The Long Case

It's only been a couple of weeks into my first senior year of medical school and feeling sleep deprived, stressed and concerned on a constant basis has become almost second nature. When I start something new, I always start off by giving it my best, my full attention. As time slowly etches my gloss of perfection to the core of reality, I realise that I have committed myself to so many things that I thought required perfection. Some demand it; others are flexible. There is always some element, some degree of expectation of it. Lingers as it does, at the back of my head more often than not and I realise that it's mostly always right in front of my face and yet, always beyond me.

Medical students are known to be good academically and their examination technique is well-established given that we all have sat more examinations than most professions require. However, there is one exam that is notorious for intimidating medical students and that exam is called the Long Case. You are given one hour with a patient to do whatever you like: you can spend it on taking a history (obtaining their reason for presenting to you) and or spend it on examining them. At the end of the hour, you are given twenty minutes to compile your thoughts and following that comes presenting your findings to two specialists from a different area health service.

So it doesn't so much test knowledge, it tests cognition. Did you compile a hypothesis based on what you heard, saw and felt? Did it all make sense? Is it a consistent, structured presentation? Are you competent in communication?


The good thing for me was that I was interested in presenting long cases and I had heard about it last year anyway. In fact, I presented a few long cases to my patient-doctor tutor last year. ML was one of the dozen hand-picked patient-doctor tutors for the second year students at our hospital. Apart from volunteering his knowledge and expertise to students, he was an Infectious Diseases specialist as well as being a phenomenal General Physician. He is a Fellow of the Royal Australasian College of Physicians and the Royal College of Pathologists Australia. He has done a Masters in Clinical Epidemiology. He is an Examiner for the Royal Australasian College of Physicians in the specialties of Cardiology, Neurology, Endocrinology, Infectious Diseases and Nephrology; as far as I know. His endless knowledge, respect of the patient and infinite persistence to help really inspired me. I wanted to show him that not all of his efforts were in vain.

So came third year and it is recommended that we practice performing long cases at least once a week. I was given a patient by the Geriatric registrar and I was ready. So I took my hour to speak to the patient, examine him and come to a conclusion. Instead of the twenty minutes allowed to compile thoughts, I had until the next day because this was just practice. Unfortunately the Geriatrics registrar had his hands tied with new consultations he had to make in the Emergency Department and asked me to postpone my presentation. I didn't want to forget the case and wanted to present it to someone. I paged ML and he was available. Meet me in my office in twenty minutes. I was ecstatic, not because I had something to do, but because I felt I had made a good case to present to this physician; a person I felt I owed something to for all his time, dedication and sacrifice to the patient first, to education second.

When I'm waiting for someone, the beginning feels incredibly slow and then, after a certain point, time just flights right past. I end up finding myself in the other person's presence wondering how long I've been sitting there. ML was in his office, desk full of papers and two textbooks in front of him. Guilt crept in as I realised I was distracting him. Okay, when you're ready.


In my limited experience, the first thing doctors do when you're presenting a case is close their eyes - envision the patient in front of them as if they had seen them first hand. Interrupting medical students during practice was also common, so that the examiners could give feedback in the mock exams. It was good because they were much more comprehensive with their feedback but the downside was, it felt like the presentation cumulatively dropped in quality as more feedback returned. Unfortunately, most feedback is negative. You are not interrupted when you're doing well. Some doctors do provide positive feedback and you have that warm feeling of success, that you made a difference. Eventually you realise that those doctors who give positive feedback to you are giving the same to everyone, making them optimistic and supportive people, which is great - but the gravity of their words drop in reliability. Well, at least that's how I feel. It could mean that I'm satisfying the requirements of a medical student, or it could mean that I have fulfilled his or her expectations; a rarity indeed.

                                      

After an hour with ML, I was almost in tears.

My confidence waned, my bubble of inspiration perforated with the physician's reality - the sting that is the Physician's touch: you've got a long way to go.


You walk out with a smile of embarrassment and they probably return a smile of pity. Composing myself, I left his office after I thanked him.

Keep calm man.. Just keep calm.


"You're a fucking idiot - how could you think that way? You know better! Fucking re-write the presentation and deliver it to the Geriatrics registrar in a palatable fashion. Seriously... You're using statistical probability to determine differential diagnosis. So what the hell was the purpose of taking a history and performing those examinations?"

Just pick up the pieces, put yourself together and move on to that next day. There's no room for grief.