An absurd article in CMAJ

[who_knows]

Hello. I stumbled upon this ludicrous article this morning. What do you think? http://cmajblogs.com/opqrst/

Briefly: two 2nd-year medical students from the U of T were tasked with taking history and doing a physical on a patient. The patient was rambling about irrelevant stuff and the students did not have the skills to stay on point and be efficient.  In the middle of the interview, the author (one of the students) decided, for some unknown reasons, that a hard structure of an interview should not direct her anymore. “For the rest of the interview, we talked about everything the patient wanted to.”
After the interview, the student’s preceptor told them, that they missed a major neurocognitive disorder in the history.

The conclusion was shocking to me. The author concluded that she should not rely on the usual hard structure of the interview but allow patients the freedom to be authentic (whatever that means).

WHAT?!  As I see it, the students failed miserably. They spent so much time with the patient and still did not take a full history. And yet, they deny the utility of a “hard-structured” interview. These templates and structures were specifically designed to avoid what they did, wasted time and accomplished little. You are exactly the person who must use it!

Just think about it, a 2nd-year medical student does a disastrous interview and says: I don't need templates anymore, I can do without them! What a perfect example of the lack of self-awareness!

They also assumed a role of a friend instead of being professional. In my opinion, they failed the patient. The patient needed a doctor to help her with her medical problems, she did not need a fake friend. 

I wonder, if a resident spends one hour with a patient, giggling and sharing anecdotes, and fails to get a full history, will this be a reason for termination?

Even 5-10 years ago, this would be an embarrassing story. Why is this admired now? Is this published ironically to warn students how not to interview patients? I doubt it.

I bet the author felt heroic by “challenging” the status quo of a hard-structured interview. But in reality, this article shows a failure and student’s distorted views. Her preceptor was probably facepalming after the interview, but could not criticize because it would be “mistreatment” and “harassment”.

[1D7]

My advice is to avoid reading these sort of inane medical student blogs. They're 50% resume padding, 50% excessive insertion of ego into writing.

But since you posted about it, I am in agreement. The egregious part is the complete lack of insight as to what learning point she should have taken away.

Quote

We were later informed by our preceptor that the patient had major neurocognitive disorder. We were surprised. Despite spending 40 minutes with her, we had no idea of her diagnosis. Reflecting back, I wonder if our inexperience prevented us from recognizing her cognitive deficits, or maybe it gifted us the open mind required to look past her medical condition.

...

It taught me to allow them the freedom to be authentic, instead of settling for a quick but fragmented image that is constructed by the hard structure of the medical interview.

 

[jb24]

I don't think it's that big of a deal. Early on in med school you have the time to spend with patients and patients often like to just have someone listen.

Life changes in residency. I got things to get done. Efficiency and service becomes more of an issue and I don't want to talk about irrelevant things as it slows me down from helping you, and treating others.

[who_knows]

3 hours ago, jb24 said:

Early on in med school you have the time to spend with patients

I do not have anything against that. Do it myself too.

What irritates me in this story is the lesson that she learned: she does not need any templates and structures, she can let patients ramble and that is all good. Neverminded a missed diagnosis and, I bet $100, a bunch of signs on the physical examination.

The author's narcissisms and the lack of self-awareness are off the charts! And also, is this really how U of T teaches its students??

[GH0ST]

My thoughts are below...

- G

18 hours ago, who_knows said:

Hello. I stumbled upon this ludicrous article this morning. What do you think? http://cmajblogs.com/opqrst/

...

After the interview, the student’s preceptor told them, that they missed a major neurocognitive disorder in the history. This already tells me they've failed, at least to their preceptor. That said, they are learning and failures happen a lot at this stage of training. 

The conclusion was shocking to me. The author concluded that she should not rely on the usual hard structure of the interview but allow patients the freedom to be authentic (whatever that means). Agree that the conclusion is shocking but that shock factor can be reconciled by the fact that this is written by a new clerkship student... and let's be fair their practical experience pales in comparison and their viewpoint has the same weakness, to put it kindly. 

 

WHAT?!  As I see it, the students failed miserably (maybe a bit harsh). They spent so much time with the patient and still did not take a full history. And yet, they deny the utility of a “hard-structured” interview. These templates and structures were specifically designed to avoid what they did, wasted time and accomplished little. You are exactly the person who must use it! Agreed. 

Just think about it, a 2nd-year medical student does a disastrous interview and says: I don't need templates anymore, I can do without them! What a perfect example of the lack of self-awareness! Agreed

They also assumed a role of a friend instead of being professional. In my opinion, they failed the patient. The patient needed a doctor to help her with her medical problems, she did not need a fake friend. Disagree... you can be friendlier with patients and still maintain objectivity. There's not enough evidence in this article to say that boundaries were crossed, and to be completely honest, I simply do not trust this narrator to give an accurate and objective recollection of events. This is, at best, a slanted viewpoint. 

