Houston, we do not have a problem

Image courtesy Screenville.
Miriam to medical student: "There's no problem at a well-child check, so we ask them other questions, like how school is going."
Overhearing this exchange in clinic one afternoon flashed me back to my third year of medical school, when I awkwardly had a similar realization in the middle of a patient encounter. (There were no friendly residents at my Peds clinic to prepare me, and no handy-dandy SmartSets either.) So what do you do when there's no problem? At annual exam visits, we ask about health instead of sickness, and we run through a litany of developmental milestones and preventive healthcare measures like visits to the dentist and eye doctor instead of reviewing organ systems pertinent to a chief complaint.

I had a similar realization while "pre-tending" with Alex and Jeremy last week. After he finished fluently presenting a thorough and nuanced plan for a patient, I looked at Alex and asked, "Now what?" What I am supposed to do as a clinician-educator when the trainee has mastered the skills I expect of them? (Besides compliment them, of course!)

When Alex and I debriefed later, we brainstormed a list of teaching tips: Ask the learner how he explained to the patient that taking an SSRI BID increases the risk of serotonin syndrome (!). Have them list the common side effects of the medications they want to prescribe. Challenge them to come up with a Plan B if Plan A doesn't work. Elaborate on the clinical reasoning and/or communication skills you heard them using. Find out when they want the patient to followup. Discuss billing (thrilling, I know, but #realworldknowledge). You may come up with your own when you pre-tend as Clinic Supe.

Jeremy gets a double shout-out in this post, because he created Clinic Passports for the medical students. I have been stamping them at the end of clinic, after asking the student what they learned. Mostly they recite developmental milestones, but sometimes we have longer conversations about the theory and practice behind the Reach Out And Read books, or about teenagers and substance use.

Houston, we do (not) have a problem.

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