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Problem Solving: a Story for Medical Educators Let’S Pretend You Are Back in Elementary School

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Problem Solving: a Story for Medical Educators Let’S Pretend You Are Back in Elementary School Perspectives Problem solving: A story for medical educators Let’spretendyouarebackinelementaryschool.IfIhadasked pulse,listenedtohislungsandheart,andfelthisabdomen.All you then what was inside your chest, what would you have waswell.Hedidhaveaheartmurmurthathadbeenpresent Bennett Lorber, M.D., D.Sc. (Hon) toldme?” foryears. “Thelungs,”saidonestudent. When I finished, I handed the stethoscope to my son. The author (AΩA, Temple University, 1980) is the Thomas “Listenagain,”Iurged.Againtheylistenedandthenwaited “Good,”Ireplied.“Andwhatelse?” “Here,Sam,”Isaid,“checkoutyourgreat-grandpa.”Heputthe M. Durant Professor of Medicine and professor of formynextinstruction. “Theheart,”cametheresponsefromtheotherstudent. stethoscope earpieces in his ears and placed the diaphragm Microbiology and Immunology, and chief of the Section “Try to imitate the sound you heard with your mouth,” I “Right,”Isaidwithabigsmile.“Now,ifyouheardanoise onmygrandfather’schest.Samclosedhiseyesandscrunched of Infectious Diseases at Temple University School of saidtoonestudent. and you couldn’t tell whether it was coming from the lungs uphisfacethewayhedidwhenengagedinseriousactivity. Medicine. Alookofpanicspreadoverhisfaceandhefroze. or the heart, could you think of a way to tell one from the Afterafewsecondshebegannoddinghisheadupanddown, “O.K.,”Isaid,directingmycommentstotheotherstudent. other?” and,afterafewmoremoments,heremovedthestethoscope n my more-than-30-year career as a medical school “Canyoumakethenoise?”Thebloodseemedtodrainfrom Panicreturnedtotheirfaces.AtthispointIfeltcertainthat fromhisearsandhandeditbacktome.“Whatdidyouhear, teacher, I have been repeatedly struck and dismayed by herface,andshesilentlyshookherhead. ifIaskedfortheirnames,theywouldn’tbeabletorespond.I Sam?”Iasked. the following observation. Students coming to medical I smiled, tried to soften my voice, and spoke with as turnedtothepatientwhoseemedtobegettingagooddeal He looked at me and answered, “His heart was making Ischool are generally bright, filled with intellectual curiosity, muchsupportandencouragementasIcouldmuster.“Don’t of amusement out of the interchange and said, “Could you anoiselikethis.”Hethenmadeashooshingsoundwithhis andinpossessionofmanyotherattributesimportanttopro- worry. Soon you’ll be able todothiswithnoef- hold your breath if these students listen again?” He nodded mouth,imitatingtheheartmurmurtoperfection.Iwasstar- fessional competence, including problem-solving skills. We fortatall.Iamsureof it. Try to forget affirmatively.Iaskedthestudentstolistenoncemorewhilehe tled,particularlyaftermyexperienceearlierintheday. thenputtheminclassrooms,lecturetothemhourafterhour, everything you’ve l e a r n e d i n heldhisbreath.Thelessonwasclear,andtheyseemedalittle “Howdidyouknowthatwashisheart?”Iinquired. overwhelm them with information, and change them from medical school foramoment. sheepish.Ispentafewmoremomentsdescribingthemurmur, “Well,atfirstIthoughtitmightbehisbreathing,”Samre- creative, energized, idealistic go-getters into passive learn- andthendismissedthem,totheirobviousrelief.Ididn’treally plied.“ButthenInoticedhischestwasgoinglikethis.”Atthis erslackingtheabilitytosolveevensimpleproblems.When thinkanythingabouttheseeventsuntilacoupleofhourslater pointheheldhishandsbeforehim,palmsparallelandfingers theylaterreachtheclinicalpartofthecurriculum,wemust thatevening. extended,andslowlymovedhishandsapartandthentogether rekindletheflameofcuriosityandhelpthemtofindanewthe MyfamilyandIwerejustfinishingoureveningmealwhen inatoandfromotion.“Itwasgoingtooslowtobehisbreath- problem-solvingbenttheyhadwhentheyarrived.Thefollow- thephonerang.Itwasmygrandmother.SheaskedifIcould ing,soIfiguredthenoisemustbefromhisheart.” ingtruestoryillustratesthispoint,andservesasareminder doherafavor.Itseemedthatmygrandfatherhadnoteaten “Sam,”Iasked,“howwouldyouliketoteachphysicaldiag- thatwewhoteachinmedicalschoolsneedtostrivetosupport hiseveningmealwithhisusualrelish,andshewasconcerned. nosistosecond-yearstudents?” andfostertheproblemsolvingabilityofthosewhoarrivein “Couldyoucomecheckoutyourgrandfather?” ourschools,andnotbreeditoutofthem. “Sure,”Isaid.