The transition

I didn't get to see any patients today - it was mostly lectures in the morning followed by case-based discussions. Once again I was reminded of how much I have forgotten, and yet also how much I still retained. Bits of pieces of random knowledge flit through my head as we go around the table asking and answering questions. All I recall from Neuroscience was falling asleep staring at the pictures of brain slices projected on the wall, and hallucinating about Mickey Mouse ears in the spinal columns. Yet, random items like the "reticular activating system", "corona radiata", jump into my head without bidding. Nevertheless, unable to make sense of much of the jumbled up bits of information, I'm dreading all the reviewing/reading I will need to catch up. I write, "Get textbook" as one of my "To do" items, along with a list of new terms I just encountered.

This transition is reminiscent of my return to medical school from graduate studies. For the past two and a half months I've been spending time in my old research lab trying to wrap up an old project and starting a new, exciting project. When I'm in the lab, I feel on top of the world - confident in my surroundings and familiar with the words, phrases, etc. of my field. When I'm in the hospital, I feel like a first year medical student all over again - timid, unsure, and uncomfortable in the basic tasks of getting a history/physical and formulating a differential. I find I much too often zoom on on a particular diagnosis and have a hard time pulling back and considering other options.

It's weird - in science I can often scrutinize the reports of other people's work as well as our own result and often bring up alternative explanations for the results. I do this to challenge the conclusions and when I'm out of objections I finally consider the results/conclusions valid. Why is it that in clinical practice I'm often unable to do this? Given a presentation, certain ideas jump into mind and I have a hard time thinking of others. Part of the problem, I believe, lies in my lack of confidence and lack of fund of knowledge, but partly also from the practice of medicine itself. I like coming up with a hypothesis and then testing that hypothesis with conclusive, diagnostic tests. However, oftentimes in medicine this is not possible. We can't always perform a biopsy to see what's going on. I feel that medicine is all about gambling - we all strive to beat the house by knowing the system, knowing the odds and betting on the odds, but rarely do we get a definitive answer. Empirical trials of drug therapy are all too common, and many of the "syndromes" and "diseases" are defined not by pathohistological/molecular/genetic standards, but rather descriptions. So many different causes can all yield similar outcomes, yet we all lump them together into a single syndrome. And then on the other hand, we have the genetic/phenotypic variability inherent in individuals that take a single causitive agent, e.g. infection with B. burgdorferis or Lyme disease, and generate multiple, different outcomes. What is medicine, then, if not simply guessing? We take a collection of symptoms and guess at the most probable cause (based on historical data) and then attempt to change the course (often with empirical trials).

Ever wondered how they got the "probability of precipitation" estimates in weather forecasting? That's right - it's a guess based on historical data compared to present day observations. Medicine is no different. We're simply glorified weather forecasters or car mechanics (more on that analogy perhaps in a later post), and that irks me.

It's odd that many physicians downplay the role of imaging - they pride themselves on being able to predict the outcome without resorting to expensive MRIs, CAT scans, etc. And yet the gold standard often remains "taking a look" - be it a surgical operation for a first hand look, a biopsy specimen for microscopic examination, or MRI/CT scans for imaging without having to open up the body. I see nothing wrong with looking at the inside of the body no matter how confident you might be in a certain diagnosis, because as I've alluded to before, it's most likely drawn on nothing more than probability, guesstimates. I believe that if we ever develop a truely non-invasive, fast, non-toxic internal imaging system, it would revolutionize medicine and change it from a "practice" to a "science". The alternative, of course, would be some sort of no-risk surgery. This idea, however, is what will ultimately doom healthcare with exorbitant costs - but more on that later.