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Scenario #3 - Abby Absolutist
Preceptor: So you think the patient has poison ivy? How do you plan
to treat her?
Abby: I plan to give her a Medrol dose pack.
Preceptor: The way you describe this area it sounded small and was not
weeping. Have you considered using something topical?
Abby: When I did my dermatology rotation with Dr. DeMarco, he always
used oral steroids so that is what I plan.
Dealing with Abby
- Medical learners often feel discomfort with the "gray areas" of
medicine and tend to gravitate toward the words "always" and "never".
- Abby in the scenario above appears to learn medicine by copying an
attending in an apprenticeship-type fashion, without knowing or discovering
the background
and evidence for diagnostic and treatment decisions. It is doubtful that
Dr.
DeMarco always used oral steroids in treating all poison ivy. But it may
be that Abby never learned how Dr. DeMarco assessed poison ivy and
the treatment
guidelines on which she based her decisions. Abby is a person who might
be surprised to find that 14 to 25 elderly people with hypertension
must be treated
in order to prevent one cardiovascular event. Very few things in medicine
are black or white, we deal in the realm of probabilities.
- Rather than giving Abby
a fish, she needs to be taught how to fish. Residents need to learn
general rules that can guide them once they have finished their
residency program. Graduates of a medical school whose education paradigm
was to teach medical learners how to solve problems (problem-based
learning) found
that their graduates were more up-to-date with the latest recommendations
for hypertension treatment than a cohort of graduates from a traditional
medical
school.1
- When a resident needs information, rather than giving them step-by-step
instructions, point them towards a reference in which you know good material
may lie. Educational "prescriptions" are
often used by medical educators to give a learner an assignment, such as "Perform
Medline search to find absolute risk increase of hyperoxalatemia associated
with coronary artery disease."
- At times, a medical learner may not even
have the background knowledge in which to make a decision in this case.
A mini-lecture of no more than one
to two
minutes may be a targeted helpful intervention. For instance, explain
the general categorization of acute renal failure and a couple of lab
tests
useful in making
the distinctions, providing the medical learner the informational piece
they need in order to make a decision.
1 Shinn, JH,
Haynes, RB, and Johnston, ME. The Effect of Problem-Based, Self-Directed
Undergraduate Education on Life-Long Learning. CMAJ, 1993; 148:969-976.
    
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