Case study: what would you do? Recognising your limits as a medical student

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    Hello everyone,

    Earlier this year, with the Medical Schools Council, we produced new guidance for medical students outlining the standards expected of you.

    We’ve come up with a series of case studies to help you understand how the guidance applies in real life scenarios, and how your medical school should support you through any issues you may face.

    Here's an excerpt of the first scenario - what would you do in this situation?

    Ramesh is a fourth year graduate entry medical student doing his first clinical placement in a rural area. His placement is at a GP practice in a small town alongside Dr Alison MacCallan, who is the only GP in the town and the surrounding area. Ramesh sits in on Dr MacCallan’s consultations and also joins her for home visits and emergency out-of-hours GP work.

    During these consultations Ramesh met Ewan, one of the doctor’s regular patients. Ewan has a chronic condition and several co-morbidities, and takes a lot of long-term medication to manage his health.

    One day, Ewan contacted the surgery about some acute symptoms and Dr MacCallan decided she needed to do an urgent home visit. Ramesh accompanied her. During the visit, Dr MacCallan asked Ramesh to help her with a diagnostic procedure.

    Ramesh had observed this procedure in clinical placements, but had not done it himself. He thought he should know it as a fourth year student, and felt bad no one else was around to help. He was also worried Ewan would think he is not competent enough.

    What should Ramesh do next? Post your answers and we can compare to them to what the guidance says.

    Cheers,
    Tanita
    #1

    He should take the GP to one side and tell him clearly that he has never done this before and honestly express how competent he feels in helping?
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    I wonder what sort of procedure the GP is going to be doing on a home visit. Is he going to take bloods and ask the medical students to pass the test tubes to him?
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    (Original post by belis)
    I wonder what sort of procedure the GP is going to be doing on a home visit. Is he going to take bloods and ask the medical students to pass the test tubes to him?
    There is skill to inverting the blood bottles

    Ramesh is in his final year of medical school (Year 4 BM4). He should have been taught the clinical skill by the medical school already. By the impression given that he himself feels he is expected to know the procedure, he likely has learnt the procedure and therefore this is a confidence issue.

    If he has been trained in the clinical skill (and he should have been...) - and we already know he has definitely witnessed the procedure before - he does at some point need to actually help in the undertaking of the clinical skill. He is under supervision and only assisting. He should not assist past his competency.

    If he has not been trained in the clinical skill, he shouldn't be involved and should ask the medical school re: clinical skill training. Why did the medical school not put it in the curriculum? Why was the curriculum approved without this fundamental diagnostic procedure being taught? Or why did Ramesh miss repeated opportunities to gain this clinical skill training at medical school? Why did Ramesh not reflect on this procedure when he observed the procedure previously? If he has seen the procedure before and believes he should know it, why has he not self-reflected and come up with a remedial plan - rather than wait to final year of medical school. In fact, if not for the GP, he may have graduated without identifying his weakness in this area & patient safety put under risk.

    The GP shouldn't be doing a procedure that actually requires 2 people anyway. Dr MacCallan would usually do home visits by herself - so why do they suddenly need a 2nd person for a procedure if they manage to cope without a medical student the rest of the time? So she can do the procedure without Ramesh if needs be.

    May have got carried away....
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    If you have a student with you, you try to get them involved so they aren't bored.
    I note that the GP did not ask the student to perform the procedure but to assist. I don't know how to do any sort of operation. That does not mean that I cannot effectively hold retractor for 4 hours.

    If he tells the GP that he feels unsure they will be able to guide him more. For example tell him exactly in what order to pass the blood tubes rather than expecting him to know which should be filled in first. I agree about the remedial plan. He will be a FY1 soon so he needs to get to grips with procedures.
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    He should whistleblow his concerns and be subsequently left out to dry by his union, employers and regulating body.
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    (Original post by belis)
    I wonder what sort of procedure the GP is going to be doing on a home visit. Is he going to take bloods and ask the medical students to pass the test tubes to him?
    Open thoracotomy. Ewan was a stabbing victim and had arrested on arrival.
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    If Ramesh does it incompetently then he may cause harm to the patient (directly or indirectly via providing incorrect diagnostic information), so it seems like a no brainer.
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    (Original post by Anonymous)
    The GP shouldn't be doing a procedure that actually requires 2 people anyway. Dr MacCallan would usually do home visits by herself - so why do they suddenly need a 2nd person for a procedure if they manage to cope without a medical student the rest of the time? So she can do the procedure without Ramesh if needs be.
    I think they meant to say 'Ramesh was asked to help the GP by performing a diagnostic procedure'.

    (Original post by Etomidate)
    Open thoracotomy. Ewan was a stabbing victim and had arrested on arrival.
    Nah he'd have learned that in first year med school surely. All the GPs are too busy writing reflective pieces and filling out CQUINs for that ****.
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    Thanks for taking the time to reply - it's been really interesting for us to get your thoughts on this scenario.

    (Original post by Anonymous)
    He should take the GP to one side and tell him clearly that he has never done this before and honestly express how competent he feels in helping?
    Exactly - the key thing here is for Ramesh to be honest about his experience and competence. He should make it clear to Dr MacCallan that he has observed the procedure before, but not got involved in carrying it out.

    (Original post by Anonymous)
    By the impression given that he himself feels he is expected to know the procedure, he likely has learnt the procedure and therefore this is a confidence issue.
    Very true - and again a lack of confidence can be addressed by being open with Dr MacCallan. She might judge that it would be better to boost Ramesh's confidence by trying the procedure in a less pressurised environment first, e.g. in a demonstration back at the practice.

