How to Apply Preclinical Training to Clinical Rotations

Graham Walker, MD

Disclosures

November 17, 2010

Question:

How can I remember preclinical teachings and apply them during rotations?

Response from Graham Walker, MD
Resident, Emergency Medicine, St. Luke's-Roosevelt Hospital Center, New York, NY

Preclinical training is called preclinical for a reason: it will form the knowledge base for your practice as a clinical student, resident, and attending. However, it's not always presented in a way that's clinically relevant. That is probably the reason for the move in some medical schools to do more case-based learning.

That being said, having a strong preclinical knowledge base will make your clinical life much easier: it often tells you the "why" of clinical practice. If you can remember why a practice is a certain way, you don't have to memorize X, Y, and Z: diagnosis and treatment will just be based on your background knowledge. Just a caveat: people don't always work the way we think their physiology is "supposed" to work, so this doesn't always work, but it often does.

Here are a few examples to illustrate my point from my daily practice as an emergency physician:

1) What are the frequent treatments for acute asthma exacerbations?

If I remember that asthma exacerbations are caused by bronchospasm, inflammatory changes, and smooth muscle constriction, I've already got the answers: inhaled beta-agonists, steroids, and magnesium.

2) A patient comes to the clinic with right upper-quadrant pain and vomiting. Liver function tests show markedly elevated aspartate aminotransferase/alanine transferase levels, and bedside ultrasound shows some gallstones.

Remembering the anatomy of the gallbladder and liver, I know that biliary colic or cholecystitis shouldn't irritate the liver and elevate the transaminases; therefore, I know this isn't cholecystitis, even though I see gallstones -- it's choledocholithiasis. I probably need to call the gastroenterology team to perform an endoscopy and endoscopic retrograde cholangiopancreatography before the surgeons take out her gallbladder.

3) A patient complains of a rash on his face. It looks like Staphylococcus aureus, but it could be something else.

I remember that most organisms on the skin are gram-positive, so I already have an idea of what antibiotics I need to consider -- those that cover gram-positive organisms.

Definitely don't throw those preclinical books out. In fact, when I see a patient with disease X, I'll pull out my old physiology and pathology books and skim through them to remind myself the key features of the disease.

How else can you apply preclinical knowledge and learn the "why?" Ask! At the right time, in the right setting, ask your resident and your attending why the patient is getting test X or getting treatment Z. It will help solidify the teaching in your head -- as well as in your resident's -- and will make your learning and experience tenfold more relevant and useful.

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