Since I was twelve years old, my life has taken place in a series of Four Year Intervals.
Four years of high school. Four years of college. Four years of medical school. Four years of residency. Four times four, nice and symbolic.
This comes to mind now because I finished my first year of residency today.
I went into it raised on a steady diet of medical TV dramas like Scrubs and House, the legends passed down by other doctors in my family, and the ideas inculcated into me in medical school. It turned out to be nothing like any of those.
I’ve written a few posts about my experiences at work: The Hospital Orientation, I Aten’t Dead, Who By Very Slow Decay, and Evening Doc. I’ve tried to avoid writing anything more specific in order to protect patient confidentiality and my confidentiality.
But I thought this would be a good time to record – for my future self as much as for anyone else – what surprised me in my first year of medical practice.
To start with, forget about diagnostic mysteries. If you’ve ever seen House or anything else remotely like it, you imagine doctors as constantly presented with weird and wonderful symptoms, then racing against the clock to figure out what rare and deadly disease it is.
In real life, patients are more like the elderly lady I got last month. She had three hospital admissions for urinary tract infections in the past two years. Now she comes in with urinary symptoms. Before I even know the patient exists, the emergency room doctor has run a urine test which reveals that it’s a urinary tract infection. He has helpfully started her on the correct antibiotic for urinary tract infections. WHAT COULD THIS DIAGNOSTIC MYSTERY POSSIBLY BE?
Yeah, it was a urinary tract infection.
Or the guy who comes in shaking and sweating. I ask him what happened. He said he has been drinking alcohol for thirty years, and two days ago he tried to stop cold turkey. Have you ever had these sorts of symptoms before? Yes, every time I go off alcohol I get them. Does anything relieve the symptoms? Yes, drinking more alcohol. SOMEBODY PAGE DOCTOR HOUSE TO FIGURE OUT WHAT’S GOING ON?
Yeah, it was alcohol withdrawal.
Not all the patients I got were like this. But probably ninety-five percent of them were. Most people come into hospital for flare-ups of chronic problems they have had for, at minimum, ten years. Most of the time they have been to their primary care doctor first, who has made the diagnosis and sent the patient to the hospital for treatment. Or if not, they go to the emergency room, where the emergency room doctors do the same standard blood test they do on everybody and which usually gives you a really good idea what’s up. Oh, you’re feeling sick and tired and thirsty and nauseous? Hmm, your blood glucose is five hundred. Are you a diabetic? Did you take your insulin? Why didn’t you take your insulin? “Being on vacation” is not a good reason to stop taking your insulin! Do you promise to take your insulin in the future? Okay, well let’s admit you to the hospital and send you to Dr. Alexander so he can clear up this massive medical mystery we have on our hands.
But okay, five percent of cases we’re not entirely sure what’s going on. Now we can page Dr. House, right?
Wellll, in reality we “stabilize” them. A lot of the time “stabilize” means “put them in a bed and give them IV fluids and they get better on their own”. Sometimes the problem looks vaguely infectious and so we give empiric antibiotics, where empiric means “let’s give them an antibiotic that works for lots of stuff, and maybe it’ll work for this”. Sometimes the problem looks vaguely autoimmune and we give them steroids.
It’s pretty funny, because in medical school you spend a lot of time learning about maybe two dozen very rare autoimmune diseases, and how to differentiate Wegner’s granulomatosis from Takayasu arteritis, and the very subtle differences in the aetiology of each. And in real life, my attending says “Huh, this looks vaguely autoimmune, let’s throw steroids at it.” And it always works.
Now I understand that when the patient leaves hospital, they go to a rheumatologist or other specialist, and the specialist probably does lots of complicated tests and then comes up with a treatment regimen perfectly suited to that patient. But at the level I’m working at, it’s more “Hey, it responded to steroids! I guess it really was autoimmune! Or maybe the patient just got better on her own. Or something. Anyway, who cares, patient’s better, let’s discharge before something goes wrong.”
Because something else always goes wrong. You may be wondering: if doctors don’t spend their time solving diagnostic mysteries, what do they do in all those long hours they work? The answer is: deal with the avalanche of disasters that inevitably begin the second a patient walks through the door into a hospital.
I want to make it very clear I’m not criticizing my own hospital here. They make an amazing effort to do everything possible to avoid dangerous complications. All the hospitals I’ve worked at do. And all of them are death-traps. God just has a particular hatred for hospital patients, which He expresses by inflicting random diseases upon them for so long as they make the mistake of staying within the four walls and ceiling of a hospital building.
Like, you can be a perfectly healthy person, who lives forty years without anything worse than a sniffle. And then one day you’re playing sports, and you break your leg and you think “What’s the worst that can happen, I’ll spend a day or two in the hospital?” and by the time you come out you’ve got two artificial legs and a transplanted kidney and a rare bunyavirus from the African tropics and you have to inject yourself with insulin every three hours or else you die.
