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Vintage Big Med – B Schwartz | On becoming senior & Germanic terms that make us sound smarter than we really are – Jan 2008

On becoming senior & Germanic terms that make us sound smarter than we really are  by Blair Schwartz

[Jan 28 08]

Ok, I know…

It has been quite some time since I wrote anything for Big Medicine.

Its not that I lost my passion for writing, nor due to the absence of several much appreciated e-notes from the editor checking up on me for signs of life. It’s just quite simply that between a ridiculous in-hospital schedule, the occasional shift on the ambulance, reading enough to ensure my patients in both domains survive and trying to maintain something resembling a life, I didn’t really have the time to write a proper entry.However, thanks to the government sending me in exile for one month of community internal medicine and intensive care practice (more on this in an entry to come), I find myself with some time to spare. So I figured I’d sit down at the laptop and instead of reading this week’s New England Journal, I’d put some thoughts down on a *.doc file and share them with you.

Since I last wrote, there has been one major change in my medical “career”… I’m now a Senior Medical Resident. I’d love to say that there was some kind of evaluation or examination preceding this vaunted transition, but the reality is that along with most things in academic medicine, it just sort of happens automatically on July 1st. Along with the nifty title however comes some responsibility. After 17h00 and on weekends, I am now the go-to guy for all things Medicine in the hospital. I’m the one the medical students and junior residents come to review admissions with, discuss concerns about crashing patients, provide medical advice to the other services and lead the cardiac arrest resuscitation team. All this as a Senior Medical Resident!!! Makes you wonder if that also entitles me to have a “Senior” moment, but also what it means to be senior.

There’s an old EMS joke that goes “Just because your partner’s certification date is before yours, doesn’t mean they know what they are doing”. While we can ALL think of individual cases in which this axiom holds true, there is something to be said for real life experience. Whether it be skillfully titrating the Narcan in a chronic pain patient as Norm Rooker so eloquently described in his column, knowing that 20+ sprays of nitro to the hypertensive pulmonary oedema patient will prevent you from intubating him long before the IV is in and the Lasix and Labetalol are on board or simply knowing when to load and go. No matter how modular, problem based or dressed up we make our training programs there are still some things that can’t be taught and herein lies the role of experience.

Medicine is no different.

People often ask me why an Internal Medicine residency is five years long and why we spend so many nights and so many hours per week in the hospital. While some of this is due to the old boy’s club mentality of “In my day this is how we did it, and so you will too” the simple fact remains that the only way to gain expertise in a vast array of diagnostic/therapeutic dilemmas and acutely decompensating patients is to be there when it happens. So when you work in a domain that requires you to be an expert in rare conditions and events, if you’re going have expertise in it, you had better spend a whole heck of a lot of time in the hospital and that’s just what I’ve been doing.

Now let’s be clear here. I am far from an Internal Medicine expert, but I’d like to think that I am starting to acquire my own sense of Geschtalt. To many Geschtalt may sound like something most likely to be served on an Eastern European grandmother’s dining table, and to that end, my grandmother makes better Geschtalt than your grandmother. Period.

In reality it refers to a gut feeling, a sort of clinical intuition that doctors get about a case. Having slugged it out in the trenches as a medical student and junior resident I’ve seen my fair share of cases, seen many sick patients of varying degrees of acuity. Slowly but surely I’m becoming more and more sure of those decisions I’m asked to make at 03h15 as my Geschtalt comes into its own.

Some personal Geschtalt highlights this past week to better illustrate this arcane term:

  • Asked to see a patient with pneumonia regarding changing his antibiotics, examined the gentleman, suggested to the doctor to consider speaking to the family about ceasing antibiotics and adopting palliative measures… the patient passed away that evening before either of my suggestions could be carried out.
  • Consulted for fatigue, lethargy, decreased appetite in an elderly gentleman admitted to long term care. Patient seen and examined, when the nurse asked me what I thought of her patient, I said if gambling on diagnoses was ethical I’d put my money on cancer… Stage 4 Non-Small Cell Lung Cancer it was.
  • Saw a patient in her 70s who was going to surgery to correct a hole in her bladder that had urine leaking into her abdomen. The surgeon told me it was either a tumour or Crohn’s. I politely raised Tuberculosis as something to include in the differential, he scoffed, she’s in isolation 😉

I can’t quite convey to you how good it feels to finally start having some Geschtalt of my own, instead of leeching it from my staff or seniors. It’s like a natural high when everything starts coming together. It’s almost like The Force. It flows through you, and when you can control it, you possess a powerful ally. It won’t allow you to lift your car out of a snow-bank, but you get the picture.

It is this Yodaesque mastery of Geschtalt that makes me hold the real senior physicians in high regards. The docs with 30, 40 and in a few instances 50 some odd years of clinical experience, never cease to amaze. Many of these medical elder statesmen learned their craft in the era before we even knew about DNA as the backbone of genetics, when penicillin and sulfa were all that existed to fight infection and bedpans were made of frigidly cold white metal. Yet I’d gladly trade in what I know about somatic mutations and all the vancomycin in the world for their degree of Geschtalt.

I’m reminded of the time as a 2nd year medical student on my neurology rotation when I saw a young woman with a headache. After I was finished with her, she asked me if she needed a CT-Scan. Feeling confident this was a Migraine I told her it wouldn’t be necessary, to which she replied that she really thought she needed one. I reviewed the case with my staff, a veteran neurologist and he agreed with my plan of action. I reported to him her concerns and with a smirk, replied “It’s understandable Blair, but don’t worry, I have more white hair than you”. She left the office contented and sans scan.

Sure, some Senior physicians may not be as up to date on the latest guidelines or therapeutic modalities, and you’ll find that just about all of them will be the first person to admit it and unassumingly confer with younger colleagues to be sure their patients get the best care available in 2008. That being said, I can’t help but listen eagerly in anticipation as a senior doctor starts a conversation by saying “ I am reminded of a case I saw back in 1959….”, they always end up being absolute gems.

So in my quest for mastery of both the art and science of Internal Medicine and my slow but hopefully steady evolution in Seniority; I will spend the 36 hours on the ward. I will be in-house three out of four weekends per month. While at times it will be brutal, I will be exhausted, sarcastic and even cynical at times. The fact remains that one day I hope to be a master of Geschtalt, and to that end, I look pretty good in a hooded cape.



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