    (Original post by Anonymous)
    If he has not been trained in the clinical skill, he shouldn't be involved and should ask the medical school re: clinical skill training. Why did the medical school not put it in the curriculum? Why was the curriculum approved without this fundamental diagnostic procedure being taught? Or why did Ramesh miss repeated opportunities to gain this clinical skill training at medical school? Why did Ramesh not reflect on this procedure when he observed the procedure previously?
    In the scenario, we didn't specify that the procedure was something from the core clinical skills that Ramesh should have gained through his curriculum. It could be something more rare and that's why he's only seen it being performed before.

    I also spoke to one of our policy managers about this. She's heard from students who go on placements in rural areas that you often get the opportunity to witness things you might not have otherwise seen, just because you are one of the few healthcare professionals in the vicinity.

    (Original post by belis)
    If you have a student with you, you try to get them involved so they aren't bored.
    That is a good point. Dr MacCallan might be asking for Ramesh's help to give him a chance to expand his clinical skills. It might not be a procedure she thinks Ramesh should know how to assist with.

    (Original post by seaholme)
    If Ramesh does it incompetently then he may cause harm to the patient (directly or indirectly via providing incorrect diagnostic information), so it seems like a no brainer.
    Spot on - patient safety must come first. While this may be a good learning opportunity, Ramesh has to be honest about how confident he feels in his ability so, as belis mentioned, Dr MacCallan can better guide Ramesh and decide how to proceed.

    If you have any other thoughts or questions about this scenario, feel free to post them and I can run them past our policy experts on Monday.

    Cheers,
    Tanita
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    While I agree that patient safety must come first, I feel like a lack of confidence shouldn't be considered the be all and end all. You're NEVER going to feel very confident attempting a procedure you've never done before, but at some point you're just going to have to suck up and do it. There's a fine balance between providing optimum care, and giving opportunities for training. Sometimes that means that patients will have 'unnecessary' adverse outcomes, and that sucks but realistically there's no way around that

    It doesn't sound like the GP is requesting anything too crazy, so unless Ramesh feels completely out of his depth I think he should at least attempt it. Not to say that he shouldn't communicate his lack of confidence/experience, but more to emphasise that where it is possible you should give things a go. Have your 2 tries before asking a senior and all that
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    (Original post by Ghotay)
    While I agree that patient safety must come first, I feel like a lack of confidence shouldn't be considered the be all and end all. You're NEVER going to feel very confident attempting a procedure you've never done before, but at some point you're just going to have to suck up and do it. There's a fine balance between providing optimum care, and giving opportunities for training. Sometimes that means that patients will have 'unnecessary' adverse outcomes, and that sucks but realistically there's no way around that

    It doesn't sound like the GP is requesting anything too crazy, so unless Ramesh feels completely out of his depth I think he should at least attempt it. Not to say that he shouldn't communicate his lack of confidence/experience, but more to emphasise that where it is possible you should give things a go. Have your 2 tries before asking a senior and all that
    Excellent point and something I personally struggle with. Its not just patient safety - its also time management.

    For instance, I was on a resp rotation and they regularly did chest drains on the ward. This would have to be done in the presence of a reg, but they were happy for you to do it under their supervision. The problem was, it was a very busy ward, rarely out less than 2 hours late etc, and you'd regularly have 5 or 6 patients waiting to go home just waiting on you to write the discharge letter. I never found the strength to say 'I know you're waiting to go home but I have to take this training opportunity now you're going to have to sit there and wait a couple hours' and as a direct result I left that ward having never even watched a single chest drain. Compare that to the other FY1, who didn't have a problem making families wait - she did 16 and was confident enough to do it alone by the end. Whilst I had happier families (and nurses), she came out with much better experience than me and has more skills, is arguably more employable etc.

    All of the patient safety stuff applies of course, but sometimes you have to prioritise yourself over patients.
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    (Original post by nexttime)
    Excellent point and something I personally struggle with. Its not just patient safety - its also time management.
    I had this same issue in my first neonatal job - I HAD to learn procedures, of which there were many - umbilical lines, neonatal intubation, long lines… But the unit was so busy and service demands so great that I'd be forever pulled to write the transfer letter whilst the transport team were waiting and hovering over me, or plodding though 30 baby checks so that families could go home.

    The way that we organised it in the end, which I appreciate is not always possible in smaller firms, is that we kept a list / tally of all the SHOs, and the list of various neonatal procedures, and then kept a tally of who'd watched / assisted / attempted each procedure however many times. Then if an opportunity for a UVC came up in ITU, if the ITU SHO had already tried a couple and the postnatal ward person hadn't seen one yet, they would swap places for a bit. Requires cooperation and willingness to help out from everyone, and can be tricky if you've got someone on the team with a 'gunner' attitude, which we had. But overall it worked well.
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    (Original post by Etomidate)
    Open thoracotomy. Ewan was a stabbing victim and had arrested on arrival.
    Unfortunately I can't rep you again, but bravo sir. Bravo.
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    Hi everyone,

    Thanks for getting involved in this discussion. You can read the rest of the case study on Ramesh here.

    I also thought I'd let you know that earlier today I posted the 2nd scenario in this series here - in case you want to flex your decision-making muscles again!

    Last but not least, here's the link to our guidance for medical students: Achieving good medical practice.

    Let me know if you need anything else.

    Cheers,
    Tanita
 
 
 
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