the thought process.

Isn’t this just good medicine? When and why did this go out of style?

This approach seems super relevant, and possibly the cure for some of healthcare’s current problems: 1) patient-doctor relationships (patient understanding and satisfaction, compliance, outcomes); 2) clinical skills, low-tech, low-cost diagnostic skills, patient-doctor relations again; 3) Using clinical findings to form the foundation for a differential diagnosis seems like a smart move, because imaging and lab tests can pick up so many non-symptomatic abnormalities that don’t need to be addressed, which would help reduce unneeded procedures, visits to specialists, and costs.

Top medical schools are developing programs to teach bedside medicine. But why are they an anomaly? This bedside approach seems to be fundamental to medicine. How did doctors drift away from it? What could be identified and addressed in the current world of healthcare to prevent similar problems?


From the comments:

You ask “what about this description has become out of date?” Medicine has changed, and importantly the rules by which we practice it have all changed. It wasn’t always like this. Patients weren’t always so complicated, or if they were, we didn’t have the tests to know about it. There weren’t as many diseases (or they weren’t named). There weren’t as many medications or as many indications for medications. When you trained, I don’t think every patient on your service was on 10-20 medications, or had a problem list with 10-20 problems. And patients stayed in the hospital for a lot longer so there was less turnover. Your patients weren’t as sick with chronic medical problems, they didn’t all come from or need to go to SNFs. Sending them there wasn’t as complicated or inundated with paperwork. You didn’t have a “documentation specialist” on your team to sit down and review your notes, insisting that all diagnoses be specified as “acute vs chronic”, “systolic or diastolic”, “mild/moderate/severe”, and you can’t say “urosepsis” it has to be “sepsis due to urinary source,” and can you add “malnutrition” to their problem list because if we do it ups the complexity of the hospitalization. Your notes were just true SOAP notes that told you what happened for that day and what you were doing next. It took 2 minutes to scribble it into the chart instead of 20 minutes of wrangling with the computer. And of course, there were no duty hours–you just worked until the work was done.


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