A tradition of mentorship

A friend was working an overnight shift in the ER for one of her mandatory rotations, so I popped in to observe. The ER was surprisingly quiet. A classmate was also observing that night, and like me, he was standing around, bored. We spotted an electrocardiogram (EKG) readout lying on a desk where a resident was working, and we asked him if we could take a stab at interpreting it (an electrocardiogram tracks the electrical activity of the heart, and a skilled interpreter can use it to reliably diagnose heart problems). He handed us not only that piece of paper, but the EKGs from some other patients who were in the ER. "I'm going to see a patient," he said, "and when I come back, tell me your results and whether any of these people is having an emergency."

A 12-lead EKG (like the one we interpreted) in a normal patient.

At that point, we had learned only the basics of reading EKGs. We wrestled with the readout, trying to flesh out the story told by the squiggly gyrations of the EKG lines. We opened a textbook on cardiac disease and reviewed the way certain diseases of the heart express themselves on an EKG.

The resident returned and quizzed us on our findings. Then, he shared strategies for reading EKGs that he'd picked up over the years. The three of us read through the EKGs together. In a final flourish, he picked up a new patient's complicated EKG readout and accurately diagnosed a subtle type of abnormality in the heart's electrical conduction.

Medical residents are extremely busy people. Even though this resident had never met us and probably would never see us again, he happily took some time out of his night to teach us. This tradition of mentorship seems omnipresent in medicine. Most doctors enjoy having medical students shadow them so they can share so-called "clinical pearls" of wisdom. They do so because they remember a time when they were medical students, when doctors went out of their way to teach them. Although an academic medical center like my school tends to attract those most inclined to teach, even when I am out in the community I find that doctors are eager to share what they know.

Another element of teaching on the wards is called "pimping." During rounds (when the full medical team convenes), the more senior person quizzes the more junior person on medical factoids until the more junior person misses a question. Pimping does a few things: it gives both people a chance to show what they know. It (supposedly) teaches. It motivates people to go home and study so that they don't get humiliated.

Pimping also puts the more junior person in their place. The teaching that goes on in the wards is only a one-way exchange of knowledge, from teacher to student. If the teacher makes a mistake, it isn't considered appropriate for the student to correct him. And so, a paradox is at play here. Teaching elevates the student, improving his level of knowledge. Yet how doctors teach fortifies the pervasive perception within medicine that those who are most senior are universally more knowledgeable, and that level of seniority automatically dictates the amount of respect one commands. Teaching students on the wards is both selfless and self-serving, humble and haughty.

That doctors have good job security contributes to their willingness to teach. Doctors don't have to worry that the person they are helping will someday be their replacement.

My sense is that medicine outshines other professions in its long-held tradition of mentorship. My superiors' consistent eagerness to teach me makes medicine refreshing. As for my time in the ER, I couldn't think of a better way to learn how to read EKGs.

Sweat the small stuff

Our professor began our small group session, on how to properly examine a patient with lung disease, by leaping onto a table. He held up his hands and explained that we would get started soon, after he returned a phone call from a patient. In one bound, he leapt down from the table and exited the room.

My classmates and I were mystified. We had never met this physician before. Although he was at least 65 years old, he had hopped off of the impressively high table with a gymnast's ease. He wore a white coat, tie, and dress shoes, and rather incongruously, a bright orange baseball cap.

After a few minutes he returned and hopped yet again onto the table. He held up his hands. "What's different about me?"

We all noticed that his baseball cap was gone. I mentioned that something looked different about his tie. That was it.

The doctor explained that he had altered his appearance dramatically. He had switched from a blue necktie to a red one. His wedding ring had switched from his left hand to his right, and his wristwatch vice versa. He had even changed out of his dress shoes, into loafers.

"One of the most important parts of the patient examination is 'inspection,'" he said. "You're now at a stage in your medical training where you need to start looking for subtle visual details. Otherwise, you'll miss something important in a patient."

And so, as a group we inspected a set of lung-disease patients with an eye for detail. We spotted tiny surgical scars that suggested that the patients' lungs had been biopsied. We noticed the "buffalo hump" (an accumulation of fat on the back of the neck) that is the signature of high doses of corticosteroids. We watched one patient who was breathing quite fast, and another who coughed constantly and whose neck muscles were pathologically straining to help her inspire. We listened with our stethoscopes to the 'crackles' at the base of one patient's lungs. The crackles sounded like the faint popping of bubble-wrap.

Slowly, without the patients saying a word, we began to piece together what diseases they might have and what their life story might be. Our spry professor had mischievously taught us a good lesson.

