Mile 6650: Aha! That could be it!

Above: The weirdest sign I saw on my May 2010 roadtrip. Talk about a one-stop tourist trap. Kissimmee, FL along Route 192.

It's been busy. There's no time to sit back and relax. Things aren't stopping. And for me, stopping could be dangerous.

BUT I LOVE THE BURN.

Week 6 here at my internal medicine rotation. I finally got the layout of my hospital down, know when and where to get coffee on my commute, what entrees at the cafeteria I should have/avoid, and even where the "secret rooms" are to do my work.

The importance of the IM rotation for anyone comes not in just getting to work in a hospitalist format, but also learning the art of medical thinking... something that I am still in awe of and want to master.

ONE CAN NEVER SAY A DIAGNOSIS IS CLEAR CUT.

It never is (unlike many medical dramas on TV put it). Its a common fallacy I run into. To me, Step 1 thinking is all about the "clear-cut" ness and classical cases, but coming into Step 2 and Step 3, things are completely different. If Step 1 thinking is taken into clinical medicine, fairly significant diagnoses can be missed, and one can head down the wrong road of management. Medicine kinda breaks the rules; it is unsafe to always think that X + Y + Z = A always. After a set of what we call "differential diagnoses" are given out (these are the lists of possible things that are going on), it is up to the clinician to rule out specific ones (especially ones with the most deadly prognoses along with the most common). A good set of differentials actually leads to better diagnostics and therefore, management.

Our tools to solving the patient's issues include the history we take on the patient, the physical exam, and laboratory tests. Each one of the tools has an advantage / disadvantage, usually measured in terms of cost (dollars and cents), usefulness of the info returned by the test, and time-to-benefit ratio (waiting 3 days for confirming something that might kill you in an hour isn't exactly a good thing). Some of the best clinicians I've seen at the hospital will perfectly balance all three by picking the right questions, exam procedures, and tests to confirm and rule out diagnoses (somehow they make the puzzle pieces fit). I'll admit, to use all these options efficiently is an art, and my mentors (attendings, seniors, and even the new interns) are always able to think of something I can't.

It's amazing that a lot of them say that the history is usually the best place to find out the diagnosis. However, even for the best clinicians, there are times where cases where the diagnosis is so unclear or takes an unexpected turn that a "Hail Mary" throw of tests needs to be done. But they're so good that this is usually last resort only.

The art of being a clinician is easy to put into words, but mastering it in practice is going to take more than 6 weeks to accomplish.

Mile 1201: Constantly Judged

Above: A wikipedia image of a "Kiss and Cry" featuring Michelle Kwan.

SKATERS GET THEIR SCORES
IN A "KISS AND CRY"

The passion for perfection can be seen in something my mom has our family watching for dinner every day: figure skating. I know, not a manly sport, but let me make a point here. We were watching one of the post-olympics championships, and I watched one skater prep-up for a triple axle, one of the significant jumps needed to be completed for a significant score in his program.

The anticipation was felt. The crowds eyes were on the skates. The skater's eyes were focused. His leg goes up... and he singles the jump.

Okay, so skaters make mistakes once in a while. The skater sets up once again, this time a triple-triple combination, according to the announcer.

The anticipation was felt. The crowds eyes were on the skates. The skater's eyes were focused. His leg goes up... and he singles the jump.

I'm glad the skater couldn't hear what the announcer was saying. All the talk about disappointment, not matching a highly expected performance, and how the failed jumps marked the end of his program. "A disaster," was the way they had put it. I could see the negative comments discouraging the skater from completing his performance. So, I give him kudos for the strength that he pulled off in putting that disappointment behind and finishing off his program, even though he knew he could no longer make up for his mistakes.

The skater was definitely not a slacker, as he had to work hard to get to this stage. However, I could feel the pain that he had as he was up on the "kiss & cry" waiting for his scores. After hours and hours of practicing to get to perfection (like many other figure skaters), I could see the skater's face in deep, deep disappointment. It seemed that he was feeling like nothing paid off: the judges gave him a score that was only a fraction of his average marks.

