Mastering the master

Auteur: Gepubliceerd op: 

Are you in the bachelor and do not have a clue how, based on what you are learning now, you can become a real doctor? Or maybe you are getting closer to your clinical internships and are panicking about how to prepare. The very first start in the clinic is intimidating and causes many people to spend every evening overpreparing just so they do not mess up. I am almost a doctor at this point and through the past few years my way of preparing internships has changed significantly. I spend significantly less time preparing now than I did back in M1, some of which is up to acquired knowledge but a lot of which is up to the skill of case preparation. 

Preparing for the internship
You are a fresh M1 intern and your first internship will be at the department of paediatric gastroenterology. You are both excited and afraid about what is waiting for you. You want to make a great impression by being super well-prepared but you also do not have a lot of time because of your job and social commitments. You ask your friend who is almost a doctor for some tips.

Very early in your internships you should realise that the way you learned about diseases in the bachelor is not too useful in your internships. You have learned about diseases, about all possible symptoms it can cause, genetic predispositions, the molecular pathways, all possible treatments that exist, etc. This scientific and complete approach (which I would call the 20th/21st century approach) is great and only possible through a body of quality research. However, most of this is not applicable to the clinical reality of a beginning medical intern. Before that knowledge is useful you first need to learn the 19th century approach, namely you have a symptom or a group of symptoms that occur often, what diagnostic steps are necessary and what are the tried and tested methods to treat them (even if you do not yet truly understand how). Only after mastering that can you work on the 20th/21st century approach.

Before starting your internship the best book you can use for preparation is not the textbook from the bachelor because you will find a chapter for each (group of) disease(s). You really should buy or borrow a book in the Probleemgeoriënteerd denken in de …-series published by Tijdstroom publishers. These books contain cases which start with very common presenting symptoms in that specialism and then the author takes you by the hand, showing how that case is solved. Relevant for paediatric gastroenterology are the ‘interne geneeskunde’ and ‘kindergeneeskunde’ editions. I cannot stress enough how much these helped in preparing for an internship, if you do any preparation make sure this is part of it. It helps to think like a clinician since you almost never start from a diagnosis, you almost always start from a symptom.

Preparing for the case
Your first case is a 16 year old boy who developed diarrhoea for a few days during the summer vacation and thought nothing of it. Over the past few months it happened more often and he keeps losing weight even though he is not trying to lose it. He has now been referred by his general practitioner to the paediatric gastroenterology department to figure out what the cause is and for treatment.

Before doing any preparation for any patient you should think about where you are seeing the patient. A patient who has been referred to a hospital has ALWAYS been seen by a general practitioner at least once with the same problem. And you always have to remember, general physicians are (generally) very good at their job. One very important job is to evaluate if a patient requires specialist intention and they have usually tried to exclude some things themselves. So most often you are seeing a patient who has a serious or complicated problem, or they need diagnostics or treatment only available in a hospital. Therefore the answer: “it’s probably nothing,” is probably wrong.

Now on to the preparation. Which diseases do you need to prepare? All of them?! You could, but that would take an ungodly amount of work. You only need TWO resources to prepare (almost) any case in (almost) any specialism well enough to get a compliment from your supervisor that you prepared well. This is not only based on my own experience but also on the experience of others who use this method based on my recommendation.

The first source is This is a website which gives you a very good differential diagnosis based on a given presenting symptom. It categorises by how often a disease occurs in the categories vaak (often), soms (sometimes) and zelden (rare). In addition some diseases are in bold which means it is a disease which can cause serious harm or is deadly when not diagnosed and treated in a timely manner. You should always prepare the diseases which are in bold and are in the vaak category. “But,” you might ask, “how do I prepare all these diseases?” It might surprise you, but you should not use UptoDate as your first stop since it gives an overload of information which you do not need for your preparation.

The best source for preparing for a patient is the BMJ’s Best Practice-website. You can only access it for free through the RUG-proxy by using the following link: (do not use https://www. Before it because sometimes it messes up the RUG-proxy).

On the Best Practice website you type the disease you want to prepare; in our case it would be irritable bowel syndrome. You will be greeted by a summary of the disease and a lot of options to learn more about the disease in question. For preparing a case the most important options are History and exam and Differentials. On the History and exam page you will find a list of symptoms, risk factors, physical exam findings, etc. which help in differentiating if it is or is not in line with the disease. Through this you will find the questions which you should ask and which examinations you should do. Write this down. Then look at the differentials page, sometimes it is very close to the differential you got from Huisartsdd. When you click on the disease you see in which way it differs from the disease which you are preparing. This will give you extra questions which you should also write down. Then rinse and repeat for the important diseases fitting the presenting symptom. You end up realising that most questions are duplicate in your list and you end up with a few differentiating questions. From now on you can always use these preparations. This is especially good because within one specialism some presenting symptoms occur VERY often, for example blood in stool or abdominal pain in gastroenterology. Please note: do not use UpToDate for preparing questions, it is not suitable for the 19th century approach, you will use it for the next step.

Preparing for your proposal for the next step
Through your preparation you manage to ask the right questions and the doctor praises you for doing so. He or she takes over and tells the patient what they can say on the basis of the questioning. The doctor tells the patient that he is not sure what the diagnosis is and orders a colonoscopy. You do not know why they decided to choose that path and you wonder why.

In M1 (or M2 for that matter) you are usually not asked to come up with the next step in front of the patient because you cannot be expected to know that yet. Usually you can ask the doctor why they chose a certain investigation or a certain treatment if it is not super-obvious. A better way of going about it, is checking UpToDate after seeing the patient to see the logical next steps. If the doctor deviates from what you find there, ask why because they usually have a good reason and you can learn from that. You can also understand more about that specific disease and it will help to inform you for the next time you see a patient with that diagnosis. Why are you doing this after seeing the patient? Because it is unrealistic to remember every single possibility, especially if you want the time to relax after a tough day of internships. Also, you usually have the time to research while typing up your report of the patient.

While typing the report in the file of the patient you find out that the specialist could also have started treatment or could have first investigated the stool of the patient. When discussing your report you get feedback about what is in there and you see what they change, apparently some things are not as important as you thought. You ask why they did not examine the stool first. The doctor explains that because of the likelihood of blood in the stool based on how it was described and the fact that they lost so much weight, an inflammatory bowel disease is very likely. This way treatment can be started faster instead of waiting for the stool examination first.

Preparation is very important for your internships, but you should not give up all of your free time to do it. It is important to be smart about it, that way you can be well-prepared AND still have a lot of free time to relax and have fun.