Recently, I was fortunate to participate in an event by the Xiehe Ba public account and received the book From Books to Clinical. After receiving the book, I quickly read one chapter without even stopping to eat, then squeezed out all my free time this afternoon to finish the first half. I can confirm that this book fully met my expectations.
This is a book written for students who have just entered clinical practice. It combines theoretical knowledge with practical work, using case after case for explanation, making it a refreshing read. The novel dialogue format allows you to fully immerse yourself as the student in the book, as if personally experiencing one clinical diagnosis and treatment process after another.
As a creator of the “Standardized Residency Training Area,” I have always believed that residency training is an important learning stage. Indeed, it has many problems, but since we are here, we accept it. If we can’t change the larger environment, we can only change ourselves by changing our perspective and methods.
I have already recorded two episodes about residency training. The preface of this book (see below) confirms the views shared by me and my guests. I hope students will reconsider the significance of residency training for themselves after reading this book and make their own choices again.
Excerpts for trial reading at the end of the text
I look forward to teachers at Beijing University of Chinese Medicine writing a similar book, or has someone already written one that I don’t know about? Please recommend.
- A recommendation from @summer — https://forum.beginner.center/t/topic/789
Preface of the Book
When we leave school and enter the hospital to start our standardized residency training (hereinafter referred to as residency training), you might ponder this question—what is the significance of residency training?
We have already learned a large amount of medical knowledge in the classroom, especially diagnostic studies, which cover almost all clinical disciplines; we have done many diagnostic exercises, experienced various exams big and small, and read countless clinical cases. These exercises have guided us through seeing one patient after another. During the answering process, we have already established basic diagnostic thinking and become familiar with many diseases.
Since doing exercises is so effective, why do we still need to go to different departments during residency training to encounter so many different patients? Frankly, when we graduate, we will choose a specific research direction that largely determines our future professional work. Residency training has us do things somewhat unrelated to our majors; could this be a waste of time?
Is all this really valuable?
The answer to this question is very clear—it is valuable, and highly so! No matter how many cases we see in exercises, they cannot replace clinical practice.
Why is this?
Let’s put it this way: although these exercises come from real clinical cases, the amount of information they provide is very limited, and the information is highly selected. In other words, all information useful for reaching the answer is retained, and this useful information can be smoothly transformed into the final diagnosis.
Under such circumstances, as long as we have a solid grasp of the knowledge from class, it is not hard to choose the correct answer. It can even be said that the question provides you with everything you need, the correct answer is obvious, and you only need to find one diagnosis to cover the relevant information.
However, such ideal scenarios do not appear in clinical practice. Every patient we encounter is a living person with different living environments, lifestyles, dietary preferences, and work statuses, all of which affect disease occurrence and development.
Especially with some difficult and complicated cases, patients may have already visited several hospitals and undergone diagnoses and treatments by multiple doctors before you see them. They may have had dozens of tests, surgeries, and other treatments. Among this vast amount of information, some guide you to the final correct diagnosis, while other parts interfere with your diagnostic process.
In other words, when facing exercises, useful information is highly concentrated, organized, and presented actively before you; in clinical practice, doctors must have the ability to actively discover effective information.
How to evaluate the patient’s condition at the first moment, find the general direction, then deepen and refine examinations to finally reach the correct diagnosis is a complex process. Only a clear-minded clinical doctor can navigate through this.
Grasping a clear diagnostic thinking process during clinical diagnosis is not easy. You should know that the experts who wrote your textbooks and clinical professional exercises have already demonstrated clear clinical thinking and removed all valueless information. But our patients don’t have medical knowledge; we must effectively identify and select the information they provide.
In the diagnostic process, we are continuously subtracting—removing valueless information. So what is “valueless”? In my opinion, “valueless” only means without value for the final diagnosis. Yet during inquiry and physical examination, these pieces of content that have no decisive significance for diagnosis make up a three-dimensional and complete person.
Our patients do not get sick according to textbooks nor according to your preferred specialty. Behind a common symptom lie possibilities spanning different systems, organs, and tissue diseases. These correspond to many specialties, and only when our vision is broad enough and we have knowledge of diseases in various medical branches can we exclude incorrect options and find the correct answer.
