Chapter 34: How Did You Know?

August 7, 1989, McKinley, Ohio

After my talk with Krista, I didn't have a good feeling, as it seemed to me that her answer of 'Learn' was said because it was what she knew I wanted to hear. I picked up another chart from the rack, scanned it quickly, then handed it to Krista. This time, I waited until she had taken the patient into the exam room before Al and I entered.

"Tiffany Gale, nineteen, complains of abdominal pain," Krista said.

I waited, but she didn't give my name, so I said, "Hi, Tiffany. I'm Doctor Mike, and this is Al, a medical student. Can you describe the pain?"

"A dull ache in my midsection."

"How long have you had the pain?" I inquired.

"A few days. At first, Tylenol worked, but it's not going away and hurts more."

"OK. We're a teaching hospital, and Krista is a Sub-Intern I'm training. I'd like her to do the primary exam. Is that OK with you?"

"Yes," Tiffany replied.

"Krista, primary exam and H&P, please," I instructed, handing her the chart.

She did a competent job on the exam, though her H&P wasn't nearly thorough enough. As was my practice, I didn't say anything to Krista in the room.

"Tiffany," I said, "we're going to discuss Krista's findings. We'll come back and speak to you in a few minutes."

"Is there something you're not telling me?" Tiffany asked.

"No," I replied. "This is normal with teaching so that students can learn without being concerned about saying something incorrect in front of patients."

Krista, Al, and I stepped out into the corridor.

"Two things right off the bat," I said. "First, you didn't introduce me or Al. Second, it's my practice to ask a patient before I touch them."

"Nobody else does that!" Krista protested.

"Be that as it may, that's what I want done when you're working with me. Remember for next time. Now, how would you like to proceed?"

"Blood tests," Krista replied.

"What and why?"

"CBC and Chem-20 because I couldn't find anything on the physical exam."

I shook my head, "Those are standard tests, but your H&P wasn't sufficient to justify them. What are you missing?"

"If I knew that, I'd have asked her questions."

"OK. We'll go back in, and I'll ask a series of questions to flesh out what you asked."

We re-entered the exam room.

"Tiffany, I have a few more questions," I said. "Have you experienced any nausea recently?"

"A few days, but not constantly," Tiffany replied.

"Have you been tired more than usual?"

"A bit."

"Headaches?"

"Yes, but the Tylenol makes them go away."

"Are you sexually active?"

"No, never."

"OK. I'd like to do an ultrasound, if that's OK with you."

"What do you think is wrong?"

"Given you told Krista you hadn't done anything which might cause a muscular injury, the first differential diagnosis is an ovarian cyst. Has anyone in your family had one?"

"Not that I'm aware. How bad is it?"

"Usually, they're benign and simply uncomfortable. Before I say more, though, I'd like to get a look. OK?"

"Yes."

"Al, get the portable ultrasound, please."

"Right away, Doctor."

He left, and I asked Tiffany to lie down and pull up her blouse. When Al returned with the ultrasound machine, I performed an exam and saw exactly what I was looking for. Unfortunately, it was about 7cm in diameter, which meant it was potentially surgical. I pressed a button to print the image and another one to freeze the image on the screen. I wiped the gel from Tiffany's abdomen and had her sit up.

"You have a cyst, as I suspected. It's large enough that I want to call for a doctor from Obstetrics and Gynecology to discuss it with us."

"How bad is that?"

"Mostly, they resolve themselves," I replied. "Have you been diagnosed with one before?"

"No."

"OK. We need to have a doctor from OB/GYN examine you, given the size of the cyst. Al, call OB for a consult, please."

He made the call, and about five minutes later, Doctor Roger 'Saint' Moore entered the room.

"Moore, OB, What do we have, Mike?"

"Hi, Saint," I replied. "7cm ovarian cyst with no remarkable features; over 5cm requires an OB consult. No other appreciable injuries or ailments. No history of previous occurrences."

I handed him the image, and he also looked at the screen.