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I feel that becoming a doctor is the same. We go through hours and hours trying to dig deep into our profession, either by putting our heads into books or spending long hours at the hospital or the office for experience. And just like figure skating, one can read all about medicine and know about the in's and out's of a hospital, but without that practical real-life practice, the information is useless.

As I'm beginning this new leg of this journey, I'll admit it is tough to take 2 years of basic sciences, and now add on clinical thought to make sure as a doctor I can think on my feet and do things right. But yet I feel that with every patient, I'm not exactly there. And its kinda disheartening as I believe the essence of perfection is needed to take care of every patient and their needs. Either, I'm missing a question here or there when taking a history or I'll miss a couple differential diagnoses on a patient. My body keeps telling me, I can't miss details.

The patients and the doctors are there judging me with every move. The former for trust, the latter for grades & marks.

Yes, I know, perhaps I am complaining too early (6 weeks into my 78 weeks of clinical rotations), but I believe that to do well in medicine, I believe I have to earn the trust of my patients. And that can't be done without proper personal relationships, a good medical knowledge base, and an ability to think clinically (what I now call "across the board thinking", I'll explain in a later entry). I feel that with each mistake I make it harder for a patient to trust me. Well, I'll need to be patient with myself, because perfection can be achieved through the beneficial lesson that each mistake teaches me.

I think I need to strive for perfection more. It's the only way I can be an asset to my patients and to my field. I'm just thankful the doctors and patients don't put us through the "kiss and cry."

Being Positive about Thinking Negatively

Above: Atul Gawande in surgical scrubs (From the Harvard University Gazette archives).

"NEGATIVE THINKING MAY BE EXACTLY WHAT WE NEED."

In the eyes of a positive thinker... that quote shocked the hell out of me!

Atul Gawande, one of my inspirations behind starting up this blog, is one of my favorite medical authors. I've read two of his books, Complications and Better. They deal with the essence of medicine's imperfections and how doctors maximize their own performance, respectively. Through the books, Gawande's excellent narration guides the reader to feel like he/she is in the action, actually holding the surgical instruments and under those huge, bright surgical lamps in the operating room. Also via adding appropriate detail, he also sets the aura and emotion (for both doctors and patients) that makes every medical situation exciting and unique. I read his books to remind me of the excitement the medical field whenever studying pages of raw material in my review books starts to make me feel all punchy in the ole' noggin.

As I was scanning through Gawande's site a few nights ago, one link caught my eye. In a 2007 New York Times article called The Power of Negative Thinking, Gawande describes the need for antagonistic-like thinking. He uses the then-current controversial situation at Walter Reed Hospital to describe two-sides of hospital care there: how staff before and during medical treatment were taught to negatively think, while post-treatment, staff kept their positive thinking. The results: deep analysis of problems that patients had resulted in better treatment, while all who thought that everything was "A-ok" in the rehabilitation process ended up harming the patients down the road.

Gawande's right. It is discouraging to think negatively for ourselves; most of us want to think positively to get through things (sometimes to even avoid them, I think). It's easy to avoid wanting to think that there's imperfections within us... I could see how for a perfectionist that thinking negatively could lead to what Gawande calls "a state of perpetual dissatisfaction." (Just imagine every moment of the day leading to some type of criticism... disturbing!) However, let's spin this idea positively: how do situations improve if one doesn't know the imperfections to look at? Progress of humanity doesn't come without changing a few things around, especially obstacles that block getting to goals. It seemed like Gawande's ultimate point was this: without thinking negatively in business or humanitarian situations, loopholes can be missed, resulting in failures.

After reading this article, I can see how the two opposites work best hand-in-hand. Through negative thinking, issues that need to be addressed can be identified, but I believe it is through a positive (and forward) attitude that they'll be actually be addressed (and addressed well).

Put the yin and the yang together... and there's one of man's greatest gifts: critical thinking.