“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.”
The words of Sir William Osler, the acclaimed father of modern medicine, are still no less profound. They hark from an age when medicine still retained a sense of ceremony: an amphitheatre filled to the rafters, the clinicians poised in their white coats and ties, all eyes convergent on their quarry or rather the patient seated before them. Any memory of such scenes live out a vestigial existence in black&white photos or histrionic depictions recalling the rise of modern medicine. To think this is how the tradition of grand rounds proceeded in the not so distant past. Today grand rounds have a more tuitional flavour to them. The Socratic dialogue which reportedly took place has been superseded by the much less appetising PowerPoint presentation. It’s a weekly event marked in the calendar. For the ever-busy junior doctor it at least offers the prospect of a free lunch. I gest, they serve a social as well as an educational function.
On the other hand medical student grand rounds are purely a learning exercise. They are most importantly not a race to find and present the most ‘interesting’ case in the trust because this is usually interpretted as a vanishingly rare condition, which even your ejudicating consultant has never encountered in a lifetime of experience. It falls short of the primary aim: to learn about the patients who you will be seeing as a junior doctor and as the addage goes - common things are common. What will make your grand round interesting, is not the patient you choose but how you choose to present that patient.
Unfortunately, as fair a point Sir Osler makes, the old practice of patient participation in grand rounds has long since faded. You will have to call upon your thespian talents to retell the story to your fellow students. Of course not everyone’s a natural showman, however fortune favours the prepared and in my experience there are only a handful of things to worry about.
Structure. This is the back bone of your presentation. Obviously a solid introductory line about the patient with all the salient points goes without saying, it’s no different to presenting to the consultant on ward rounds or in the clinic. Always set the scene. If you clerked your patient on a hectic night oncall down in majors, then say so. It makes the case less one dimensional. The history is your chance to show off - to consider the presenting complaint expressed in the patient’s own words and to form a working differential, which you can encourage your colleagues to reel off at the outset. The quality of the history should guide your audience to the right diagnosis. Equip them with all the information they need, so not just the positive findings. Showing that you have ruled out important red flag symptoms or signs will illustrate good detective work on your part. However you wish to order the relevant past medical/family history, medications, social impact etc is up to you. It’s a subjective thing, you just have to play the game and cater to the consultant’s likes. You can only gage these after a few cases so do the honourable thing and let your colleagues present first.
Performance. Never read your slides in front of an audience. Their attention will rapidly wane (especially if they’re postprandial). The slides are an aide-memoire and to treat them as a script is to admit your presence adds nothing more to your presentation. Communicating with the audience requires you to present uncluttered slides, expanding on short headings and obliging your colleagues to listen for the little nuggets of clinical knowledge you have so generously lain in store.
Insight. When the consultant asks you the significance of an investigation, always know on what grounds it was ordered and the limitations of the results. The astute student will be aware of its diagnostic or prognostic potential.The same may be said of imaging. Perusing the radiologists report and using it to guide the audience through (anoynmised) CXRs, CTs, US etc is a feather in your cap. Literature reviews of your choosing constitute a mandatory part of the presentation. They are demonstrative of not only your wider reading but your initiative to find the relevant evidence base e.g. the research underlying the management plan of a condition or perhaps its future treatments.
Timing. Waffling is only detrimental to the performance. Rehearsing the presentation with a firm mate is a sure way to keep to time constraints.
Memorability, for the right reasons, relies on a concise and interactive presentation. A splash of imagination will not go unnoticed. The consultant marking you has seen it all before; surprising titbits of knowledge or amusing quirks in your presentation will hopefully appeal to their curious and humorous side. If anything it might break the tedium grand rounds are renown for. Oratory is a universal skill and is responsible for so much (undue) anxiety. The more timid can take comfort grand rounds aren’t quite the grand occasions they used to be.
Illustrator Edward Wong
This blog post is a reproduction of an article published in the Medical Student Newspaper, December 2013 issue.
Many may be familiar with aspergillosis as the infecting agent in acute cases where the patient is severely immunocompromised - but there is more to this fungus' repertoire. There are rare cases where the patient's immune system is overwhelmed by a large inhalation of spores e.g. after gardening, but these are insignificant in terms of total numbers effected.
The following are far more common:-
Aspergillus and other fungi are increasingly identified as the active agent in sinusitis - if you have cases that don't respond to antibiotics this is worth thinking about.
Chronic pulmonary aspergillosis (CPA & aspergilloma) is an infection of immunocompetent people, causing respiratory difficulty, coughing and haemoptysis. The UK NHS has a specialist centre for these patients In Manchester (National Aspergillosis Centre (NAC)). NAC has particular expertise and extensive facilities for the diagnosis of CPA, ABPA, SAFS and use of systemic antifungal drugs.
Allergic infection (Allergic Bronchopulmonary Aspergillosis - ABPA and chronic sinusitis) is thought to be heavily underdiagnosed and undertreated. ABPA is particularly common in Asthma, Cystic Fibrosis patients and those with bronchiectasis. There is estimated to be 25 000 cases in the UK alone.
Many (50%) of the most severe asthma cases are sensitive to fungi (SAFS) - in particular Aspergillus. These tend to be the most unstable cases that don't respond to antibiotics and several studies have been published that show giving an antifungal helps reduce the use of steroids for these patients.
Last but not least - Tuberculosis is on the rise in the UK and the rest of the world. It is estimated that 2% of cases progress to CPA and should be treated using an antifungal - this is usually not done until considerable time has passed and much damage has been done.
In total it is estimated that many millions of people across the world suffer from aspergillus - ABPA - 5 million, Tb - 400 000 per year and Asthma (SAFS - 1 - 4 million cases in EU & US). Sinusitis cases may number many tens of millions worldwide.
So - the next time you assume aspergillus infections and aspergillosis are rare and confined to those who are profoundly immunocompromised - think again! If you have a patient who has increasingly severe respiratory symptoms, doesn't respond to multiple courses of antibiotics then give aspergillus a thought. Browse around these articles for further information Aspergillus Website Treatment Section.
NB For a broader look at the prevalence of fungal diseases worldwide the new charity Leading International Fungal Education (LIFE) website is worth looking at.
A doctor is nothing without patients. But, unless they make themselves known in the community, and make themselves available, they are not going to be able to attract a lot of patients. One of the most important thing for many people is that doctors have convenient hours. This is no longer a nine to five world, and people often need to have appointments that will fit in with their schedules. One way that doctors can gain a good reputation in the community and increase their caseloads is to be accessible. This means offering things like early or late hours. When doctors increase their availability, it means fewer trips to the emergency room for patients when they need to see doctors after hours.
In addition to having better hours, there are other ways that doctors can attract new patients. These include:
Electronic Health Records
One of the things people hate the most about visiting a medical office is having to fill out a bunch of forms each time they visit. When you have electronic health records, they will only have to fill out one form. All of their information will be recorded and easy to access, so you will always have the information you need, when you need it. You can even use the system to send out prescriptions to pharmacies.
Better Telephone Hours
Many people don’t have time to call for a medical appointment when they are working, and prefer to call during their lunch hour or even after work. If your office closes for lunch, you are going to miss getting calls from patients who need to call at this time. Have a member of your staff on hand to answer the phones during the lunch hour. That way, patients will be able to get through, and you won’t be missing any calls. If there is no one to answer the phone, most people are likely to call another doctor, and will never call you back again. You may also want to consider extending your telephone hours, so patients can call after 5 pm.
You need to get your name out there, and one way to do it is to be up front with pricing. Often, patients will want to know what procedures cost before having them done. You can use Yempl.com to inform potential patients about your rates. They compare your information to that of other doctors in order to make the best decisions.
No matter how organized your office is, there are still bound to be patients waiting in the office for appointments. They are not getting anything done while they are just sitting around, but they can be more productive when they are able to connect to the Internet. You can provide free Wi-Fi services so your patients can use their mobile devices to connect to the Internet and check emails, shop, chat with friends, get work done, and more. With so many people carrying mobile devices these days, it makes little sense not to offer this service.
Create a Web Portal
When you have a web portal that is easy to use, patients can schedule appointments, reschedule appointments, access and print out forms before their visits, and more. You can use the portal to easily update things like contact, insurance, and personal information about your patients. This is a great way for patients to be able to make payments, get prescription refills, get results from tests, and get messages from doctors to avoid missed phone calls. Be sure to include a smartphone app so patients can contact you from anywhere.
Image Source: Seaside Medical Practice
Through out my 6 years studying, I made huge number of medical notes simplified from medical textbooks to one A3 paper in a well-organized manner that will let students to study easily and effortlessly ,,
You can imagine this by looking at my "COPD" in the attachment.
My COPD explanation video in "Ahmados Academy youtube channel" :
My facebook page :