“I’llbethereinalittlewhile.”Iturnedtomy Theauthor’saddressis: eight-year-oldson,Sam,andaskedifhewouldliketoaccom- SectionofInfectiousDiseases Onthefirstdayofthemedicalschoolcourseinphysi- panymeonalittlehousecalltoseehisgreat-grandparents. TempleUniversityHospital cal diagnosis, my task as preceptor was to perform a When we arrived at their apartment, we were greeted at BroadandOntarioStreets demonstrationhistoryandphysicalforthetwosecond- thedoorbymygrandfatherwholookedwellandwasclearly Philadelphia,PA19140 yearmedicalstudentsassignedtome.Ididthat,butI peevedthatmygrandmotherhadcalledme.Iaskedhimsome E-mail:[email protected] wanted the students to be excited, to remember their questions,watchedhimwalk,tookhisbloodpressure,felthis firstvisittothehospitalformorethantheirfirstoppor- tunitytoweartheirstarchedwhitecoatsandcarrytheir newstethoscopes.Itookthemtotheroomofamanwho hadsevereaorticstenosis,andwhowastohaveanaortic Perspectives valvereplacementthenextday.Hehadtheloudestmur- mur I had ever heard. I prearranged the visit, and the Sports physicals patientwasexpectingus.Athisbedside,Iintroduced Dean A. Blumberg, M.D. the students to him and asked them to place their stethoscopes on his chest and listen for a moment. The author (AΩA, Chicago Medical School, 1982) is as- ogyhadturneduppositive.Shewastoldthattherearemany Aftersometime,theyraisedtheirheadsandlookedat sociate professor of Pediatric Infectious Diseases at the reasonsforfalsepositiveHIVantibodyassays.Didshehave meexpectantly. University of California, Davis. cross-reacting antibodies? Perhaps she had an autoimmune Iturnedtothefirststudent.“Whatdidyouhear?” disorder?TheHIVserologywasrepeated,andwasagainposi- Iasked. hefirstquestionIaskedMrs.Carter,whohadbrought tive.Amonthlater,shecamedownwithafeverandacough, “Iheardhimbreathing,”shesaid. herthreechildrentothePediatricInfectiousDiseases ending up in the ICU with Pneumocystis pneumonia. HIV Iturnedtothesecondstudent.“Andwhatdidyou Clinic,was,“Doyouknowwhyyouareheretoday?” infectionwasconfirmed. hear?” TMrs.Cartersmiled,noddedyes,andsuggestedthatsheand Mrs.Carterstartedantiretroviraltherapy.Shetookaleave “I heard him breathing, too,” was his reply. Of Italkinanotherroomwhilethekidsgiggledandplayedwith of absence from her work at the beauty shop. Her husband course,thesoundfromthemurmurwassoloudthat thebloodpressurecuff. changed jobs so he could help with the children. Instead of nobreathsoundscouldbeheard.Ithoughtforamo- Threemonthsago,Mrs.Carterhadundergoneanevalu- beingoutoftownforweeksatatime,henowcommutedfour ment. ationasshewasupdatingherlifeinsurance.HerHIVserol- hoursaday.Andtherewasthisenlargedcervicalnode,sched- 32 The Pharos/Summer2005 The Pharos/Summer2005 33 Problem solving Illustration by the author uledforbiopsytomorrow.Couldbelymphoma,shewastold. fewyearsago,andtheywerewaitingforittogoaway.Indeed, Mrs.CarterthoughtshehadacquiredHIVfromherfirst itlookedlikemolluscumcontagiosum;itwentfromherelbow husband,whoshedescribedashavingriskfactors.Hercurrent toheraxilla.Itriedtochangemythoughts.Ipalpatedaxillary husbandofeightyearstestednegativeforHIV.Shewashorri- nodesbilaterally.Myheartsank.Ifeltherspleen.Iwascold fiedtothinkthatshemighthaveinfectedherchildren. andsweatyandlightheaded.Iwantedtobealone,tocurlup Mrs. Carter lived in a small rural town. Everyone knew intoaball. everyone else. She was not sure how others would react to IsmiledandlookedatGene,fiveyearsold.Hisgrinwent herdiagnosis,wasafraidherfamilywouldbeostracized.She fromeartoear.Hardlyeversick,startingkindergartensoon, hadn’tfiguredouthoworwhattotellthekidsyet.Theirvisit growinglikeaweed,developingwell.Hisexamwasnormal. toourUniversityclinictoday,severalhours’drivefromhome, TheperinatalHIVtransmissionrateisabout30percentin wasfor“specialsportsphysicals.” theabsenceofantiretroviraltherapy/prophylaxis.Oneoutof Wereturnedtotheexamroom.IstartedwithKeith,anine- thethreechildren’sHIVserologieswaspositive.Combination year-oldboy.Hehadnounusualorfrequentillnesses,wasdo- antiretroviral therapy can reduce the perinatal transmission ingwellinschool,growingwell.Hisexamwasnormal. ratetolessthantwopercent. Next,ItookalookatDonna,aseven-year-oldgirl.Shewas alsohealthy,Mrs.Cartersaid.Shehadhadlotsofearinfec- Theauthor’saddressis: tions as a kid, even requiring tubes, but plenty of children PediatricInfectiousDiseases hadthat.Thetubesfellout,andshestillhasadrainingear. UCDavisMedicalCenter Otherwiseshe’sfine,doingwellinschool,active.Herheight 2516StocktonBoulevard andweightwerefifthpercentileforage.Donnascratchedher Sacramento,California95817 arm,andIaskedaboutthebumpyexcoriatedrash.Mrs.Carter E-mail:[email protected] said Donna was diagnosed with “something contagiosum” a 34 The Pharos/Summer2005.
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