Better

It was six months into my first year in medical school, and I was shadowing at the University Hospital with a classmate after morning lectures. Our attending, not one to have us simply tail him around the floor, had assigned us a patient to interview, obtain a full history and provide an oral report. “Shadowing is for pre-meds,” he’d said. “You’re a med student now, you learn by doing.”  I’d done this before, and felt comfortable with the task. I had my Perfect H&P notebook – that was the actual trademarked name of the History and Physical spiral bound template book – and we’d had several Standardized Patients (actors playing the part of a patient) over the past six months. My classmate and I decided to split asking questions, but both take notes, and we would report our findings together.

We checked the room number and the patient name, walked in and were on the verge of introducing ourselves when a doctor – a resident it turned out –motioned for us to come out.

Confused, we excused ourselves and joined him in the corridor.

“Are you guys first years?”

We nodded, slowly, puzzlement written on our faces.

“Okay, you’ll learn this later, but whenever there’s a precaution sign on a patient room, you’ll need a gown and gloves,” he said, patiently, indicating both the bright, unmistakable sign and the yellow gowns and gloves in the cupboard beside us.

I could have burst into flames; my face was so hot. How could we have both missed the sign?

We thanked him, embarrassed, but he said it was normal for our first time and was incredibly nice about it. Naturally, that just made me feel even worse, especially since at the same time I recalled the memory of our first Practice of Medicine classes on Safety Precautions. Several classes in fact, had highlighted the importance of preventative measures. In Atul Gawande’s book, Better, he says, “Stopping the epidemics spreading in our hospitals is not a problem of ignorance – of not having the know-how about what to do. It is a problem of compliance – a failure of an individual to apply that know-how correctly.” Today we were part of that problem. As we donned the gowns, nervously joking about how terrible we were as first years, I made a mental vow not to let it happen again.

Properly attired, we re-entered the room and met our patient. She was young, petite, sitting upright in the bed, with an air of nervous anticipation.

“I’m going home today,” she announced. We smiled, joining in her excitement. We asked her if it would be okay if we asked her a few questions. “Yes,” she said, okay with that, and then asked did we want to sit down?

At one of our first classes, we had learned about OLDCARTS (Onset, Location/radiation, Duration, Character, Aggravating factors, Reliving factors, Timing and Severity), and it was the basis of most histories I had taken from our Standardized Patients. But as our patient began her tale, it became increasingly obvious that OLDCARTS was too simplistic in this case. Her ailments did not fit the clean lines of that format. It was a tool to guide students to ask the pertinent questions, and worked excellently as a place to start, but real life medicine demanded more complexity.

As we reviewed her extensive and complicated history, I felt the full weight of what lay ahead of us still to learn. It was illuminating, somewhat overwhelming, and even a little exciting. When we reported our findings to our attending, he confirmed my suspicion, telling us he had wanted us to see this particular patient because it was important to see that all cases weren’t as tidy as in our Pathology textbooks. The prospect of handling a case with this level of complexity, held an irresistible appeal; where multiple signs and symptoms could either be the result of an overarching diagnosis, or could be viewed as having individual but equally important causes. Our patient had a litany of symptoms, some acute, some chronic, some clearly associated and others seemingly unrelated. The pressure throughout her body, complicated by rashes, chest pain, joint pain, weakness and extremity edema seemed firmly under her past medical history of a chronic autoimmune disease. As did the headache, nausea and aphasia-like symptoms. However, she had presented with a flare-up of her autoimmune condition in conjunction with walking pneumonia, which was associated with skin rashes, headache, chest pain and generalized weakness. She had also mentioned the possibility of caffeine withdrawal, which I had added to my notes under, “Other.” That could theoretically contribute to the headaches and nausea. Indeed, as one attending described it, it was tantamount to holding a few dozen puzzle pieces with many potential sample pictures and the likelihood that not all pieces belonged to the same puzzle. The prospect of handling such a case held promise – the requirement – of more knowledge, more practice, more time, more novelty, more trials, and more errors.

There is something about being a medical student that gives experiences like this one the air of riding with training wheels, but I have no idea when those wheels will get taken off. When do the expectations change?  I have so much work to do, and I’m not even sure it’s possible to somehow reach perfection.  For now, I’ll simply continue to get better.