Tuesday, 5 May 2009

Teaching Point

One of the great advantages of my current life is the ability to see/think/learn and/or shamefully forget something new every day! For example today, in a CLL (Chronic Lymphocytic Leukemia - as in: cancer of blood) clinic, me and my fellow students were in consultant territory. What I really love about consultants is their unique ability to digress and get away with it. Even saying things like "you are a beast" randomly to a patient and then laughing manically at yourself don't really get you in trouble because, well, you are so good a doctor. So, as a species consultants may appear very... random and very often just plain crazy, but it's really only because they are in the position where they get away with having a personality. This is an example of how we interact:
Consultant: Never get old, never! It's no good.
Me: [pause, then shyly] I like this saying that it's not how old you are but how you are old.
Consultant: Haha, that's too deep, too deep for me!
Later in the day...
Consultant: So, you see, this [and at this stage I have no longer any idea what he is refferring to as "this"] is a little bit like the discovery of penicillin!
We: [plain looks, some nodding of heads]
Consultant: Now, can anyone tell me who discovered penicillin?
S.: Florey.
Consultant: Brilliant! Yes, dear Howard Walter! And what did he do?
We: [silence]
S.: He was Australian.
Me: Did he leave dirty petri dishes lying around?
Consultant: [to me, with disgust] Nooo! You are thinking of Flemming! His contribution was purely accidental but of course the Nobel prize was between them and Chain...
S.: I've seen a chamber pot they used for their experiments.
Consultant: Ah, yes! They were very interesting, very interesting indeed! Of course they had to have just the enamel on the inside and they were all made in Stoke. Because during the war, well you just couldn't get them anywhere... Remarkable, remarkable. [turning to S.] Tell me have you worked in a lab?
S.: No.
Consultant: Because, you see, the dishes we use now are all based on those chamberpots aren't they? And when I was a student they had a plaque in the hospital in Oxford, a wooden plaque on the ward that said: this is where penicillin was first administered. Remarkable thing. And cephalosporins! The work was also done in Oxford.
S.: I think they are now converting that wing of the Infirmary into some research extension...
At which point I'm looking at S. with a mixture of fear and bewilderment. The conversation then moves on to viruses, Occam's razor and then...
Consultant: You should all come and do haematology! It's brilliant! We actually get to cure patients. Some of them.
Other consultant: The ones that have the right cancer [chuckles slightly]
Consultant: [to us] What other specialty can you name that actually cures people?
S., future paediatrician, begins to open his mouth...
Consultant: Apart from paediatrics.
We: [silence]
Consultant: [chuckles] Come on?
Me: Musculoskeletal surgeon?
Consultant: Bah! They're just carpenters!
Me: GI [gastrointestinal] medicine?
Consultant: What there?
Me: Well, um, tumours? GI cancer?
Consultant: Peh! You lot always come up with these! They don't count! Come on!
Me: Respiratory medicine?
Consultant: What in respiratory medicine?
Me: Well, TB? [TB = tuberculosis]
Consultant: Oh! You are very close!
H.: Infection?
Consultant: Yes! Infection is the other major area of disease we can actually cure.
Consultant scribbles in notes.
Me: [shyly] ...but of course one could argue that you can never be cured of cancer, I mean we're always just waiting for it...
Consultant: [laughs a bit maniacally]
Me: ...because the "cure" is just taking your risk down to the level of the general population and it may still come back and...
Consultant: Yes, yes, but tell me this: if you're on a transatlantic flight and one of the engines in your plane breaks down, what are the chances that the other one will too?
We: [staring at him blankly]
Me: well, the same as the chances of the first one!
S.: No, because there is more strain on the remaining engine!
Me: Really? Don't they use just one engine at a time anyway?
We: Hmmm...
Consultant: [laughs - definately maniacally this time] But what if... the same mechanic repaired both engines?!
S.: Well...
Me: Well...
Consultant: [laughs some more]
Me: I think this analogy is too... complicated.
It is worth adding that during the course of the day we also learned that the Consultant's favourite comedian Eddie Izzard was on tour soon.
For comparison this is the interaction we had this morning with a doctor a level below a consultant (a Specialist Registrar). See if you can spot the difference!
SpR: I would like you to examine the patient's abdomen. Observe each other and look for areas of improvement in your technique.
We examine the patient one by one.
Patient's wife: We should be charging for this!
C.: How much would you charge?
Patient's wife: Hahaha, 10p?
SpR: [to C.] what did you feel?
C.: Hepato- and splenomegally?
SpR: What was the extent?
C.: liver about 5cm, spleen 10-15cm
SpR: Right, you'd need to use a ruler for a start. And 5cm from where?
Me: Costal margin
SpR: Subcostal margin. Subcostal margin where?
Me: Midclavicular line.
Spr: Yes. [turning to me] You might find it easier to palpate if you use the whole of your palm. And you may want to kneel next to the patient but that's optional. You just have to work on your own technique. [to all three of us] Now remember that feeling the liver subcostally does not neccessarily equal liver enlargement. It could be pushed down in lung disease - like emphysema, which this patient has. So ideally you do not report hepatomegally untill you measure the liver size with percussion. Now who can tell me 5 things to help you differentiate between kidney and spleen enlargement on palpation?

As you can see, the "matter-of-factness" (and some might say "relevance") factor in the two conversations is very different. But both are unique and colorful forms of didactic teaching I simply couldn't live without! Also: can't wait to be a consultant...


  1. So... Which of the two methods teaches you better?

  2. I best get taught by youtube and corporal punishment.
    And now for how it's really done!: