Fortunately it is often effective to use the perplexing case as a teaching tool and sometimes it is possible to have the patient as a partner in the teaching and learning process. It also gives the opportunity to treat the learner as a colleague.
This approach can be used for either medical students or registrars. Supervisors often call in registrars to see a “classic” rash and this is great in increasing clinical exposure. Sometimes we are tempted to leap in with answers rather than leading the learner to work out the solution to a diagnostic or management dilemma. However, if there isn’t yet an “answer”, there can be an even more valuable learning exercise.
In the past I have asked those finishing a gastro term for suggestions on abnormal LFTs or a student with a previous life as a physio for advice on musculoskeletal problems, but this is still seeking answers. The patient I have in mind is where we are still puzzled and are trying to work out how to proceed. This brings in the opportunity to make clinical reasoning skills a bit more overt. This calls to mind when I had a patient with an itchy annular lesion that wasn’t quite “classic”(barely visible scale) and was getting worse. The registrar and I discussed the top-of-the-list differential diagnoses and the most useful investigation to do as the next step. It raised the issue of tinea incognito (which skin scraping confirmed).
Sometimes you see a patient’s name on your session list with a medical student booked in also. You have gone a certain distance in the diagnostic process but all is not clear. I might speak with the patient beforehand and ask them to be part of the learning process. I guess this is more than just signing the consent form before they enter the room. You might admit to the student that you still don’t have an answer so your “interrogation” of their history and examination is not an attempt to catch them out (or demonstrate your superior expertise). When the patient has a skin problem, you might structure it by leaving the student to take a “dermatology history and examination” and return to ask them to present their findings (with the patient to comment as need be). You can add anything they might have missed in the history (and discuss why it’s important) and also chat about how to describe things in “dermatological language”. You might share your own diagnostic process so far (and this can be informative for the patient). You may lead the student to the next diagnostic step that you perhaps already have in mind. With the patient gone you can put the learner on the spot a bit more with asking them to commit to (say) three differential diagnoses and ask them to identify some questions that remain – for self-directed learning. You can share online resources for instance if relevant (useful sites might be https://www.dermnetnz.org/ or http://www.pcds.org.uk/ )or share brief stories of other cases if relevant.
I thought I would use this approach a couple of weeks ago but then the patient went off on holidays so I had to adapt. The patient had already given me permission to take a photo and use it to discuss with colleagues or for teaching. In fact she was happy for this to happen since we didn’t have a diagnosis as yet. It was on a nicely unidentifiable part of the body. The evening before the session I put the picture into a power point and structured the slides historically with the questions that arose as the case unfolded. I put questions at appropriate points and printed out the half dozen slides. I had also sent a question around my colleagues at the practice asking their opinion and one of them said it reminded her of an article she had just read in AFP on skin biopsies which I printed off and gave to the student to read later https://www.racgp.org.au/afp/2017/may/skin-biopsy-in-the-diagnosis-of-inflammatory-skin-disease/
The session had my usual collection of older complicated patients with multiple problems, some with diabetes, a couple of teenagers, a person with an unexpected result to explain etc. We took five minutes between patients and I suggested we pretend the patient was there and we worked through the printed case thus far. We reasoned through it and I asked for suggestions.
This particular student was very knowledgeable and the diagnosis (revealed at biopsy later) was on their list of differentials. At the end of the session as they left they said “Oh, and thanks for the teaching session with the dermatology case. It was great.” And I thought I was teaching the whole afternoon! Amazing what a bit of structure does.