Auchtermuchty, Fife
A few weeks after returning from the Christmas and New Year break in 1st year, it came time to mix up the Generalist Clinical Mentor (GCM) groups that I have written about previously here. We all said goodbye to our maiden GCM families and began an 18-week voyage with a new group that would take us to our final destination – the main 1st year exams in June.
I was allocated to Auchtermuchty with Dr Kenny Bell – made famous by a certain bowel cancer screening advert and a 1999 beer advert – Auchtermuchty I mean, not Kenny.
Our GCM days in Auchtermuchty followed a similar plan to those in Elie. We would typically have some patients to see that Kenny had organised to come in for us and sometimes some acute patients that had presented that day. We would have our learning outcomes that we would present to our peers, and these were delivered in a variety of ways. There were the standard Powerpoint presentations, some Kahoot quizzes using our phones, some whiteboard drawings and occasionally something a bit more creative like ranking steroid potencies using characters of different power levels from ‘The Lord of the Rings’. We would sometimes spend time with other clinical staff learning about triage, doing some bloods with the phlebotomist or sitting in with one of the other GPs or Advanced Nurse Practitioners.
Uncertainty
If you have read the piece I have written about some of the lessons that clinical exposure in Elie taught me, then you might not be surprised to know that those lessons only continued in Auchtermuchty. Kenny took me on a home visit to see a patient he had seen the previous day who he was a bit concerned about. He had suspected a chest infection and started them on antibiotics and wanted to check in on them and see how they were doing as he had felt a bit worried about them. This was the first time I had been on a home visit to see an unwell patient with a GP. Previously I had visited patients with peers to speak to them about specific conditions they had or to do some simple tests like blood pressure monitoring. He outlined the situation to me that the patient was unwell and off work but that all their vital signs were normal when he had seen them.
We entered the patient’s house and found him lying on his couch accompanied with a glass of juice and some tissues. He looked awful. Kenny asked them a variety of questions about how they were feeling compared to yesterday, how much fluid they were able to take and then began examining the patient and allowing me to do the same. We took the patient’s pulse, temperature, oxygen saturation, blood pressure and capillary refill time – all were normal. We also had a listen to their chest and could hear nothing abnormal. We came to the same conclusion that this patient was – by all measurements available – well. However, to look at, they looked really ill. The patient lacked colour, it seemed an effort for him to answer our questions and generally looked completely knocked flat by whatever was happening.
One of the great things about being a student is being exposed to situations like this, where you get to examine patients who are unwell in the hope of detecting abnormal symptoms – hearing crackles or a pleural rub when listening to the chest, feeling an irregular pulse in a patient’s wrist or finding a long capillary refill time – all things that you see on lecture slides, notes and virtually on a computer screen but are ultimately elusive until you see a patient with them yourself. This patient unfortunately disappointed me in this department, but I did not have the headache of deciding what to do with him – that task fell to Kenny. He discussed his concerns with the patient, making it clear to them that he could find nothing to worry about from his examination – but that he was worried about them anyway. He offered the patient a few options, like continuing with the current antibiotics, but advised the patient that if he could somehow find a way to get to a walk-in X-ray clinic locally that afternoon, he would be able to get an X-ray that might pick up something he had missed. This was pitched as a safety net, if the patient could manage he could get some extra peace of mind that nothing was wrong with him via an X-ray, or waiting and doing nothing for another day which might let things deteriorate without any further answers. The patient felt comforted by this offer and said he could get someone to take him up to the X-ray clinic later that afternoon. We left the patient’s house, I mulled over what I would have done (I didn’t know) while Kenny seemed concerned and frustrated by the uncertainty around the patient, but ultimately satisfied that he had done what he could.
I found out from Kenny the next week that the patient had their X-ray and was immediately admitted with bilateral pneumonia detected on the chest X-ray, receiving treatment and remaining there for a few days before making a recovery. I was totally impressed by how Kenny handled the situation. He was thorough with his exams and allowed me to help too, genuinely asking me for what I felt and heard in my examinations, I think in an effort to reassure his own findings. He was candid with the patient that he did not know what was happening, and offered them a few options for them to choose from, with a caveat of what he felt would be best. In short he was a doctor that cared about the patient in front of him, a doctor that was certain he was uncertain, and a doctor that was honest about that fact with the patient.
The Apprenticeship Model of Medicine
In addition to spending time with our GCMs, learning from them and trying to absorb their knowledge each week, since we are based in GP practices we quite often get to know the other staff quite well too. As I mentioned earlier, there are lots of jobs we can muck in with around the practice and the more we get involved, the more opportunities present themselves as people can gauge what we can do. One of the partners in Auchtermuchty – Dr Alex Collinson – would sometimes pop his head in and take some of us to see patients if there was someone he felt would be particularly useful for us to see. These were great opportunities because I have always found it useful to see how different doctors operate, how they speak to patients and how they efficiently ask patients the right questions in 5 minutes that would take me 25.
