0:28
That at first was just happening while she was walking or
going up some stairs but now it's been happening at rest.
It lasts about ten minutes resting and
relaxing seems to make it get better, or it did initially.
And, she describes it as going down into her left arm sometimes.
She has not, she's only taking stuff for blood pressure.
She's not tried any aspirin or anything else for it.
She did try taking Tum's once, which didn't work.
And, she's worried that this could be related to her heart,
because her dad had a heart attack when he was 60 and ended up having a bypass.
So her physical exam is all fine her vitals are all stable.
There's nothing that I can hear, abnormal in her heart.
So my concern is, that she may actually have unstable angina.
So what I'd like to do is get an EKG on her.
Check some cardiac enzymes.
If that's all okay I'd like to send her home and
have her follow up with her PCP in a couple of weeks.
>> Okay.
All right.
Can we, can we talk about this case?
I'd like to give you some feedback.
>> Sure. >> Great.
1:39
>> So, I think that she able to interpret what was going on okay.
But what about management?
>> Mm-hm. It's a little bit concerning.
because you know?
Being the ED doc here.
I'm like when I hear that some body is having chest pain.
And it's starting to happen at rest.
And it's starting accelerate.
That's unstable angina.
>> Right. >> So, she seemed to
interpret that the symptoms were unstable angina
that probably needs rapid testing like to the ED or quickly being tested.
So concerned about that.
>> Yes, so when you would give this resident feedback,
again you want to use the language so you can tell her reporting was excellent.
You can give examples.
You can give examples on why she interpreted it well?
And then management was the area, where she kind of had her downfall.
So you can use those words and
say, I'm concerned about your management of this patient.
And then you might ask her to take a step back and think about.
Thinking about the clinical listing in a pertinent positives and
negatives, are there other possible management plan she could put forward?
>> Mm-hm. >> Depending on what level of the learner
is, you might actually accept that they don't know exactly what to do for
management, but they can offer you three different types of
solutions depending on their differential diagnosis.
>> Mm-hm. >> If this is a third year resident,
that probably wouldn't be enough, for you.
>> Mm-hm. >> And you would say that she was
still failing at the management level.
>> Which is to say, I think we,
we set our expectations differently based on the level of the learner.
>> Yes.
>> But I guess one of the other things that,
that I sometimes find is the complexity of the patient.
Do you feel like that affects the level of the learner?
>> Sure it absolutely does.
So let's say maybe a second year resident might be able to.
Manage this very, very well.
But then if they saw a presentation that you see maybe once in
your career that you don't see very often.
They're probably going to go back to that re, reporter or interpreter level.
>> Mm-hm. >> And that's okay,
because they're not as familiar with that material.
>> Mm-hm. >> So that's actually very common,
that a learner can be at very different levels depending on the complexity
of the case.
>> Uh-huh. I sometimes find that you know,
a student can do really well if it's a single problem like an ankle sprain.
>> Mm-hm. >> But
as soon as it's like ankle pain plus redness plus swelling plus fever plus oh,
I've got some chest pain, they can't do it, manage all of those problems, or
understand all those problems together.
And that they drop in their level.
>> Yes, and I think we see that frequently.
And actually what you just explained to me,
that's actually great feedback to give the learner.
I think a lot of times we are thinking those things, but
we don't explicitly state that to the student, and
again by making it very nonjudgmental, using these simple vocabulary words,
you can state that in a way that still feels safe and reassuring for them.
>> That's good. I think that's helpful to
figure out how to get good feedback to them.
>> Mm-hm.
Sally Santen, M.D., Ph.D.Associate Professor - Emergency Medicine
