The early part of the student’s clinical career is always the most important. Every doctor knows that the initiation into clinical work is one of the most difficult intellectual and personal trials of the student’s career. The best help that the clinical teacher can give to his students during the early part of their career is to insist that they use their words both in speaking and writing carefully, exactly and without ambiguity. Only by this means can the student be helped to think clearly. As we speak and use our words so we become more wise or more foolish! We must be logical and exact in medicine, and the student must be taught the value of logic in clinical medicine. Note-taking must never be scamped, what is written about a case demands the same care as what is said about them. Careful history-taking is of paramount importance in the education of the student and the student’s responsibility must never be omitted in this matter—he must appreciate he is an integral part of the team and he is responsible for the day to day clinical record of his patient—he must get to know the patient and his disease intimately—otherwise he is not being educated in clinical medicine.
There can be no element in the student’s clinical training of greater or more permanent value to him than the careful and methodical recording of his cases. There is no better discipline in clear thinking and statement, and no better way of fixing in his memory the clinical pictures of disease. The good clinician takes a just pride in his notes, and there is no clearer index of an untidy mind than untidy notes. The student is, therefore, urged not to regard note-taking as drudgery. Moreover, the good clinical history is not a mere chronicle passively accepted from the patient. It is the joint effort of patient and examiner, in which the latter must often direct the patient’s attention, by judicious questions, to aspects of his story which, since he may not relate them to his illness, he will not mention. Experience goes to the taking of medical histories, and this is obtained only by vigilance and repetition.
“Medicine is to be learned only by experience; and it is not an inheritance; it cannot be revealed. Learn to see, learn to hear, learn to feel, learn to smell, and to know that by practice alone can you become expert.” (Sir William Osler.)
He must be drilled in the best methods of clinical examination but only in those methods which will be of permanent value to him in his career. The clinical teacher has a big responsibility in these early years. It should never be forgotten that to watch the teacher’s own methods is of greater help in the earlier stages of his clerking than to try and understand what he is talking about.
Medical education should mean more than the acquisition of scientific facts; it should train the mind in such a way that it may be ready to take the initiative, to adjust itself quickly to new situation, to apply to each case in a free and understanding way the principles, the routine, the discipline, which have become second nature. The years spent as a medical student are only an introduction to a study which must continue and grow throughout professional life.
The training of the student must be directed above all to the cultivation of careful clinical observation and on understanding and appreciation of signs and symptoms. In this way only can he acquire that vital yet intangible discipline we call clinical instinct or sense. Clinical instinct, born of observation, nourished by experience, and educated by deduction, must and always will remain one of the greatest and important gifts a medical man can have.
All clinical teachers know the bewilderment which the student emerging from the study of anatomy and physiology experience on entering the crowded out-patient department or the wards of a large general hospital. He enters a world where facts seem no longer the masters of the situation, a world in which an arbitrary selection of unverified and often fantastic details has become the accepted substitute for controlled observation and logical inference. The difficulty is usually greater in those who have served the longest apprenticeship to the biological sciences. They have been taught to tidy up reality by cutting it up into convenient bits and dealing with each bit separately. But now they have to take reality in uncouth lumps and to grapple with nature’s incredibly dirty and complex experiments. They cannot always measure, they cannot verify, they are thrown back upon their judgment and this has usually never been trained. They now have to acquire that nebulous “sense” and the gift of “clinical judgment.”
The application of rules in clinical medicine is a matter of trained judgment, but it necessarily rests upon careful observation and is therefore a logical process. The practical clinician has to learn to recognize states of disease by something less than a complete study and inventory of all its components; for he has to deal with urgent human needs. This is essentially a synthetic task which appears so different from the analytical method of the scientist.
The practice of the art of medicine makes the fullest demands upon both intelligence and character; it develops common sense and offers ample scope for research in clinical science. It provides those contacts with our fellow men which no other occupation offers in like measure.
Eric Baker Bates (ca.1960)