the art of medicine

^ I used to think that phrase used to be a steaming pile of an eye-roller cliche. It would be in essays, medical school admission interviews, etc. and I grew sick of the phrase before I even got into medical school. Sure, we all used to say it was about talking to the patient, listening, being a decent human being, and all that jazz. Strangely enough, I think it's a bit more than that.

I used to think that if you knew your shit, you'd be set when it came to medicine. In a way, I couldn't give a good reason why the computers wouldn't eventually replace physicians (think: Watson from Jeopardy). I know I'm only had about a year and a half of solid clinical experience but I'm already seeing why it takes so @#*%ing long to get trained properly - it's so much more than knowing the facts.

Even at this stage, an orangutan that knows how to memorize things could tell you why a patient is vomiting after eating two-day old burgers sitting at room temperature, or why a toddler at this time of year  is developing a barking cough that is worse at night. Classic presentations of diseases or infections don't require much thinking, and even if it's of a relatively rare condition, it doesn't take long for it to be picked up.

The "art" I'm talking about is when there is a patient in the emergency department who is a 55 year old diabetic male, obese, a 30-pack year smoker, having chest pain and all their tests for a heart attack come back negative. Do you really let them go?

How about when that same patient comes in with pretty severe flank pain that's not resolving? Their kidney function and urine are fine. What next?

Each day, I'm learning it's not about the facts. Well, it sort of is. If you're a dumbass physician that doesn't really help... but that's not the point. I never realized that so much of medicine is about clinical gestalt. There were a couple of times early in my clerkship where I saw a patient, examined him or her, ran bloodwork which came back normal and reported that they should be OK. The physician would walk in and simply say, "Hmm, they just seem sick." And eventually we'd find out there was something seriously wrong with them.

Those were always humbling experiences. I used to think geniuses could get so far in life and move up whatever ladder they were a part of much faster than the rest of us. They'd be the ones who didn't have to practice or train as much, and would therefore be a step ahead.

Coupling what I read in Malcolm Gladwell's "The Tipping Point", and what I'm seeing every day in medicine, it's more about exposure, repetition and practice.

One way or another, most people appreciate or gain the science of medicine pretty easily. It's the art of medicine though, that remains elusive.