How did "The Expert Clinician" take shape?

I first started putting "pen to paper" in 2015 when I was teaching students and trainees and actively involved in managing education and training. The project was born out of a concern that many of my colleagues and I had, which was that the perceived value of the consultation among many trainees had declined. As trainers and educators, we did our best to emphasise the importance and relevance of the consultation, but to little effect. More often than not, it seemed that trainees were "taking a history and examining the patient" to fill in a proforma rather than to try to help the patient. It was obvious to all that experienced clinicians no longer relied on the trainees' written medical records: they preferred to learn the information for themselves. I, therefore, wondered what was wrong with current training and what could be done to restore the value of the consultation among medical trainees.

 

I knew what I wanted to achieve but was uncertain how to bring about change. After all, who was I to say that there was a problem and change was needed? I knew I would not be able to do a clinical trial and was highly skeptical that journals would publish my opinion. Therefore, I felt a book would be needed.

 

Initially, I wrote about the physiology, anatomy, and pathology of the different organs and systems, describing how problems present and are managed. However, these initial thoughts simply replicated traditional practice and could not address the concerns. Nevertheless, through writing and reflecting, ideas began to crystalise about what was wrong with the standard approach and what to do about it.

 

Trainees are taught the basic sciences, pathology, and how the different problems may present and be managed. They are also taught reasoning skills so that they can apply this knowledge in clinical practice. The difficulty faced is that they have to reverse their learning. I therefore thought that I was approaching the problem the wrong way round: how can I help trainees use the symptoms and signs to determine the underlying abnormality? However, this created a new problem: how to explain the pathogenesis of the many different presenting symptoms. While thinking about how to write this, I realised that I did not need to explain each and every symptom because patients' problems fall into one or more of four problem categories: pain(s), deranged function, such as breathlessness, feeling ill, or an external abnormality, later to become a visible or palpable abnormality. I only needed to describe the principles for each. The emphasis should be on learning to understand and using a knowledge of medicine and the basic sciences to know what questions to ask or signs to look for and to understand and interpret the available information. These now became the main chapter headings for my first proper draft.

 

Over the next few years, I researched and wrote in detail about each topic, explaining the principles of how to clinically determine the underlying abnormality from the symptoms and signs. I used teaching opportunities to test these ideas out and to refine the details and method. However, as the chapters were completed, it became apparent that there was a lot of repetition and the focus was on formulating a diagnosis. On reflection, this seemed to be incomplete. Consultations are undertaken for many different reasons and not just to formulate a diagnosis. For example, some are undertaken to share information with the patient, such as the results of a test; some to deal with concerns from an aggrieved patient; and others to discuss management options. A different approach was needed for each consultation. As I thought more about this and critically thought about my own practice and watched others, I realised that we used the context of the consultation and first impressions to determine the aims and then ensured questions were asked and signs sought to ensure the outcome met the aims. In other words, meeting the aims of the consultation was more important than applying a proscribed history and examination format. While thinking about the many different aims, I realised there were essentially four core aims and these apply to all consultations to a greater or lesser extent. The core aims were to exchange information, to establish a working relationship, to formulate a diagnosis, and to plan management. Sometimes information exchange or establishing a working relationship were the principal aims, but more often they were enablers: they enabled the clinician to formulate a diagnosis and plan management. This led to the book being completely reorganised and re-written so that the methods available to meet each of the aims were brought together as four separate chapters.

 

I now had to decide how to describe the application of the method in clinical practice. As I thought more about the consultation and watched other clinicians, I realised that there were three distinct parts to the consultation: the start, the body, and the concluding conversation. I, therefore, wrote the first chapter in this section to describe how experienced clinicians use the start of the consultation to confirm information, such as the patient details and the context of the consultation, to help the patient relax, to assess the patient, and to determine the aims and decide on the initial focus of the consultation. The detail of how to learn and understand information about the Person, the Patient, and the Problem and from the Examination to ensure the outcome meets the aims is described in the next four chapters. The final chapter describes how to conclude the consultation so that the patient is left informed and happy, knowing that they are being helped. The layout of this section of the book now mirrored the format used by experienced clinicians during the consultation.

 

The final layout of the book only took shape after I retired in 2021 when I had the time to concentrate on writing the book and to ensure the style and format were consistent. It has been a long journey, with many revisions and rewrites, and at times I did not think it would ever get finished. I found it particularly difficult to think "outside the box": there was always a tendency to return to traditional practice and thinking. I also found it difficult to describe some concepts, such as "learning to understand, determining the location of the abnormality, and the type of problem," and struggled to find a way to emphasise the importance of focusing on meeting the aims, i.e., knowing why you are asking a question or performing an examination, rather than defaulting to routine.

 

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