"Hi, Tiffany," he said once he'd looked at the images. "I'm Doctor Moore from Obstetrics and Gynecology. You have an ovarian cyst, as I'm sure Doctor Mike has explained. In nearly every case, they are benign and resolve by themselves. Yours is a bit larger than typical, but given you have no history of cysts, I believe the best approach is to have your OB/GYN monitor you. Do you have a gynecologist?"

"Yes; Doctor Patricia York."

"I know Trish," Doctor Moore said. "Make an appointment to see her, and she'll advise you. For now, Tylenol or Advil for the discomfort. Doctor Mike will give you written discharge instructions, and Doctor York will receive copies of your charts. Do you have any questions?"

"How long does it take to resolve?"

"Unfortunately, I can't tell you with any certainty. One way to prevent new cysts is the use of combined oral contraceptives — what are commonly called birth control pills. They won't help with current cysts, but they'll help prevent new ones. You should discuss that with Doctor York. Any other questions?"

"No."

Saint made notes on the chart, signed it, and left. I went over the discharge instructions with Tiffany, which were quite simple. Given there was no treatment administered or recommended, I signed the discharge form, gave Tiffany a copy, and reminded her to call her OB. That completed, I directed her to Patient Services and led Krista and Al to the consultation room.

"How did you know?" Al asked.

"Krista?" I prompted.

She shook her head, "I'm not sure how you knew."

"It begins with the differential diagnosis. You started OK by asking about any activity which might have caused a muscle strain, but then you didn't follow up with additional questions. What is the differential diagnosis? You should know that from studying for Step 2 of the MLE."

"I don't have my diagnostic handbook memorized," she said. "I did study for the exam, obviously."

"Do you have your handbook in the pocket of your medical coat?"

"No."

"You should. I carry mine. There is no harm in looking at it but step out of the patient room before you do that. The main alternatives are appendicitis, which you did check for when you palpated her abdomen, bowel obstruction, ectopic pregnancy, uterine fibroids, dissecting aortic aneurysm, and a number of postpartum diagnoses. There are other diagnoses which only occur in pregnant women, and you didn't ask that important question. If none of those pan out, you explore further.

"So we have a young woman with abdominal pain, nausea, headaches, fatigue, who has never engaged in sexual intercourse and who denies any activity which might have caused an injury. At that point, having not found obvious signs of appendicitis, ultrasound is called for, as it can find ovarian cysts, bowel obstructions, and aneurysms. The most common answer is an ovarian cyst, so that's what I looked for first.

"Krista, you had your OB rotation, so that should have been something you thought of, even without looking in your book, because it's such a common diagnosis for young women. I didn't see any ultrasounds in your procedure book, though I know that's not always done with Third Years. That said, this is a common enough ailment you should have known."

"I don't think it's right that you're reprimanding me in front of another student," Krista protested.

"Have you been to any M & M conferences?"

I was reasonably certain of the answer, as I hadn't seen her at any.

"No."

"Which explains your reaction to a teaching moment. The entire point of an M & M is to learn from errors or omissions, and they are done before your peers. It's not about fault-finding but about learning from experiences. Yes, it was correction for you, but it was a learning experience for both you and Al. The only way he can learn is to observe, and that includes me pointing out how you can improve your diagnostic skills and your handling of patients.

"You said you wanted to learn; this is how you learn. If you want to pass this rotation, you have to show me that you can handle clinical work. What happened in the first two years of medical school has nothing to do with being a doctor but everything to do with preparing to be a doctor.

"I don't care if you aced the MCAT and Step 1 of the MLE. I also don't care if you were first in your class. All that matters now is if you can be a doctor. Besides your other assignment for Thursday, you need to find out who Sir William Osler was and what he had to say about medical education."

She muttered something under her breath, which I didn't quite catch, but I was positive it was derogatory. I decided the best course of action was to let it pass and see how she responded.

"Let's go see some patients," I said.

