Getting Past the Hype

Only one percent of all visits to physicians take place at academic medical centers. And yet, because as medical students and residents we spend all of our time at these institutions our views of the profession are colored accordingly. As I am a resident at a large academic medical center (Duke) you need to take what follows with a grain of salt.

Medicine is not as glamorous as you may be lead to believe by depictions of the profession in the media. I know that you, gentle reader, already know this but I don’t think the typical medical school applicant realizes exactly how much of a grind certain aspects of medicine can be.

First of all, the patients are not all nice looking and don’t all come with compelling stories. Sometimes your patient is going to be an 87-year-old senile lady transferred from a local nursing home on a “soft admit” who’s past medical history runs to two pages and who is taking twenty different medications. She will be demented, diabetic, fluid over-loaded from heart failure and renal failure, a double below knee amputee from diabetes, and she will just lay there making occasional primitive noises.

Name a system and she will have a major problem with it. Dialysis on Moday, Wednesday, and Friday. Ileostomy for total colectomy. History of multiple angioplasy. This is a patient who will be wearing an adult diaper and will be spoon fed by a nurse’s aid if she’s not being fed through an nasogastric tube or a PEG.

And the transfer note will give as a reason for transfer, “Shortness of Breath.”

Duh.

Or you may find yourself in the Emergency Department working up a local gang-banger and you will realize that the typical thug is just not that glamourous. They beat their girlfriends, have the emotional development of twelve-year-olds, and do not have the souls of poets. Not that I don’t enjoy this kind of patient, because I do, but these are not gritty philosophers who have any legitimate things to tell you about your own life except perhaps to reinforce your decision to send your kids to private school.

After you pick up a patient, you will also find that the majority of your interventions and decisions are going to be pretty routine. Many aspects of medicine lend themselves to algorithms which you pretty much follow mechanically for most patients. Someone comes in with chest pain, for example, and you will automatically get an EKG, chest films, cardiac enzymes, and lytes while you start him on oxygen, nitro, and morphine. If his enzymes are elevated or he shows acute EKG changes you will route him to the CCU for thrombolytics or to the cath lab for an emergent cardiac catheterization.

Most chest pain patients, however, do not have dramatic EKG changes and elevated cardiac enzymes and settle down pretty quickly under the onslaught of your algorithm. When you first start your cardiology rotation as an intern you will be terrified when the Nurse pages you with a patient in acute chest pain. By the end of the rotation you will be non-plussed unless they show you the money.

On the other hand you always have to be wary of the patient who will not follow the algorithm.