Few things in medicine are harder than trying to explain to a patient that you don’t understand what is going on. As is common, I recently had an adolescent patient that had either psychosomatic stroke symptoms or actual acute resolving weakness exaggerated by anxiety. As we very gently let him down, we explained that we could not find a physiologic reason for his weakness, now better, and that we would likely never know what caused it. All the patient often hears in these conversations is a booming, “It’s all in your head.” So it was under these conditions that the patient caught me off balance. “How can you not know, you have been studying this stuff for your entire life?!”
Avicenna, legendary Islamic physician and philosopher
For someone who aspires to the sage wisdom and trusted repository information that is a physician, few words are harder to get out than, “I don’t know.” Not only does it mortally wound our own pride, but it is extremely frustrating to patients. Oddly enough, there is great comfort in carrying a diagnosis. It allows you to read up on what to expect in the future. It allows you to give your physical and psychic torment a name. It often allows you to locate a support group of people with the same struggles as you have had. It can allow you to keep up with the latest research, even to participate in the studies. What I am learning however, is that giving a diagnosis is a surprisingly uncertain process. It is this uncertain process I have been studying my entire life.
A lot of this is set up by the maxim, “When you hear hoof beats, think horses, not zebras.” Rare diseases will typically go through a string of misdiagnoses or at least mystery before the real problem is located. The reason is that common things are common. We typically need to treat the common things first because that is what the problem is the vast majority of the time. When this fails, then we can go zebra hunting. This is really the most efficient way to avoid a slew of expensive and unnecessary tests, along with false positive results that will happen more than true positives if rare conditions are tested for indiscriminately.
This is efficient in general but frustrating to the extreme to the patient with the zebra diagnosis. In fact, the very reason we try not to write conditions off as anxiety or psychological, is because far too many physicians are tempted to throw there unknowns into this untestable category. It is the easy out, problem solved. Granted, no one wants to be told it is in their head because of the pervasive stigma these problems carry in our society. The sick role is well established in western medicine. The mentally ill or anxious role most certainly is not. They get the short end of the stick.
We who journey into the field of medicine usually do it with the idea that we are going to be doing something good, with the perks of prestige, respect, money, and all that good stuff. Getting into medical school is not easy, and this is probably a good thing. Those who end up in the field have to be dedicated. Often we are more than that. We pursue this career with single minded determination. Medicine becomes something that defines us. This is actually unhealthy and can lead to severe crisis or burnout if things go awry. This makes a teens accusations of wasting my entire life much more threatening and hits close to home. In what is an important trend for doctors, far more prone to suicide than most, more and more of my generation are asking for more and more balance to our lives.
Still the trend in medicine continues that many, myself included, become obsessed. We are the ones on the college campus complaining about every B+, hassling every professor about grades. Why? Because they really matter. We are separated out on the basis of GPA and test scores with experience and volunteerism thrown in for good measure. Standardized tests are an interesting thing. They tend to teach us that questions always have a right answer. In the first two years of medical school, textbooks are our great repository of information on how to diagnose, treat, and bind up the wounds of the wonder that is the human body. We learn the key words, the classic descriptors, the actions and course of disease in the body. You work hard enough, the understanding comes.
The problem is, that for too many, when we suddenly throw ourselves into the world of patient care in the third year, we learn that not only do we know very little about what is going on with the patient, but too often there is uncertainty even with the attending physicians who have been at this for decades. In fact, it seems the more experience you get, the more you realize you do not know. Residents are both more confident and less accurate than their attendings. As we mature, diagnoses come with more caveats and qualifiers.
The art of medicine is learning solutions that don’t always involve causes. Beyond that, patient’s are not as passionless and rational as textbooks. This can be a hard thing for a scientist. After all rationality is the only virtue that matters in science. Emotions will only get in the way. On the other hand, The doctor patient relationship is deeply complex, much more that say, mechanic and automobile, or scientist and experiment.
This leads to the frightening realization that the effectiveness of treatments to some extent depends on how much the doctor believes in them. It turns out patients and their diseases don’t read the textbooks. People react differently to the same things. They don’t listen to what you say just because you have spent your life studying how the body works, but they do listen based on how much confidence you project.
To further complicate the issue, science and knowledge are not static, they advance. What is pushed as medical gospel and bedrock one day can be thrown on its ear and discredited the next. It’s unnerving, and at some point a little jading. Is exhibiting confidence in medical science decieving yourself? It may be from the scientific skeptical mindset. Medicine has been a powerful tool historically, but it has also led to a sad share of bogus treatments, even patient harm on rare occasions.
It is this world of science and uncertainty, emotion, pain, anxiety, and hope that I have thrown myself into. This is what I have been studying, “my entire life.” Indeed this is the art and science of medicine, and I am excited delve into its mystery and gain experience for the rest of my life, in its entirety.