By Mary Ruth Yoe
In October, the first-year students at the Pritzker School of Medicine file into "Clinical Skills 1A" in their newly acquired "professional dress"--pristine white lab coats with a gold-and-maroon phoenix emblazoned on the left breast pocket. In January, the white-coated crowd saunters back into a first-floor auditorium in the Basic Sciences Learning Center for "Clinical Skills 1B." Bearing testimony to individual laundry regimes or lack thereof, each coat has assumed a distinctive shade of pale.
Personal style within a professional standard is what "Clinical Skills" is all about. Team-taught by a quartet of physicians--led this year by Eugene Geppert, professor of clinical medicine--the four-year sequence provides what the med students' on-line handbook calls "a nice break from the basic sciences," a people-focused course with regular feedback and evaluation, no books, and no exams.
At the first class session, Geppert gives the students a "road map of where the clinical skills are taught at Pritzker." The first quarter, he explains, targets "the rudiments of learning how to talk to a patient." Concentrating on listening, students will get their chance to organize what they hear in the second quarter, when they begin to learn to write up a case. Year two focuses on how to conduct a physical: "At the end, you'll be ready to go out and examine people." Third-years learn how to draw blood, "how a hospital works, and how to function as a team member." And fourth-years hone the skills already learned, preparing for their residencies.
"Clinical Skills 1A" starts where the practitioner does, and so Geppert quickly introduces the fall quarter's first patient. "Mr. J." moves gingerly to the front of the room, carefully lowering himself into an upholstered chair opposite course co-director and associate professor of medicine Halina Brukner.
"As you listen to Dr. Brukner," Geppert instructs the class, "try to follow her road map, her strategy. Generally, we try to identify one problem as the chief complaint." In gathering information, he cautions, "we want our questions to be asked very, very tactfully. It's a good idea to rehearse them in your own mind to see if they have any possible negative undertones."
Microphones clipped to their lapels, Brukner and Mr. J. sit talk-show style. The lighting is subdued enough that Geppert can tap spellings and explanations of unfamiliar terms into a computer, which broadcasts his notes onto a large, overhead screen.
The lighting adds to the air of intimacy that develops as Brukner, who's meeting Mr. J. for the first time, elicits his history. (The patient volunteers who visit the "Clinical Skills" classroom have all been asked by their own U of C physicians to share their stories with the doctors-to-be.)
As the interview unfolds, students hear a mini-bio. Retired after 27 years as a domestic-violence counselor with the Chicago police, the 71-year-old Mr. J. went to college on a football scholarship, made an All-America team, and briefly played in the NFL before joining an all-black league. Separated from his wife, he has two grown sons. With a 40-year history of hypertension that kept him out of the Army, he traces a hip problem--bad enough to require a hip replacement in 1989--to an old football injury. He's had kidney-stone surgery and, most recently, cataracts removed successfully from both eyes. Now the hip is starting to hurt again.
The pain, he explains, interferes with his dancing. Mr. J. goes step dancing three nights a week. "I'm quite a hip-hopper," he laughs.
It's not his first or his last joke of the morning, and it's easy to believe Brukner when, 20 minutes into their conversation, she concludes, "It's been an absolute pleasure to speak with you," then invites the class to question him.
Has he been vaccinated against pneumonia as well as the flu? Does he see his sons regularly? Has he ever fallen since his hip surgery? Is there pain in the other hip? Is he scheduled for another hip replacement? Have his doctors treated him well?
Mr. J. leaves to a round of applause, and Morton M. Silverman, associate professor of psychiatry and director of the University's student-counseling center, takes over at the lectern, reviewing Brukner's interview technique.
First, he notes, the doctor regularly summarized what she'd heard the patient say. "That's a way to signal that we're listening, to be sure we have the story right, and to go through the list of topics associated with a symptom--it's a way of thinking out loud.
"Did you notice how Dr. Brukner asked Mr. J., `Can you tell us about your family?' rather than, `Do you have a wife?'" Silverman inquires. "Her question was open-ended, so that he could choose how he was going to answer."
Although the questions that Brukner asked about Mr. J.'s pain hit all the necessary targets--where it starts, where it goes; how often, how long, and how strong it is; and what makes it better--Silverman notes that "there was no formal order in which Dr. Brukner asked the questions--no memorized order that she was determined to use come hell or high water. Instead, she touched on everything in a way that was natural, that followed the lead of the patient.
