My people

(For reference, "Medicine" refers to internal medicine as a specialty; "medicine" to the field in general. Hopefully that will prevent some confusion.)

I often get questions about what kind of doctor I'm going to be. At this point in my life, I can't say for sure (even though Diana would like the answer RIGHT NOW). I can say that Internal Medicine suits me well. Why? Because it allows you, nay, even encourages you, to be skeptical.

For the past week, I've had a very interesting patient (see my previous post on being "interesting"). He was good-interesting in that his diagnosis was a mystery while at the same time he was not in danger of "crumping", to use ward lingo. In short, he was a man in his 60's who was brought into the ER by his son for what amounted to failure to thrive. He acted confused, hoarded possessions and rotten food in his house, and was isolating himself. His only complaint was abdominal pain, but he was extremely unkempt and in generally bad shape. What was interesting about him were his labs, which suggested that he had a hidden infection, that his red blood cells were slowly bursting like balloons, and that his liver was failing to produce many essential proteins. As we always do, we came up with what's called a "differential diagnosis", which is a list of all the possible explanations for what's happening. Ideally, there is one unifying theory, but in reality there are often many processes occurring at the same time.

Most of the other people on my team thought that he had a Vitamin B12 deficiency. I presented the case to my classmates with the attending physician in charge of medical education. We went through the differential diagnosis, discussed the labs, and even looked a smear of the patient's blood under the microscope. All signs pointed to B12 deficiency. The attending confidently stated that this case was "classic" for B12 deficiency. On the board where we keep track of our patients, next to the patient's name "abdominal pain" was replaced with "B12 deficiency". Fortunately, there is a simple test to determine if the patient is indeed B12 deficient. Unfortunately, it takes days for the result to come back.

I didn't buy it. When this patient was admitted, I stayed up all night on call trying to explain what his labs had shown. B12 deficiency was one of the first things I considered, and I thought it was very likely. But I just wasn't convinced that it could explain everything. I tried not to be too vocal in my dissent because one of the most important lessons you learn in 3rd year is that after two years studying your butt off, you still don't really know much. But every once in a while I couldn't resist registrating my dissent. After we had looked at the patient's apparently convincing blood smear (the matter of the blood smear deserves a separate post) and my attending made his remark about this being a "classic" case, I said, "So what are we going to do when his B12 level comes back normal?" I felt like I could say this because my impression had been that skepticism is rewarded in Internal Medicine - you just better have a good reason to be skeptical.

The B12 level came back that afternoon and was normal. It was not even in the borderline range, which is a problem with B12 tests. Based on this result, it was virtually impossible that the patient was B12 deficient. It was late in the day though, and no one on my team was around to watch a wave of vindication light up my face. Naturally, I went to see the attending, and when I told him, he just laughed and laughed. He loved that he was wrong! And this is the attitude I've seen while on Internal Medicine.

Most of the Medicine doctors I've met love a diagnostic challenge, and they know that nothing in medicine is certain. That's why it's okay to be a contrarian. When it turns out that being contrary is correct, the pressure is on to provide an alternative explanation: you sit and review all the data, you talk with various people, you devise crazy explanations that you know sound ridiculous. I find that this process suits me very well. Those of you who know me well know I can be something of a skeptic - I've even been accused of being a contrarian. In my own defense, being skeptical means not accepting assumptions without reason. It requires examining your thinking at each step. Medicine seems to attract these kinds of minds and tends to be one of the more intellectual fields within medicine. Medicine doctors are not just intellectuals though, they also have more contact with patients than most other physicians in the hospital (not to mention that most Medicine docs work outside the hospital). For that reason, as I explained to Diana, I feel like I've found my people.