There are some good reasons for this. Obviously hospitals are full of sick people which means the potential for contagious infectious is high. People in hospitals are always getting lines stuck into them and surgeries performed and otherwise having foreign objects stuck in the body, and of course that’s a risk factor for all kinds of stuff. People in hospitals are often taking medications, which often have side effects. People in hospitals are often having tests, which sometimes involve injecting large amounts of radioactive material into the body and hoping it doesn’t fry anything important.
Then there are reasons you never expect until someone teaches you about them. If you don’t move your legs enough – maybe because you’re lying in a hospital bed all day – the blood in your legs settles and clots, and then the blood clots travel to your lungs, and then you can’t get any oxygen and potentially die. If you don’t fidget enough – maybe because you’re lying in a hospital bed unconscious – the constant pressure on a single patch of skin produces an ulcer, which gets infected and you potentially die. If you take five different recreational drugs every day, and your dealer doesn’t visit you in the hospital, then you go into withdrawal, and if you don’t want to admit what’s going on to your doctor maybe they miss it and – yeah, you potentially die.
But probably the biggest reason – and one you never think of – is that the hospital is where they’re finally doing tests on you, which means all those diseases that were lying dormant before and which you put down to normal old age finally get detected. You come in for a kidney stone, but your doctor does a blood test and finds you have diabetes. Also your calcium is a little off, we’re going to need to give you calcium pills and set up an appointment to get your parathyroid checked. And also when they did the CT of the kidneys they found a suspicious-looking mass in the colon, so you’re going to have to get that checked out. Uh, the gastroenterologist pulled the joystick controlling the colonoscope a little too hard and now you have a perforated colon, you need surgery. Uh, the surgeon put on her gloves the wrong way, now the surgical site is infected, guess you need antibiotics. Uh, guess you’re allergic to that antibiotic, let’s use a different one. Wow, allergic to four antibiotics in a row, guess this isn’t your day!
While Dr. House is diagnosing Chikungunya fever, the rest of us are treating the person who came in with a nosebleed (final diagnosis: blew nose too hard) but now has a DVT, hyperkalaemia, Sundowner’s syndrome, and a line infection.
Well, sort of treating.
John Searle came up with this really interesting philosophy-of-consciousness thought experiment. Suppose that a man were put in a room with a bunch of books, each of which contained a set of rules about Chinese characters. Sometimes, a paper with Chinese characters would come in through a slot in the door. The man would apply the rules in his book, which told him to write certain Chinese characters if certain conditions about the characters on the paper held true, and slip the output back through the slot in the door. The man does this faithfully, although he doesn’t know any Chinese and has no idea what any of it is saying.
On the other side of the door is a Chinese person. In her mind, she’s writing questions to the man, and he is responding back in fluent Chinese. She thinks they’re having a very productive conversation, and is starting to get a crush on him.
And the question is, in what sense can the man in the room be said to “understand” Chinese? If the answer is “not at all”, then in what sense can the brain – which presumably takes inputs from the environment, applies certain algorithms to them, and then sends forth appropriate outputs – be said to understand anything?
Daniel Dennett and various other materialist philosophers have a response to this challenge, which is that the man does not understand Chinese, but the man, his books, and the room can be conceptualized as an emergent system that does possess the property of Chinese-understanding and which may or may not be conscious.
I bring this up, because I understand what’s going on with patient care about as well as the man understands Chinese. I feel like maybe the hospital is an emergent system that has the property of patient-healing, but I’d be surprised if any one part of it does.
Suppose I see an unusual result on my patient. I don’t know what it means, so I mention it to a specialist. The specialist, who doesn’t know anything about the patient beyond what I’ve told him, says to order a technetium scan. He has no idea what a technetium scan is or how it is performed, except that it’s the proper thing to do in this situation. A nurse is called to bring the patient to the scanner, but has no idea why. The scanning technician, who has only a vague idea why the scan is being done, does the scan and spits out a number, which ends up with me. I bring it to the specialist, who gives me a diagnosis and tells me to ask another specialist what the right medicine for that is. I ask the other specialist – who has only the sketchiest idea of the events leading up to the diagnosis – about the correct medicine, and she gives me a name and tells me to ask the pharmacist how to dose it. The pharmacist – who has only the vague outline of an idea who the patient is, what test he got, or what the diagnosis is – doses the medication. Then a nurse, who has no idea about any of this, gives the medication to the patient. Somehow, the system works and the patient improves.
The patient thinks “My doctor must be very smart”. Meantime, the girl outside that room in the thought-experiment is thinking “This man must be a brilliant Confucian scholar.”
Part of being an intern is adjusting to all of this, losing some of your delusions of heroism, getting used to the fact that you’re not going to be Dr. House, that you are at best going to be a very well-functioning gear in a vast machine that does often tedious but always valuable work.
Well, other people are. I plan to go into outpatient.
Starting tomorrow, I abandon this exciting world of urinary tract infections and broken legs and go into psychiatry full time. I’m looking forward to it, especially since psychiatry is a little slower-paced and more focused. But this year was meant to teach me some appreciation for the wider world of medicine.
And boy have I got it.
[Good luck to SSC commenters Athrelon and Laura and everyone else starting an internship or residency tomorrow, and congratulations to everyone finishing one up]