As the second year of medical school drew to a close, our education moved from lectures in the classroom to rounds at the bedside. We assumed the role of apprentices, expected to model ourselves not only on the clinical acumen of the senior physicians, but also on how they communicated with patients.
Each student followed a sequence of assignments to the different wards, and my first months were spent with the surgeons. