Stumped by the simplest things

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This community medicine rotation was a little different than the previous ones. For the first time, I actually felt I might have something to offer. Having completed my pre-clinical coursework, prepping for Step I, I felt equipped to at least handle some basic office-based cases–not on my own, but certainly with some basic supervision.

I quickly realized that I don’t know squat, or at least not practically, anyway. I never had the idea that I was in any way special beyond my training, but I was a bit shocked to have it hit me how useless I seem to be (at least in my own head) when confronted with a real patient thinking of differentials in real-time. The brains of end-of-2nd-year students are chock full of information from all sorts of sources, and obviously, individual knowledge will vary on all sorts of factors, but what’s common to all in “traditional” schools at this point are three main things: 1) almost all information has come from books/lectures, and as such, has focused on “classical” or typical presentation of diseases, 2) no class has really extended beyond itself to intentionally integrate other subjects, and 3) a vast majority of the space occupying our brains (especially owing to the first two points) is really not useful at all in the real-world practice of most aspects of medicine.

Regarding point #1, we all have the idealized patient in our heads when we think of a particular disease. The reality is that not only do disease presentations not obey such standards (how dare they!), but we are taught in such a way that stresses the “bullet points” of disease facts on paper, with no focus about the actual person. How many diseases have I learned in which there was no picture of a patient suffering from it? Or maybe there was one, but it was a histological slide of the basement membrane of their such-and-such epithelium–you get the drift. Even if there was a picture, there was ONE picture, and anything deviating significantly from that is new territory.

Regarding point #2, every professor thinks their basic science subject is the foundation of medicine. How can you know medicine if you don’t know your anatomy? How can you understand the body’s response to disease if you don’t understand the intricacies of immunology, or for that matter the pathogens that cause them (microbiology)? Well, all of that is dependent on your understanding of basic physiology isn’t it? ….  The message here is that each course focused on itself and only itself, and as a result, so too did our studying. Whether it was memorizing tables of interleukins for immuno or which inhibitory interneuron modulated which thalamic nucleus, each subject demanded its own narcissistic world view.

Fast forward, and here I am in front of a 9-month-old girl with what looks like mosquito bites all over her torso, some on her hips, a couple on her right knee, and one or two on each arm. I keep thinking bug bites over and over, since it looks rather obvious, follows no real pattern, and the small, reddened welts are neither fluid-filled nor crusted. But can I be sure? I strain my brain for my micro knowledge, thinking “Could there be a virus that could be the cause here?” I come up empty, but that means nothing in my case. There is no fever. The mother says they have no pets other than some chickens outside which the girl doesn’t play with. Bug bites. The mother says that she’s the only child in the house that has them. Uh oh–not looking good for me. I ask if she’s been to anyone else’s house for any period of time, the mother says no.

Now I’m feeling like the guy at the poker table holding two pairs and the guy across from me just raised the pot with way too much enthusiasm. I’m out of my league. I want to fold the cards and defer to the doctor there, only to suffer the humiliation of not being able to suggest simple topical hydrocortisone for some mosquito bites if that’s the case. (At the same time, I laugh to myself at the prospect of being a real dermatologist and saying, “Let’s get a biopsy to be $ure” LOL)

Honestly, at this point I’m just waiting for the night shift to go from the community clinic to the Red Cross so I can suture, splint–DO SOMETHING WITH MY HANDS FOR GOD’S SAKE–instead of all this fucking mental masturbation. Perhaps it was that I actually came with some expectation to be able to help, to offer something for a change other than be total scut monkey or a useless shadow in the corner, observing.  Perhaps it’s just me wanting to flee to do something far more simple and focused with immediate reward than constantly face my own inadequacies.

We pre-clinical students are almost universally dying for a chance to “get our hands dirty.” We disdain all the histories, all of the vitals-taking, all of the throats/abodmens/etc. exams that by now we are adept at performing. Performing, not necessarily interpreting. And I guess the take home point here is that it finally hit me that there’s a wealth of information that is easy to overlook because it seems boring, mundane, or repetitive. I am always excited, scared, and humbled by how much there is to learn, but I also know that I chose this profession in part because of that very fact.

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  By R, March 12, 2007 @ 3:01 pm

  Its so true! I feel the same way, its so hard thinking up differentials in realtime. But it will come with practise. You seem very stoic about the difficulties. I, on the other hand get very down about it! Sometimes it feels too much.

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