Dr Collinson took a student and I in to his consulting room and said a patient was coming in with a chest infection and he hoped we would be able to hear some clinical signs. We took up the obligatory medical student seating arrangement, slightly further away from the GP and patient seats situated at the desk, out of the way of the impending action about to unfold – ready to to answer the call of duty if asked to. Dr Collinson called the patient in and greeted them and their partner at his door with a handshake, directed them to the two seats next to his desk and then took his own seat. He quickly asked the patient a few questions, how they were feeling, were they coughing anything up and a bunch of other questions in a rapid-fire manner. He took a few quick measurements to check that the patient was not acutely unwell and then proceeded to ask the patient if he could listen to their chest. The patient duly obliged and Dr Collinson listened to their chest for about 10 seconds before asking if the patient would be happy to let us listen as well and report what we heard. They were more than happy for us to do so and we duly unholstered our stethoscopes and listened to the patient’s chest.
It is nervy when you are asked to report what you find, you know exactly the things you are meant to hear, having listened to audio recordings online, had simulated patients describe their symptoms and know the jargon for lung crackles, wheezes and pleural rubs. However, as soon as a doctor asks you to report what you find on the spot, all you can hear is the blood in your own ears, the movement of your own clammy fingers fumbling around the chestpiece of your stethoscope reverberating up the tubing and the pounding of the patient’s heart – which is of course reassuring – but not exactly ideal when you are trying to hear the breath sounds from the lungs of a patient. Taking longer than Dr Collinson’s 10 seconds I was satisfied that I had heard crackles in the base of one of the lungs and then duly retreated to let my peer examine the patient as well. We sat back down and Dr Collinson asked us to report what we both heard and we were actually in agreement – much to our mutual surprise. We awaited the verdict from Dr Collinson – hoping that there actually was something to be heard – and sure enough he turned to the patient and their partner and said, “You know, these guys are actually quite good, that’s what I heard as well! These guys are only first year and this is something I would expect for a 4th or 5th year to be getting right, not bad eh?”. What a relief.
Dr Collinson prescribed the patient some antibiotics, gave them some advice about what to do next and if things got worse, shook their hand and sent them on their way. After the patient left, he asked us,”What am I doing? How do I know that patient needs antibiotics?”.
This was met by an awkward pause and some perplexed looks between my peer and I. “Eh, listened to their chest?” we said.
Dr Collinson smiled, “Yes, but much more. When the patient arrives I shake their hand, I am feeling the temperature of their hands, I am checking their capillary refill when I let go of their hand, I am watching them walk from my door to their seat. Is it a struggle for them? I know this patient. They are usually fit and well. Today they were laboured in their speech and movement. I do my checks to make sure they are not in any immediate danger. I am looking at the body language of the patient – and their partner. Is the partner concerned? After all of this and more I am almost certainly sure that I am going to hear something in their chest and I have barely touched them – and only 30 seconds has passed. In this situation, having known this patient a long time, I know they are struggling with an infection almost immediately. They never come in to see me so I know they think it is serious. Listening to the chest is important, yes, but in this instance? Not as much. It is everything else you need to pick up on, and it makes the hard stuff a lot easier. Now off you two go, you guys did really well – seriously.”
This interaction was just one of many of the valuable interactions I have had with senior doctors in ScotGEM, but it is one of my favourite moments because of Dr Collinson’s desire to teach us and impart his advice in a constructive way that helped us. There is a growing viewpoint that being put on the spot by senior doctors as a form of teaching is old-fashioned, but in the same way with many things in life, it is more about the manner in which it is executed. I did not know Dr Collinson as well as I knew Kenny, but I felt from his manner and his attitude towards us that he had us there for us to learn, and not be examined, patronised or shamed if we didn’t know an answer or got something wrong, and so I was willing and prepared to try and to fail with reporting the lung sounds and be okay with whatever the outcome. The flip side is that these are also opportunities to reaffirm that you actually are learning. It was great to be genuinely praised in front of the patient and it seemed that we actually had impressed Dr Collinson which was a really rewarding feeling.
Looking to the Future
Learning in the sort of apprenticeship model that ScotGEM uses, being a student learning from experienced GCMs and doctors you come across in practices and placements, allows us to constantly pick up on the skills demonstrated by our seniors that are far more experienced than us. We get to see the results of all their training, their experiences, successes and failures, distilled down into the doctors they are today. As we are constantly trying to figure out what kind of doctor we want to be in the future, it is a privilege to have a pool of great role models to be inspired and influenced by. It makes sense, to me anyway, that the key to producing better doctors for patients in the future, is to surround them with passionate and proficient clinicians. I think, while early beginnings, ScotGEM is on the right track for that.
Note: Any posts on ScotGEM Stories involving patient stories are anonymised, with details and scenarios altered or combined with other experiences in order to protect patient confidentiality.