Being able to work under pressure was a key trait, but given Krista's history, the paucity of procedures she'd done, and her attitude, I decided to handle the next two patients — an arm lac and a mild concussion. I kept an eye on my students, and their responses couldn't have been more different — Al was taking notes while Krista was fuming. That concerned me, and I wondered if I'd been correct in coming down so hard on her.

"Mike," Nate called out. "EMS four minutes out with an MI! Use Trauma 3."

"Got it. Which nurse?"

"Kellie."

"Thanks," I said, then turned to my students, "Let's go! Gowns and gloves."

We put on gowns and gloves and went to the ambulance bay, and a few seconds later, we were joined by Kellie.

"With a rule-out MI, we do a standard set of things," I said to Krista and Al. "Oxygen, either by mask or cannula. We draw for a trauma panel, which consists of CBC, Chem-20, ABG, a pregnancy test for any female between twelve and sixty, and cardiac enzymes. We also set up a five-lead EKG, and if the patient is being bagged or receiving CPR, we intubate. If the EKG shows arrhythmia, we insert a Foley catheter.

"Kellie, blood draws; Krista, EKG and pulse oximeter; Al, either take over bagging or oxygen by cannula or mask, whichever the paramedics have used. If he needs a Foley, I'll show you how."

Two minutes later, the EMS squad pulled up, and Bobby hopped out.

"John Cowling; forty-nine; diaphoretic; BP 180/100; tachy at 130; PO₂ 93% on ten litres by mask; resps labored and shallow; reported dizziness and severe chest pain before collapsing; GCS 6."

"Trauma 3!" I ordered.

We quickly moved the patient to Trauma 3 and transferred him to the trauma table. Everyone performed the tasks I'd assigned, and I performed a primary exam, detecting a murmur. I heard the click of Krista turning on the monitor and looked up.

"Inverted T wave, about 8mm, biphasic; QRS complex deflected up and slightly long, but sub 120ms. Al, page Cardiology and tell them we have a suspected incomplete right bundle branch block."

Al made the call and reported the resident would be down right away.

"Kellie, Al will need a 16 French and instruments. Al, please cut away the patient's slacks and underwear, and I'll talk you through inserting the Foley."

He did a credible job following my instructions, and we finished just before Doctor Shore came into the room with a Third Year I didn't know.

"Shore, Cardiology," he said. "What do you have, Mike?"

"Hi, Pat. This is John Cowling; forty-nine; morbidly obese; catheterized with urine in the bag; diaphoretic; BP 180/110; tachy at 120; murmur on auscultation; PO₂ 91% on ten litres; resps labored and shallow; reported dizziness and severe chest pain before collapsing; inverted T waves on the monitor, suggesting an incomplete right bundle branch block."

"Angling for my job?" he asked with a smile as he moved to examine the patient.

"Confirmed," he said. "Let's get him upstairs."

I made notes on the chart and signed it, then handed it to Doctor Shore.

"Al," I said, "switch to portable oxygen; Krista, switch to the portable EKG."

They completed the tasks, and I instructed Krista to go with Doctor Shore and his student. They quickly left the room, and Al and I followed them out.

"Can I ask a question or two?" Al inquired.

"Of course. Let's step into the consultation room."

We walked into the office, and Al shut the door.

"Is the problem with Krista going to negatively affect me?"

"Only if you allow it to," I said. "You'll get procedures appropriate for a Third Year. Earn my trust, and you'll get more."

"How do I do that?"

"Follow instructions, learn what I teach you, and have a good attitude. I saw you taking notes during treatments, which is exactly the right thing to do. I've taught you how to insert a Foley for a male, and you should be able to do the next one without me giving you express instructions.

"By all means, ask questions, and I'll watch and guide you if you need it. Females are different, obviously, and I'll teach you to do that when we have the opportunity. Also, do the things I suggested earlier — practice suturing, read your cardiology textbook, and study your differential diagnoses. How did you study for the MLE?"

