Lesson I Learnt from Jefferson

It's about two weeks since I have come to Jefferson Medical College, Philadelphia, PA, USA. Everything is new to me here and I have had really good time, as well as bad time here. Lots of mistakes and just tons of things I need to bear in mind when in clinical examination.

I will just point out the serious mistakes I made, some ideas of thoughts and comments I would like to make.

1) History taking.
I need to be more focus on what I should be doing. Do not shoot like a shotgun, and hoping u hit something, instead ask specific and more case related questions. DO NOT SAY TOO OFFENSIVE THINGS. Say it in a rather indirect and polite way. Do not ask a patient some judgmental questions. "Are you obese?" (Duh, bad question. Whether you are overweight or underweight rely mostly on BMI. In other words, just don't ask this question) "Do you have sex with men?" (You are being judgmental about the patient being gay)

Try to speak in a layman level, besides not speaking medical jargon, as it's not just them altogether. If you suddenly utter some too medical jargons, explanation should be made to make them understand.

Review system. Try to do as appropriate. As told earlier, try to generate some questions pin-pointing yourself to the right track. Housing and working environment can be asked at social history (?). If you have the high likely suspicion that patient is not telling the truth, try to prompt them to saying them, ex. smoking. Patient may just say I quit smoking last year, then they tell you that he/she smoke a few cigarettes yesterday. Same goes for drinking. (I forgot how Dr. Majdan phrase it, but it's something like asking you how many you drink, instead of asking do you drink) ALWAYS DEFINE THE PATIENT'S DEFINITION OF BEING NORMAL. Always ask what is normal to patient, ex. bowel movements (no need to say a lot, you know what I mean. :-p)

ALWAYS REMEMBER TO SIT DOWN. Don't bring into your mind any idea of person seeing at eye-level is respect. They WANT you to really sit down and really care for them, and REALLY listen to what they say. Just imagine if you are standing up and taking history, you can just walk out of the room. But if you are sitting, you are showing to patient that you really a caring doctor. Thus, never stand up. Remember to sit down. Screw the eye-level looking respect thingy.

Obstructive Sleep Apnea (OSA), questions like snoring, sleeping well should be asked. "Does your wife tell you that you snores at night?" "Do you feel breathless during the night?" etc.

SEXUAL HISTORY
Just be sensitive. Maintain confidentiality, that's utmost important. Questions like "Do you have regular sexual partner?" "How do you avoid pregnancy?" "What do you mean by protection" In cases of underage sex, ask "Do you have boyfriend or girlfriend?" "Can you talk about sex?" (I remembered that sexually abused kids normally have a really "adult" knowledge on sex)"Have you been abused?" can be replaced by "Do you feel safe at home?"

RELIGION
"Are you raised in any particular faith?" "Do you still practice them?"

2) Clinical skills
In GI, always make a point of auscultate before you palpate the abdomen. IT'S A MUST! Don't be shocked in front of a lady patient or be stunned. Quote from Dr. Majdan: "Do not let the situation controls you. YOU CONTROL THE SITUATION." Just be yourself, be authoritarian somehow but not too obvious and too exaggerating.

A note about american way of doing clinical examination. First and foremost, is standing on patient's RIGHT side, not only it's for the exam, but all the equipments are on patient's right. So, why not? Why not take this as a note, always go for the equipments side to do your examination. The bed or couch (I not sure of myself) is a fantastic bed/couch which can be extended on the leg side (it won't be taken out, if you don't open them, patient's legs will be left dangling, which is bad. The bed can be tilted 45 degrees too, to do your CVS and Respi examination. Better to use the antiseptic solution than using the soap. Seriously. If vitals are not given, DO ALL THE VITALS, ex. BP, pulse etc. Basically just do everything.

Respi and CVS examination can overlap, especially the apex beat.

3) Conclusion
If you don't know, say you don't know. Do not push your responsibility to other people, ex. the doctor who will be doing the imaging will tell you what's wrong with you (something like that). You are solely responsible of the well-being of the patient upon coming to you. Just tell him/her what you want to do, let him understand the procedures, and to be considerate of patient's possibility of phobia of your words like surgery (maybe the guy have had surgery before and will be traumatized that you tell him/her that she need another surgery).


Oh yeah, most Americans will know the generic name of the drugs. Therefore, be familiarize with the terms so that you will know what drugs they are. They may or may not be as well knowledgeable as you do.

There are lots more to learn. I need time to compile them and put it on my blogspot. I hope that these are all the deterrents that will help me and anyone who is reading this blog. AMITABHA!!!