Hi everyone:
Yesterday, a PGY2 asked me about the best way to learn. Here’s what I said: most of what I know I’ve learned from patients.
I’ve learned from classic presentations. As an intern, I cared for a heroin user who howled when I touched his back; he had a paraspinal abscess. I also cared for a veteran with pneumococcal empyema who spiked fevers for weeks despite appropriate antibiotics- “a textbook case” said senior faculty. As an attending, I cared for a NICU patient who peed liters of clear urine after pituitary surgery; the central DI I’d read about but never seen.
I’ve also learned from mistakes. As a resident, one of my MICU patients aspirated tube feeds after extubation. To this day I ensure patients’ stomachs are empty before pulling their tubes. As an attending, I treated a patient for “pneumonia,” dismissing the fact that she had neither fever nor sputum; after she died, her autopsy showed saddle PE. To this day her case reminds me to keep asking questions when the facts don’t fit. Another time, we admitted a patient with septic shock who crashed because his first dose of antibiotics was scheduled for the next morning, a reminder that it’s not enough to order antibiotics; they have to go in.
I’ve learned from attention to detail. During residency, I diagnosed a college kid with aortic insufficiency after noticing wide pulse pressures and a diastolic murmur. As a young attending, I diagnosed hypersensitivity pneumonitis in a husband and wife who’d recently bought a hot tub (I bronch’d the wife and diagnosed the couple). On one of my last floor rotations, we diagnosed a massively obese man with hypogonadism—months into his hospitalization—after we noticed gynecomastia and sparse facial hair, a reminder that there are still diagnoses to be made in patients “awaiting placement.”
Over the past week at SRC, we diagnosed hepatic hydrothorax in a patient with cirrhosis but no ascites, a rectus sheath hematoma in a patient with a mysteriously high platelet count, and IBD in a patient with colitis that was not responding to antibiotics.
I could go on, but here’s my point: we learn the most important lessons from our patients. Yes, you should read papers and books and you should attend conferences, but you learn the best and the most at the bedside, from the histories, exams, labs, images, discussions, and outcomes, both good and bad. If I’ve learned anything over my long career, it’s this: our patients teach us nearly everything we need to know.
Enjoy your Sunday, everyone. I’m heading into the SRC MICU for my last day with the Purple Team.
Mark
What I’m reading:
Pride and Prejudice By Jane Austen
Anatomy of a Disappearance By Hisham Matar
The Moral Paralysis Facing Iranians Right Now By Morteza Dehghani
Autism Rates Have Increased 60-Fold. I Played a Role in That. By Allen Frances
Backyard Hydrangea