Ah, Medicine

I was on campus to turn in my receipt for step 1 to the MD-PhD office. We get reimbursed! Yay! Well, for step 1 only, but I'll take what I can get.

Anyway, I ran into a classmate of mine. Not one I normally talk to, but a nice enough-seeming guy. Since I hadn't spoken to anyone besides my parents or my husband in approximately three days, I decided to say hi. He didn't look overwhelmingly busy.

It turned out he was going into medicine. This was interesting to me, as I had always pegged him as a surgery person. I asked him why. He said he really loved coming up with a differential diagnosis. On rounds, the team would stand outside the patients' rooms discussing what the problem could be and what they were going to do to narrow things down, and collaboratively come up with a plan. Then they would continue said discussion with whatever consultants they had decided to call that day.

He had also loved peds, but didn't really enjoy babies (they couldn't talk), and liked patients who were a bit more complex. Peds patients seemed to have only one problem at a time, and he found this less interesting.

Ah, yes. This is what medicine is supposed to be. Sounds appealing, right?

I congratulated him on his choice. I think he'll do great in that field. Hopefully he won't succumb to the medicine malaise that plagues many residents, or the asperger's-like way of communicating with patients that so many of the medicine residents I worked with had. But I doubt either of these things will happen to him.

I reflected on my own experiences. And you know, he was right in some ways. Coming up with the differential was cool. When it happened. We'd do this in small group sessions every Friday afternoon, and I can say that I had a lot of fun with this. I could also see my knowledge base grow, as well as heightened sophistication in the way in which I approached the problems.

The problem was that when it came to actual patients, I cannot recall one time that we actually sat down and developed a differential. The vast majority of the patients were already differentiated, and those that weren't usually remained a mystery. And when they didn't? Well, usually that happened when three days into their hospital stay, the Lupus patient just happened to mention that UTI they had last week for which they were given bactrim.

And all of a sudden, the acute-onset thrombocytopenia was magically explained.

Those times, you could just sit there and watch your resident and attending look at each other knowingly and make mental notes: Med student failed to take complete history the first time. Med student is incompetent. Reducing "History Taking" portion of evaluation from 7 to 5.

(Med student is scapegoat for all oversights by rest of team.)

I would have LOVED it if teaching and developing a differential were goals of my team. Instead their goal seemed to be to identify flaws so they could give me a lower grade.

Med student says that NSAIDS are the most common cause of acute interstitial nephritis, when everyone KNOWS it's penicillin. Stupid med student. Poor fund of knowledge.

or

Med student WASTED THE TEAM'S TIME today by introducing the team to the patient before she interviewed her in front of us. God, didn't she see me do this ten minutes before? God. Med student totally unaware of her surroundings.

or

Med student failed to realize that the ONLY THING IN THE DIFFERENTIAL WORTH CONSIDERING in a patient whose chief complaint is "pulsating neck vein" is a ROMI.* Even though patient has a medical history complicated by multiple endocrinopathies and domestic violence. Incompetent medical student.

or

Med student asked patient whether she had ever been pregnant, and then later if she'd had any miscarriages. Doesn't she KNOW that a miscarriage is a pregnancy.... SO PATRONIZING!! (Then later.) Med student used acronym "STD" with patient. Doesn't she KNOW that patients might not know what that means?

See, it wasn't the feedback. I expect not to know everything. I expect not to be perfect. I expect to improve over the course of a clerkship. The thing was, every time you did something that wasn't completely perfect, they'd give each other these knowing looks. You could just see your grade slowly swirling down the drain. It shouldn't be about that, but that's what they made it into.

And then there is the problem with the work environment. On every other rotation, I felt it was ok to have a personality. To kid around. Be a person. On medicine, whenever I laughed or smiled I felt like I had to look over my shoulder. I was sure that someone would think I was being unprofessional. They really love that word on the medicine service. The sad truth is that one of the reasons I liked surgery was that they actually laughed at my jokes and seemed to enjoy having me around.

And then there is the fundamental problem with general medicine for me. While I think working up DVTs, MIs, COPD, diabetic ketoacidosis, anemia, and non-acute abdominal pain would be interesting for a while, I could not imagine feeling fulfilled if my entire career was comprised of nothing but that. The interesting things happen so rarely. If I did do medicine I know that I would have to specialize.

I once made the joke that the medicine people need to come up with this blown up differential so that they can make themselves feel better about the fact that nothing exciting ever happens. It's like, "Well this ROMI turned out to be just a panic attack, but if the patient had had an MI two weeks ago it could have been DRESSLER'S SYNDROME!!! Quick, medical student -- how would you treat that?"

Or, "That ulcer turned out to be due to h. pylori, but if his gastrin level had been higher, it COULD have been Zollinger Ellison syndrome! Quick, medical student -- what other conditions is that associated with?"



Plus, I like making decisions and then going with it rather than pontificating for hours with 15 consult teams (did I mention the constant "touching base*")about all the possibilities. And hand-writing notes the length of War and Peace is just not my cup of tea.

Sigh. I'm glad that my classmate enjoyed his experience in medicine. I only wish I could have said the same about mine.



*ROMI = rule out MI
*I wish I could say I was making these examples up. Sadly the examples have been modified only slightly in order to protect patient confidentiality. PS -- Dr. M, you are truly a loathsome person.
*Frankly, some people on my team seemed like they could have used some base touching of their own.... Oh wait, that was unprofessional. Forget I said that. :-)