I wonder, if a resident spends one hour with a patient, giggling and sharing anecdotes, and fails to get a full history, will this be a reason for termination? Ok I get you're upset but let's not explode shall we? A reason for termination? Come on... 

Even 5-10 years ago, this would be an embarrassing story. Why is this admired now? Is this published ironically to warn students how not to interview patients? I doubt it. This is published on a blog, and while I don't know how it got past any review process, I agree this article was poorly written, but it's a blog post ... I'm not expecting the Gettysburg address here. 

I bet the author felt heroic by “challenging” the status quo of a hard-structured interview. But in reality, this article shows a failure and student’s distorted views. Her preceptor was probably facepalming after the interview, but could not criticize because it would be “mistreatment” and “harassment”. I think the preceptor criticized fairly here though... I mean what else are they going to say other than they missed stuff and what they could do better? 

 

[HounsfieldUnit]

Note, this is a CMAJ blog, not an article within either of our CMAJ journals.  Also, see the footnote--this is a work of fiction.

[indefatigable]

These are both 2nd year medical students writing an apparent "inspired fiction" for a medical humanities Blog under guidance it seems from some staff.  The article seemingly juxtaposes their own interview goals with the patient's digressive stories resulting in a substandard assessment.  They do include some reflection, although from a medical point of view it may not be an article that would impress too many staff - not sure it would be one to go on the CV.  Still given their level of training and the context of the article I think there's some leeway- I'm sure during clerkship their medical assessment will improve.   

I think with more re-working it could have been a better article - as I recall, Osler stated "The good physician treats the disease; the great physician treats the patient who has the disease.” which I think does sum up the importance of patient-centred care which I think the authors are trying to get at.  

[ellorie]

I think it's a relevant but very tired and overdone theme - there wasn't much in it that felt particularly novel or interesting to me, just the usual points about balancing different aspects of patient centred care, learning to be a good listener, learning to find your own style within the physician role, how medical students can be better listeners sometimes because they have more time, the compromises we all make, etc.  But I think it's very normal and healthy physician development to ponder these questions at that level of training as you're learning to balance everything, I know I did.

I think I get a little bit tired of reading over and over about how doctors don't listen enough/care enough/spend enough time in the absence of acknowledgement of all of the systemic factors that set us up to practice how we do and why we have to make these kinds of compromises.  The reason we are all burning out is because of constantly being expected to shoulder responsibility for all of the systems level factors that cause medicine to be practiced in ways that patients generally dislike.

[shikimate]

They must've been trying hard to get their staff that extended consultation billing code haha.

Seriously though guys take it easy on 2nd years. Back in the days I am sure we all had naïve thoughts and feelings.

[Edict]

On 9/6/2022 at 5:55 PM, who_knows said:

Hello. I stumbled upon this ludicrous article this morning. What do you think? http://cmajblogs.com/opqrst/

Briefly: two 2nd-year medical students from the U of T were tasked with taking history and doing a physical on a patient. The patient was rambling about irrelevant stuff and the students did not have the skills to stay on point and be efficient.  In the middle of the interview, the author (one of the students) decided, for some unknown reasons, that a hard structure of an interview should not direct her anymore. “For the rest of the interview, we talked about everything the patient wanted to.”
After the interview, the student’s preceptor told them, that they missed a major neurocognitive disorder in the history.

The conclusion was shocking to me. The author concluded that she should not rely on the usual hard structure of the interview but allow patients the freedom to be authentic (whatever that means).

WHAT?!  As I see it, the students failed miserably. They spent so much time with the patient and still did not take a full history. And yet, they deny the utility of a “hard-structured” interview. These templates and structures were specifically designed to avoid what they did, wasted time and accomplished little. You are exactly the person who must use it!

Just think about it, a 2nd-year medical student does a disastrous interview and says: I don't need templates anymore, I can do without them! What a perfect example of the lack of self-awareness!

They also assumed a role of a friend instead of being professional. In my opinion, they failed the patient. The patient needed a doctor to help her with her medical problems, she did not need a fake friend. 

I wonder, if a resident spends one hour with a patient, giggling and sharing anecdotes, and fails to get a full history, will this be a reason for termination?

Even 5-10 years ago, this would be an embarrassing story. Why is this admired now? Is this published ironically to warn students how not to interview patients? I doubt it.

I bet the author felt heroic by “challenging” the status quo of a hard-structured interview. But in reality, this article shows a failure and student’s distorted views. Her preceptor was probably facepalming after the interview, but could not criticize because it would be “mistreatment” and “harassment”.

I agree this story is a bit embarrassing, but its not as bad as some others out there. The students like taking their time with patients, there are some specialties that take 1 hr long histories, maybe this is the specialty those students want to pursue.