6. Appendices

6.8. Novice to Expert Transition

Gathering information  

  • Learning to ‘take a history’ is a daunting task for some students  

  • Novices tend to be over controlling - they can lose sight of the patient as the managing a lot of information and are eager ‘tick all the boxes’ (especially in the systems review)  

  • Maybe they have seen the history more as an interrogation  

  • They can lose their focus on the patient agenda very quickly as they navigate history taking (the doctor's agenda) and think about the examinations they may need to do  

  • At the same time the conversation has to be purposeful – the questions they ask have to related to the patient’s problems – so they need to BEGIN TO THINK CLINICALLY  

 

Diagnostic hypotheses  

Everyone develops a diagnostic hypothesis in 30 secs – (even the old man on the top of the bus) Students should be encouraged to develop hypotheses. They will see their accuracy of their hypothesis increases with expertise 

 

Attending to the patient's agenda 

  • Not just a nice thing to do! 

  • The key to being trusted and appropriate 

  • Being trusted is key to being effective and safe – that is making shared management plan  

 

The generalist contribution is to consider: 

  1. Patient may have complex narratives/contexts  

  1. There may not be any ‘pathology’ or label possible or needed – there may be ‘illness without disease’  

  1. Physical symptoms may be explained by psychological processes (and occasionally the other way round e.g., anxiety in thyrotoxicosis)   

  1. Over-diagnosis and over-investigations can lead to HARMS  

  1. Things can present very early and in an ‘undifferentiated’ manner – uncertainty is common – but plans can still be made  

  1. There may be reasons for the consultation that are not always obvious (to the doctor or the patient)