Nobel Prize for Economics

This year's "Nobel Prize for Economics" (see footnote) went to Alvin Roth and Lloyd Shapley. They studied ways to design markets that efficiently match up agents according to their preferences. Medical students like myself are indebted to these two economists for their hand in setting up and refining "the Match," the process whereby medical students are assigned to residency programs.

Medical students apply to residency programs and then rank, in order, their list of preferences. Residency programs also submit a ranked list of their preferences among applicants. Sometime in the spring, a computer processes the preferences and assigns students to programs.

The algorithm used is quite elegant and favors student preferences to the greatest extent possible. It is always to a student's advantage to rank his choices according to his actual preferences. Roth even helped refine the Match to allow couples to match jointly.

It's cool how the application of economic theory has made the lives of medical students like myself less stressful. Now, if only the process of getting into medical school had been that straightforward.

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Historical footnote: Alfred Nobel endowed in his will an annual set of prizes to be awarded "for outstanding achievements in physics, chemistry, medicine, literature, and for work in peace." The prize for economics was set up many decades later by a Swedish bank, but it is still considered a "Nobel Prize."

Diagnosis II

A patient at the free clinic complained that over the past few years he had lost most of his ability to taste and smell. "I put lots of spices on my food, but it barely tastes like anything."

The patient clearly had "hyposmia," a decreased sense of smell. It's potentially worrisome, because it can be an early sign of degenerative brain diseases like Parkinson's and Alzheimer's. It could also be a symptom of a brain tumor. I wanted to get to the bottom of whatever was going on. How could I approach this diagnosis?

I did so by breaking the action of smelling into its constituent parts.

• First, air carrying a scent is transported to the bridge of the nose, where olfactory receptors reside.
• Next, the olfactory receptors fire. They send a signal along nerves that traverse the skull and enter the brain.

And so, there are two main categories of causes of diminished sense of smell:

• Conductive: a problem getting air to the olfactory receptor. Usually treatable.
• Sensorineural: A problem affecting the olfactory receptors, the nerves, the skull, or the brain. Usually permanent.

Now my job was to figure out what category of hyposmia the patient had. So, I asked a simple question: "Have you ever managed to temporarily regain your sense of smell?" The patient had. He had bought a nasal spray from the dollar store, and when he used it, for a few hours he regained some of his sense of smell.

Although the patient couldn't remember the name of the spray, it didn't matter. I now knew that the patient had conductive hyposmia. We ended up prescribing him a nasal steroid, which would help improve breathing through his nose. And he didn't need to get a head CT, which is expensive and would needlessly expose him to a hefty dose of radiation. I made this diagnosis methodically, drawing on my knowledge of the mechanisms of disease.

I've learned how to formulate diagnoses by reading textbooks and medical journal articles entirely about how to do them properly. Diagnosis as a stand-alone academic subject has been given only a superficial treatment in our classes. I like studying it on my own because I see the art of diagnosis as fundamental to the practice of medicine.

'Incidental Findings', by Danielle Ofri

In this collection of essays, Dr. Danielle Ofri muses on transitions: of maturing into an attending physician, of becoming a caretaker to her patients, of becoming a mother, and of becoming a patient.  

Ofri's interactions with her patients evoke powerful memories from her past. While working a brief stint as an internal medicine physician at a Catholic medical center, one of her patients has an unwanted pregnancy and wants an abortion. Ofri is forbidden from referring her to an abortion center, but feels conflicted. Ofri reveals to the reader her experience of undergoing an abortion as a frightened seventeen-year-old. Ofri decides that helping her patient is more important than following clinic policy. She refers her patient to an abortion clinic and helps the patient through an emotional trying time.

In another story, Ofri describes a bright 20-year-old patient who has no medical problems but lacks the ambition to go to college. Ofri encourages him to pursue higher education. They set up follow-up appointments, in which Ofri tutors him on his SAT.

The stories cut at the heart of the issues clinicians face. With the tremendous demands on clinicans' time, how can we still take care of the emotional needs of our patients? How can a doctor overcome his hospital's impersonal rules? How much should we reveal about ourselves to patients? How much can we trust what our patients say? Ofri parses these issues in an insightful and personal way. The "incidental findings" of the book's title are the unexpected life lessons Ofri gets from practicing medicine.

In these essays, Ofri is finding her voice as a writer. She experiments with different writing styles, and a few of the chapters are clunky as a result. Still, the richness of Ofri's perspective made reading this book worthwhile. I enthusiastically recommend this little book.
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Note: I also reviewed Dr. Ofri's "Medicine in Translation" last month. I enjoyed them both, yet "Incidental Findings" seems the stronger of the two.