How to Study From Clinical Cases
Using a clinical case to study may seem like an antiquated and sometimes unnecessary task, given all the notes, guides, textbooks, question banks and databases that the modern medical student has access to on any device, at any time. I mean, why ride a horse when you can drive a car? This attitude of expediency over experience, of course, neglects two important points: firstly, there is something especially memorable and profound about attaching a condition — and its presentation and management — to a real person and a real story. It’s not the kind of thing you’ll forget quite as easily as that frantic, last-minute cram you undertook the night before an exam. The quality of case-based learning cannot be replicated through the more convenient, but infinitely less involved, methods of remote study.
And, perhaps more importantly, we must remember that we’re in medical school to gather experience to guide us during our medical career. As a pioneer of our field, Sir William Osler once stated, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”
Identifying Cases for Studying
So, our first obstacle: what is a case that I am going to gain something meaningful from? The idealist would say that every case has something meaningful to teach you, and there is an element of truth to that. But just to play devil’s advocate, let’s be extra cynical here for a moment. Let us say we want to engage in learning that’s really going to give us a commanding knowledge of what’s important, and as a helpful by-product, give us an advantage in our assessments. This guide will walk you through picking that perfect case for your studies!
Considering Your Experience
To do this there are two things that need to be considered: your level of experience and, as a consequence of this, the curriculum at your level of study. It would be quite overwhelming and counterproductive to drop a student who is undertaking their first week of clinical placement into a room with a patient with Ribose-5-Phospate Isomerase Deficiency and hope they yield meaningful medical theory from it. A seasoned consultant, however, may find the experience useful despite the rarity of the condition.
In short, know thyself. If you are particularly apprehensive about the mystery of clinical cases, start by asking for a case that is a common presentation of a core condition (we’ll get into who to ask a little later: refer to “A Clinical Teacher”), and maybe even do some specific prior research on it, whether from a lecture, textbook or database (we’ll also delve into resources a little later too: refer to “The Reality and the Theory”).
Your medical school will have a curriculum, study guide or matrix for each year level. It will contain the conditions (or presentations) that are prioritised in assessment, and oftentimes even have a system whereby the most important topics are identified by a ranking system. For a beginner, this is a great tool to work off when attempting to navigate the myriad of potential clinical cases to study.
Once you’ve done a few of these, and you’re feeling lucky enough, you may begin to lean towards cases that are more complex, and potentially identifying cases based on interest. But how comfortable you are doing this, and how complex these cases may be, will hinge on having adequate guidance.
A Clinical Teacher
One really cannot overstate the importance of meaningful direction in this realm. A beginner will find it very difficult to identify exactly which cases to use as a springboard and what about said cases dictate the more intricate details of diagnosis and management. The take home messages can be lost in translation. This is why medicine famously maintains its apprenticeship-style training; the real-world application and reinforcement of theory cannot be executed in solitude. This makes finding a clinical teacher pivotal when starting to navigate the world of clinical medicine.
Allocated Clinical Teachers
So how does a medical student position themselves to be taken under the wing of one of these fantastical shepherds? Well, depending on how your medical school is run, the difficulty of this could vary. If you are lucky enough to have been allocated a clinical tutor, either for an entire semester or for a particular rotation, you will have a weekly allocated session of teaching based on real clinical cases.
The formality of this arrangement can lend itself to well-structured, frequent, and cumulative teaching that can serve as a solid foundation for a clinical career. It may land on you to find cases for such tutorials (refer to “Identifying Cases for Studying”), or, some tutors may take it upon themselves to identify the most applicable cases, leaving you with more time to read around, review and, most importantly, formulate pertinent questions (the art of asking productive questions is something that should be carefully considered: refer to “The Reality and The Theory”).
Incidental Clinical Teachers
If such an arrangement is not made available to you, or you hunger for clinical experience above and beyond what an allocated clinical tutor can offer, then you may be on the hunt for an incidental clinical teacher. The ward or team to which you are allocated is the best place to start looking. It’s often the case that the person immediately senior to you can offer the most relevant clinical knowledge. They undertook your stage of training most recently, and their memory of the required knowledge remains fresh and well structured. So, if you’re in third year, a senior medical student may have a lot to offer, while an intern or HMO might be the first port of call for a final year medical student.
Of course, while the relevance of knowledge offered here will be impressive and the similarity of experience makes them the most approachable, there is no replacement for experience when it comes to the more complex management side of things. While it can be more intimidating to attempt an interaction with a senior doctor with whom you are not familiar, their almost unending well of knowledge in their field makes the initial dread worthwhile. As long as you show genuine interest, understand the priorities of the team and make your intentions to learn clear, you can be confident that your team will be amenable to teaching and answering questions about the clinical case you are investigating.