"With notes and summaries prepared by our study group."

"Review those. What I said earlier is true — those notes have nothing to do with being a doctor, but everything to do with preparing to be a doctor."

"That was going to be my second question. What the heck does that mean?"

"I'll give you the answer I asked Krista to look up — Sir William Osler was the co-founder of Johns Hopkins Hospital and the creator of the first Residency program. He said, and I'm paraphrasing, that medicine is learned at the bedside and not in the classroom. Your notions about disease shouldn't come from lectures or books but from examining patients."

"Ah! That makes total sense!"

"There was an optional textbook for Practice of Medicine that you should read — The Principles and Practice of Medicine — which he wrote."

"Shit," Al swore. "I didn't read any of the extra material."

"No time like the present. Do you subscribe to any medical journals?"

"No."

"At a minimum, you should subscribe to the Journal of the American Medical Association, The New England Journal of Medicine, or The Lancet. When you decide on your specialty, then whichever journal is appropriate to it. My personal choices are The Lancet and The Journal of Emergency Medicine. Any idea what you want to do?"

"I'm not sure, but surgery was the most interesting Preceptorship."

"That's an extremely competitive Match, which means you need to bust your butt."

"Can I come to you for advice?"

"My door, such as it is, is always open. Let's see what we have in the way of patients."

Krista returned just as Al and I went into Exam 5, where Nurse Carol had brought a young man with a dog bite.

"Good morning, Mr. Sayles," I said. "I'm Doctor Mike and with me are my students Krista and Al. We're a teaching hospital, and with your permission, I'd like Al to conduct the preliminary exam."

"Why not?" he asked.

"Al?" I prompted.

"Good morning, Mr. Sayles," Al said. "Could you tell me what happened?"

"The neighbor's rat dog is always barking and yipping when I'm in my yard. Today, he came and stole my son's ball, and I tried to get it back. The little fucker bit my hand."

"Do you have any other concerns?"

"Besides shooting that little rat fuck if he ever comes into my yard again?"

"I was thinking more health concerns," Al said with a smile.

"Nah, just my hand," Mr. Sayles replied.

Al washed his hands, put on gloves, and examined Mr. Sayles' hand.

"Mr. Sayles, can you close your fist?" Al asked.

The patient did so but winced in pain, which wasn't surprising.

"I believe it simply needs irrigation and a topical antibiotic," Al reported. "Simple punctures and no tearing. NSAID for pain and discomfort."

I washed my hands, put on gloves, and verified his exam.

"I agree. No tendon involvement. Proceed with irrigation."

"Nurse," Al said, "irrigation syringe and a basin, please."

Al did a good job washing out the wound, then asked for the topical antibiotic, which he applied.

"When was your last tetanus shot?" I asked.

"A few years ago," Mr. Sayles replied.

"Less than five?" I inquired.

"Yeah, it would have been in 1986 when I stepped on a nail at a construction site."

"Then we don't need to update it. Let me complete some paperwork, and we'll get you on your way. Just keep the hand clean and dry, and see your physician on Thursday or Friday to check your wound. You can take Tylenol or Advil for pain, whichever works best for you. If you see any redness or discharge that isn't clear, come back right away."

"What about work?"

"So long as you can keep the wound clean and dry until you see your physician, and the pain isn't too bad, you can work. I can also provide you with the equivalent of a doctor's note if you want to take sick time."

"Nah, I want to work; I just want to make sure it's OK."

"It is. Give us ten minutes to complete the chart and discharge paperwork, and we'll have you on your way. Carol will bandage your hand for you."

"Thanks, Doc."

Krista, Al, and I left the room and stood in the corridor.

"I should have asked about tetanus," Al said as soon as the door closed.

"Just remember next time," I replied. "More importantly, if you think your Resident has forgotten or missed something, ask if you can speak to him or her privately, step out and state clearly what you're thinking. The only exception is in a serious trauma, where you ask immediately because that can be the difference between life or death."