"All of this information is essential, but the order is not. Dr. Brukner was patient with the patient. He had a story to tell, and she let him tell it in his own words. That builds rapport, a base of operations for the future."
A student wonders, "Would the physical examination be done before or after you take the medical history?"
"After," Silverman replies matter-of-factly. "It would be very upsetting if the first thing a patient heard was, `Get undressed, I'm going to examine you.' Taking the history first also lets you know where to focus during the course of the physical examination.
"For this particular patient," he asks, "where would you put your time? Checking his blood pressure, his hips, his eyes. You'd listen to his heart but--," Silverman breaks off to general laughter, "that comes next year."
The first session of winter quarter finds the students considerably more at home in their rumpled dress whites. Holly Humphrey, MD'83, associate professor of medicine and the fourth member of the "Clinical Skills" teaching team, announces cheerfully, "This quarter, we're going to focus on the medical write-up. At the moment, it may seem a little challenging, but it will come with time."
A photocopied outline provides the challenge: to create a "detailed and chronological account of the patient's current problem." The write-ups begin with a statement of the chief complaint and go on to describe the history of the present illness, the past medical history (including diet, sleep patterns, and drug use), family history, and psychosocial history (home situation, occupation, and sexual history). In real life, a case write-up also contains a "review of systems," or the actual physical examination, and a treatment plan.
The outline, Humphrey stresses, is "the skeleton" of a good report, and students should use it each week as they listen to interviews and prepare their own summaries. The medical residents who'll evaluate those write-ups will expect the skeleton to be clearly visible, appearing as headings within the write-up and helping them to check the students' work against a point system that measures clarity, organization, and the ability to recognize salient symptoms.
The lights dim, and Halina Brukner again meets a patient. This time, however, the scene unfolds on a video screen and the "patient" is an actor. "I'm glad we got all dressed up to watch a videotape," a student grumbles, scribbling notes.
Onscreen, "Mr. A.," the middle-aged manager of a shoe store, tells Brukner that he woke up that morning at 4 a.m. "with the most intense pain I've ever had in my life--like a sharp knife going into my right side, down into my stomach, and into my groin." On a scale of 1 to 10, Brukner asks, how bad is the pain?
"This would be a 12." In the six hours since, there have been four half-hour episodes, each as intense as the first. Did anything make the pain better? "Everything I did made it worse," Mr. A. says. Initially, he "tried to urinate...but I strained....There was blood in the urine. That scared me." Drops of blood, Brukner wonders, or a pink stain? "It was tinged with pink."
From her gentle questions, the students learn that Mr. A. smokes about a pack of cigarettes a day, though he's "tried to quit a half-dozen times." He doesn't drink, and he hasn't made any recent changes in his diet, except "I did have Mexican food the other day--but my wife had it, too, and she's not sick."
The last time he was hospitalized? Four years ago, for a broken leg. Medications? Just over-the-counter cold remedies, "but I haven't had a cold for a long time."
Interview over, the lights come back, and the students get 15 minutes to flesh out their reports. "This is just for practice," Humphrey reminds them. "You're not going to be handing it in." Instead, everyone gets a copy of Brukner's own report.
Under "Chief Complaint," the physician has described the patient as "a 42-year-old male who comes into the Walk-In Clinic complaining of episodic sharp pain of six hours' duration in his right side."
"Is is appropriate," someone asks, "to further ID the patient--as Caucasian or African American?"
"That's optional," Brukner says. "If it's not really relevant, I tend not to do it. In some situations, it's absolutely critical--a genetic illness found mostly in a certain ethnic group, for example."
"Why weren't you more specific about the location of the pain?" a student inquires. "There's a fine line," Brukner replies, "between setting the stage" and giving details that will reappear in the report: "You want to be as succinct as possible to set the frame."
"Is it okay to say, `The patient has pain" or should we say, `The patient reports pain' or `states that he has pain'?"
"I'd avoid that construction," Brukner answers. "People tend to assign a judgmental value to that statement." Her voice takes on a tinge of disbelief, "The patient says he has pain but...."
There are more questions than time, but the quarter is young. Each week, the Pritzker first-years will hear a live interview, ask questions of their own, and write up their notes. No books, no exams, white coats required.--M.R.Y.