The Patient Encounter
A seasoned general practitioner once told me that — with regards to attempting to reach a diagnosis — “the patient will tell you the answers.” This is very true once a certain threshold of clinical experience has been reached, but for our purposes, the patient encounter is best supplemented by the existing knowledge of the patient already collected by the treating team. Reviewing the patient’s notes regarding diagnosis, investigations and management before the patient encounter is pivotal in grounding yourself and directing your history taking and examination should the opportunities arise. Under the wing of a mentor, and as you accumulate experience, you can test yourself by leaning on this less to sharpen your diagnostic skills. Once you feel competent, you can also extend yourself by considering differential diagnoses, and how they can be ruled in and out with the relevant investigations.
History and Examination
The actual bones of the encounter should follow a structure you already know and practice for your OSCEs, in that the same thoroughly structured and direct approach works best. There is more time, however, allowing for more depth, so make the most of it. Having a working knowledge of what examination findings and systems reviews you should be focusing on from practice with colleagues will be an invaluable aid here.
You are ultimately looking for relationships between findings here, searching for a constellation of symptoms, so to speak. The skill we are sharpening here is pattern recognition: there are a few key signs that unite the traditional presentations of common conditions, so this is your chance to identify, associate and remember them.
Remember, getting used to normal is equally as important. Listening to plenty of “normal” heart sounds is a crucial part of being able to recognize an “abnormal” heart sound. Don’t be too eager to dismiss a patient with no signs!
The reviewing of investigations can vary greatly in difficulty, and while you may feel at ease interpreting the findings of an FBE to rule in or out certain types of anaemia, don’t be disheartened if more complex investigations aren’t easy to make sense of. This can be the case with more advanced types of imaging, i.e. ultrasounds and MRIs. This is where your clinical teacher may offer support while you build your experience and interpretation skills.
The Reality and the Theory
In an in-depth case study, thorough research and reading should follow your work on the ward. You should be aiming to understand what the diagnostic criteria and treatment algorithm are relevant to the case. But of course, the natural question follows: where should one read from? We are lucky enough to be paralysed by the freedom of almost infinite choices today. Databases, clinical guidelines, textbooks, lectures, and student written summaries are just some of the resources we can choose to tap into.
Guidelines and Databases
For an initial overview of the case at hand, guidelines and databases may be of the most help. Electronic Therapeutic Guidelines (eTG), UpToDate, British Medical Journal (BMJ): Best Practice and the various specialist guidelines (RCH Clinical Practice Guidelines, The Royal Women’s Hospital Clinical Guidelines, etc.) are the ones you are most likely to encounter. These differ in purpose and structure, and you should consider precisely what you need to know when selecting one of these resources.
The Electronic Therapeutic Guidelines are geared towards the “prescriber”, i.e. the general practitioner. They cover all conditions and presentations likely to be encountered in the primary healthcare setting. Therapeutic advice is categorised according to diagnosis, and its Australian origins lends it a particular relevance advantage to the Australian medical student.
UpToDate is a combined database of 25 specialties and makes the bold claim of being the only known clinical decision support resource that is associated with improved outcomes. This American database provides immense depth in diagnostic features and treatment approaches for all imaginable presentations and scenarios but presents it in difficult-to-digest slabs of information and may be a little overwhelming for the novice. It is, however, the go-to resource when very specific details are required.
The British Medical Journal’s Best Practice database is the most effectively structured of all the databases. It makes it the easiest to absorb, and provides you with distinct pages for the presentation, investigation, treatment and more for each condition. There is sometimes ambiguity regarding what is first line in the treatment algorithm, as it can inundate you with pharmacological choices, but rest assured its structure and breadth make it particularly useful where other resources are unwieldy.
Specialist Guidelines, like the Royal Children’s Hospital Clinical Practice Guidelines and The Royal Women’s Hospital Clinical Guidelines, provide specific information regarding their specialties. They are concise and generally make use of flow charts and criterion lists as these are the resources clinicians generally use in the field. They provide precise management advice in a stepwise manner and leave little room for misinterpretation.
A Note on Textbooks
Textbooks are sometimes slated by the new world medical student for the haste with which they approach obsolescence, as where the above databases are constantly updated as new research is published, a textbook will stagnate until its next edition is released. They can serve as an all-purpose solution to pre-clinical dilemmas and theory learning, but once in the field, a student should consider the time and locality of a text books publication, and, where there is uncertainty, call on other resources to fortify their learning.
Apparent Clashes Between the Reality and the Theory
Sometimes you may have lingering questions about why there is a discrepancy between the treatment advice in a certain guideline and what was done by the treating team, or a difference between the traditional constellation of symptoms for a certain condition and the actual presentation. In such cases, one should not fret, and remember the motivation behind studying from clinical cases is to develop experience and diagnostic skills, and even anomalous cases can help us achieve that.
But if questions regarding such discrepancies linger, it could be any one of a number of things; underlying risk factors and past conditions may have led the team down a different pathway in management to deal with the entire scenario in one fell swoop, a clinician’s experience may dictate that certain therapies may have issues of compliance and/or a severe side effect profile, expectant management might be preferred in less severe presentations, the list goes on. A clinical teacher can be of help in explaining away these inconsistencies. But, even when they can’t, remember that the valuable lessons of your clinical study remain, and your experience of variability between presentations and management will only be to your benefit in your medical career.
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