Residency training offers us the chance to understand different specialties, which benefits your entire medical career. Consider this: if you specialize in surgery in the future, could you encounter patients with acute myocardial infarction? Of course. In clinical work, knowledge of non-specialty diseases and preliminary mastery of broader medical skills are very important, and these abilities need to be gradually developed during residency training.
To help you transition from books to clinical practice, we wrote this book. In each article, we introduce a real case that lets you experience a clinical diagnostic process firsthand. More importantly, we explain our thought process during diagnosis, telling you how we exclude incorrect diagnoses. We hope you will master the core of medical diagnosis in your career and achieve clear and organized diagnosis.
The book’s content reflects the PBL (Problem-Based Learning) teaching model, which is practice-oriented. Each article carefully prepares a vivid case. Through the case, you develop questions, and we guide you step by step from symptoms to causes, definitive diagnosis, and deeper understanding of pathogenesis.
When learning about cases, whenever some basic knowledge is needed, we review it; whenever a clinical test is necessary, we revisit its significance. You can see that this teaching model notably emphasizes practicality and integrates fragmented knowledge.
The cases and diagnosis/treatment processes explained are ones you might encounter in clinical work; every skill point involved is useful to you.
Since we aim to help you establish basic diagnostic thinking, do we only choose common cases? No. The book also includes some rare cases. Why, as a book teaching relatively basic diagnostic content, include rare cases?
During diagnosis, our mind forms a tree structure. Daily changes in a patient’s condition and each test result provide possible paths. Ultimately, these possibilities form a complex tree.
For a specific patient, starting from the root of this tree, we will eventually reach the required result—the correct diagnosis—at the tip of a branch. Patients only need to focus on the result, but for doctors, every branch is important as it means another possibility.
Thus, diagnostic thinking is tree-structured. Common diseases have a simple tree structure, while rare diseases have a complex one. We include some rare cases not because you must master them, but to present relatively complex diagnostic thinking. In other words, learning rare diseases allows us to connect the dots and complete much of the common disease learning.
Besides these rare cases, we also select urgent conditions possibly life-threatening within each specialty. The reason is simple: regardless of the specialty you choose as your future research direction, you might encounter these diseases. Being able to identify and manage these diseases in time can save lives.
Whether a nephrologist, endocrinologist, hepatobiliary surgeon, or oncologist, you may encounter patients with myocardial infarction in outpatient or inpatient settings. Although you’re not a cardiologist, the likelihood of facing acute myocardial infarction during your career always exists. Failure to provide timely diagnosis and treatment would have serious consequences.
Additionally, in this book, we want to convey the basic concept of evidence-based medicine. In today’s modern medicine, knowledge gained from experience alone cannot guide clinical practice. In clinical work, we must strive to ensure our knowledge and treatment concepts have sufficient evidence.
How does this basic concept arise and influence our work and study? We hope to demonstrate this in the book. In other words, we aim to help you understand how clinical experience and scientific concepts are dialectically unified.
Finally, even though our case narratives are vivid, there is still a certain gap between the cases you learn from this book and your real clinical practice. Despite our best efforts to make this book authentic and lively, you have probably experienced in previous studies that when senior doctors assess patients during rounds, this process happens very fast in their minds. We are not mind readers and cannot understand what is going through their rapidly working brains.
To understand their thoughts, we must ask valuable questions that prompt them to express their diagnostic thinking. If we cannot keep up with their pace and don’t have classmates with clear thinking and good questioning skills nearby, how could senior doctors voluntarily share their thought process? To solve this and make clinical scenes closer to reality, we designed the characters “Teacher” and “Student” in the book. You can imagine “Student” as yourself, who asks questions you want to ask, and “Teacher” answers them.
This book also adds relevant content on medical humanities. After all, medicine has always been a warm and compassionate discipline whose past, present, and future should never be cold.
Chen Gang, Sun Yifei
May 2022
Trial Reading
实践与临床