General description of the problem
Mrs. Catherine Mitchell is a 23-year/old MS3.
As soon she began her clinical clerkships her evaluations were judged as
unsatisfactory. Her poor work was not clearly limited to internal
medicine, but given her weak performance in previous clerkships (Family
Medicine 6 wk., Pediatrics 6 wk., ob-gyn 6 wk.) her work in medicine was
observed very carefully. Based on all of her clerkships and particularly
her work in internal medicine, she was noted as deficient, placed on a
remedial program, and asked to repeat the third year. Despite the remedial
year her work has continued to be unsatisfactory so that she now has
actually repeated the entire 3rd year twice. Catherine is now almost half
through the internal medicine clerkship for the third time - an
unprecedented event.
Her attendings and residents described Catherine's problems in two
ways:
- lacking clinical reasoning skills and
- having weak interpersonal communication skills, particularly with
patients and frequently with staff. Her interpersonal problems are thought
to be due to her significant introversion and personal reserve. This leads
to a perception of her, which is that she has "an attitude." Despite
ongoing feedback over the past three years regarding her need to be more
forthright and to be more openly communicative, her behavior and "her
attitude" have hardly changed.
Catherine describes herself as having made progress in expressing her
thoughts and believes that her clinical reasoning is much improved,
although you -- as this month's chief attending -- greatly disagree.
Catherine thinks that her preceptors are unable to perceive her real
knowledge and skills. She believes her knowledge and skills are more than
sufficient and that she needs to move forward into the fourth year.
It has been urgently suggested that Catherine direct herself toward a
field other than medicine. As you might expect, she has refused to
consider this alternative, arguing that she is, and has been hard working.
She further asserts that she is motivated to be a good physician and that
she had good results in her Step I USMLE exam - which you have determined,
is true.
It is the consensus of your colleagues and the residents that even now, at
this point in the internal medicine clerkship, Catherine is still at the
level of a 2nd year student, although some progress has been observed
since the beginning 5 ½ weeks ago. But she still lacks adequate clinical
reasoning and interpersonal communication skills, and has extremely weak
insight and awareness about her problems.
Just yesterday you had the opportunity to observe her with a young woman
complaining of gastrointestinal pain, who it turns out had appendicitis.
The patient, Mrs. Holt, a 26 y/o Caucasian in otherwise good health, with
one child moved through the classic quartet of sudden onset periumbilical
pain, nausea and vomiting, RLQ pain and a low-grade fever. Interestingly
Catherine focused on the fact that the patient probably had diffuse
abdominal pain from gastroenteritis.
You now must to give Catherine feedback. You set up this meeting in
advance.
Standardized Student Script
1. General Behavior
You have to stay in a stiff, distrustful and defensive attitude. You lack
openness and gesture infrequently, have little expression, and you speak
in a monotonous voice. You look very withdrawn, you don't greet people,
and you do not answer well to any social solicitations.
Many people think you are clinically depressed. You are not. Often people
think you have "an attitude", whatever that means.
2. Answers to specific questions
- married for one year and have no children.
- if you are asked about your medical curriculum, refer to the general
description of the problem.
- you recognize that you are reserved, but you don't see it as a
disadvantage, as it is your natural way to be, and typical of the way
people behave in your family.
- regarding your present abilities, you find that, since you have
remediated, you feel more comfortable taking a history and performing a
physical examination. You think that your preceptors were poorly informed
regarding your knowledge and your skills, because they interpreted your
quietness as a lack of knowledge and skills, whereas you feel that you
possess them. You think that, now that you try to express things more
directly and more forcefully, your reasoning process and thinking are
better, and that this is no longer a problem.
- if it is proposed that you withdraw from medical school and think
about another field because of your failures and your overall clinical
record, you adamantly refuse to consider the idea, arguing that you have
been hard working and are motivated to be a good doctor, and that you have
had good results in Step 1 of the USMLE exam. Moreover, you feel you have
made a lot progress during the past 5 ½ weeks of this current internal
medicine clerkship.
3. Technical drawbacks in medicine
If you have to perform an encounter, you lack the following skills:
- Interpersonal skills: you greet patients coldly, or don't greet at
all.
- Interview skills: you program yourself for your own questions, which
are generally pertinent on a theoretical point of view. You are unable to
change your approach after the patient's answers, and have difficulty
determining anything from their attitudes or affects. During the
encounter, you repeat the same questions several times. You are unable to
assimilate the information included in the patient's answers.
- Examination skills: you don't take into account the patient's comfort,
uncovering him/her without consideration, examining him/her in an untidy
way.
- Compiling: you lack the ability to join together the various elements
of a clinical evaluation; you are very much able to make lots of lists and
even do a credible Ddx
- Linking the data to diagnostic hypotheses pertinent to the chief
complaint