Learning to think backwards

As you may have gathered by now, I like lists.

Lists of symptoms,

Lists of clinical features

Lists of investigations.

 I like lists.

Even more than that, I like lists that someone else has written.  So I went out, and I bought a lot of revision books (or got them from the library, if I could fight off the medical students…) that contained lists.  I copied them out, I re-wrote them with my own comments, I amalgamated different  lists, I split them into different components…

(It was just an excuse to buy more notebooks, honestly.  I have a notebook thing, not a list thing.  Not the lists, just beautiful stationary.)

My lists looked something like this:

Clinical features of Trisomy 21:

  • Brushfield spots
  • Sandal toe
  • Hypotonia… etc, etc, etc

If I was being really organised, then I had them arranged by system.

Or head to toe.

Or with a diagram (not reproducing those – drawing is really not my strong point).

Or chronologically if the features changed with time…

And then I realised how pointless this all was.

We don’t walk into clinic or clerk a patient with a diagnosis, and then try and find all the features that go alongside it.  Patients don’t come with nice labels attached to them, neither in real life nor in the exam. (And yes, someone is going to point out that some patients have diagnoses, like Trisomy 21.  They do – but that’s not why they’ve come to hospital at 3am on a Friday morning.)

What I had to do was learn to think backwards.

I’d been starting with the diagnosis, and learning lists of features.  What I needed to do was look at a presentation, or a feature, and work backwards from there.

Rather than thinking that Trisomy 21 is associated with hypotonia in neonates, I needed to think about hypotonia in neonates and what caused it.

Maybe this seems obvious to you (in all honesty, it now seems completely obvious to me!) but it changed how I approached the exam.

I didn’t walk in thinking it was a disaster if I couldn’t remember all the features of Trisomy 21.  I did think I needed to understand how to check for tone in a 3 month old, and what the possible causes of low tone in that infant would be.

This is how we work in real life.  It’s how the exam works. (It also meant that I had to write new lists… which meant more notebooks… Ah well)

I’ll post some examples this week, once I get my notes back!

But I did that!

I came out of one station in my disaster exam feeling incredibly annoyed with the world because I’d done a good examination, and nobody paid any attention to my findings.

What I’d actually done was found clinical signs, but I hadn’t demonstrated any of them.  I knew they were there, but the examiner had no way of knowing that I’d seen them.  I came out feeling very aggrieved: I’d found the signs, identified the diagnosis… what more did they want??

And then, I remembered my experiences of examining the medical students a few years ago.  It was a summer afternoon; it was hot; I was tired and I’d left my registrar on my ward.  By the time the 3rd candidate came through, it was really hard to focus on exactly what they were doing.  Added to which it was a tiny room, and I couldn’t see half the examination.  I was completely dependent on the candidate’s approach to telling me what they were doing, and the reaction of parent and child to decide if I felt they were competent.

The clinicals were the same.  I hadn’t been clear in what I was doing, and as a result, the examiner had no way of knowing what I’d actually done.  Finding the answer/diagnosis at the end isn’t what the exam is really measuring: it’s about how you get the answer.  And you have to show your working; demonstrate your findings (not just identify them).

It’s like a driving test…

I failed my driving test first time around too, btw.  Just saying.  And I can’t drive: I have a licence, but please don’t get me behind the wheel of a car.  It’s so long since I drove that my photocard has expired, and I can no longer use it for ID. Not that I get asked anymore…

Digression aside, just like in the driving test, you have to demonstrate that you’re doing all the right things.  Especially if the examiner is crammed into a tiny corner, or isn’t feeling too good (or just really, really needs a coffee).

Everyone has their own way of doing this.  But if your practice group don’t think that you’ve demonstrated the clinical signs, then the chances are, the examiner won’t think that you have either.

Giving feedback

I found this article in the BMJ, which I thought was vaguely useful. http://www.bmj.com/highwire/section-pdf/9102/10/1

It’s also made me think a bit more about the practice sessions that I had in the run up to the disaster exam, and the the lovely exam.  Basically, the point of doing clinical practice sessions is to get feedback from other people! Otherwise, you might as well just be at work*.

So, here are my tips on giving/receiving feedback, preferably without turning into a speechless, gibbering wreck (ok, that might just be me…)


1. Do it.

This is practice for the exam.  It’s not an exercise in sycophancy.  It’s not much good if you’ve spent 7 minutes examining someone’s nervous system, only to be told that “that was fine”.

2. Constructive criticism

It’s supposed to be constructive: so instead of just saying how not to do something, suggest an alternative.

3. Be specific

(See the “that was fine” comment above: what was fine???)

Instead of saying that someone has a good rapport with their patient, think about how they’ve achieved that.  This is for two reasons: 1. it’s more useful for the person who’s just put themselves through the trauma of being watched by 6 of their colleagues, 2. it’s more useful for you to think about what you can learn from each other.  Which leads me onto my next point…

4. Use the group!

I (very personal view here) don’t think this should be an individual vs. the group scenario.  I think it’s really useful if an individual’s examination is used as a starting point by the group for further discussion and suggestions.  Time is limited: think about your own CVS examination; what do you do differently and why; discuss it.  Use the expertise that you have = each other.  Much more useful than a textbook; usually easier to understand; and definitely easier to find the right information quickly

…and receive

1. Listen to the feedback

It’s not personal.  It’s not about what someone thinks of you as a doctor (I have to keep telling myself this).  It’s not about your ability to lead a crash call, or make a diagnosis, or talk to your patient.  It’s about demonstrating that in the exam.

2. Decide what’s important

Listen to the feedback, but you don’t have to let it change your practice.  Everyone has a different style and way of doing things.  (One of the criticisms I had in the “good” exam was my technique for examining ankle reflexes: it was how I’d been shown on a clinical course by a neurologist.  You can’t please everyone all of the time 🙂 )

3. Don’t dismiss it: take some time

I find the whole thing of having someone else watch me really, really upsetting.  I hate it.  Generally, I am in no fit state to listen to anyone else once I’ve finished.  Go away.  Have a coffee/glass of wine/gin/box of chocolates.  Watch a silly film/Scrubs/Cardiac Arrest (if you’re feeling really grim).  Then think about what the feedback was again.  You might still think it was completely wrong.  Repeat the Scrubs/gin/chocolate again, and think about it again after a week.  It might make more sense.

Basically, the feedback is more important than the practice.  You work a 48 hour week; you practice all the time.  Thinking and reflecting about your practice (see, the management speak is taking over my blog!) is what makes the difference.

At some point, I will share my personal disasters from the exam/practice sessions.

The disaster exam was almost two years ago… I still can’t quite face thinking about it!

*you can revise/practice at work as well.  It’s just not as predictable – might write about that later on