Today we had a small group discussion for on of my classes, and were instructed to talk about possible causes for a patient's heart failure. We came up with the usual ones, like myocardial infarction or congenital abnormalities, but the case description was not totally straightforward, so we tried to come up with some of the more obscure ones as well. In the course of our continual brainstorming, one of my classmates declared: "It could be all in his head. Psychosomatic is always in my differential!"

Whoa. To me, that was an incredibly insensitive thing to say. Yes, I know that these cases do exist, where there is no identifiable medical cause for a patient's symptoms. But to say it's always one of the main possibilities you think of? No way, not for me.

I think as doctors we owe it to the patient to assume that whatever he is describing is real and based on something we can help with. Several years ago, when my mom was going through a period of major medical distress, she was basically told by one of her doctors that she was crazy and to go talk to a psychologist about it. (She wasn't; a different doctor identified the real cause and treated her successfully.) To this day, when she tells me about it, I can tell it was such a hurtful experience. In reality, I doubt that doctor was trying to be mean; he probably did feel like he had exhausted his diagnostic options. Still, I know there must have been a better way to present that conclusion, including keeping options open for a second opinion.

When I am in practice, I will include psychosomatic cause on my differential, but I never want to consider it until I'm sure we've ruled out any other possibilities. Of course, this may change as I get more clinical experience; many of these sort of "when-I'm-a-doctor-I'll..." convictions have already been overturned in the short time I've been in medical school. I hope that this one, at least, will stick with me as I can imagine nothing more devastating to a patient in distress that his doctor has given up on finding out the cause. I'd rather say, "I'm not sure what's going on, but we'll work through it together."

I think my new favorite word is "Candesartan". Doesn't it just roll right off the tongue? It reminds me of so many lovely things all at once: candles, satin, candy; and it just has an exotic ring to it. If I didn't know what it was I would think it was a kind of fancy foreign sweets, like they sell in really nice candy stores. It just sounds smooth and creamy and delicious.

However, the reality is far less interesting. It's a lowly blood pressure pill, an angiotensin receptor blocker, to be specific. But it sounds like it could be something so much sweeter...

You know you're studying too much when...

...it feels more unusual to be biking without a backpack than without a bike helmet.

More than once in the past couple weeks I've absentmindedly forgotten to put on my bike helmet before heading home from school, only noticing right about when I was arriving home. On the other hand, when I left the library for a little while today, leaving my backpack behind (intentionally), I noticed something seemed different before I even left the parking lot. How did I ever survive before I had a 20+ lb weight permanently strapped to my back?

Can you blame me?

So my medical school, like most medical schools (I assume), has a class to teach doctoring. You know, all the stuff a doc needs to know and do that doesn't get covered in anatomy and physiology and those sorts of courses. Stuff like interviewing patients and doing physical exams. And even though most of us treat this as sort-of a not-class, in that it's not as intellectually demanding as, say, pharmacology, I actually quite like it. Don't get me wrong, I like hard science too, but it's nice to have a class to think about the people side of medicine.

Anyway, this year (year 2 of med school), in Doctoring, they are starting to stress differential diagnoses, so that's what we were working on at our first small group session a couple of weeks ago. And as part of this practice, I was performing a physical exam on a standardized patient who (fictitiously) had pain in his right elbow. We learned basic physical exam skills last year, but not really any focused skills. In this case, apparently, I needed to do a joint exam, and in my original attempt to pinpoint the location of the patient's pain, I gently touched his elbow and said, "Is this about where the pain is?" And he replied, "Well, it doesn't hurt now; you're being so gentle." So I laughed and replied smilingly, "Well, I don't want to make the pain worse," thinking that this must be the right sort of thing to say and do.

But no! I got mildly scolded by our group leader (an Internal Med resident), who told me "It's okay to cause pain." Which, I guess I understand. After all, we've already gotten the lecture on how Hippocrates' "First, do no harm" couldn't possibly be followed literally by any doctor, or surgery (and may other fields) would not exist. I guess I felt that in this case, there was little reason for me to even come close to causing this man pain, since I was not going to be offering him any sort of treatment based on my findings anyway. Furthermore, he was a standardized patient (an actor, basically, for those not familiar), so I didn't think I would have been able to find anything interesting even if I did examine more thoroughly.

Thinking about this episode, I hope this is the kind of doctor I end up being. I don't mean it literally, as I'm sure I will end up being more aggressive with physcial exams like this. But I hope I stay the kind of doctor who errs on the side of not causing more pain, the kind of doctor who can't put out of her mind that the physical exam may be uncomfortable for the patient, the kind of doctor who remembers what it's like being a patient.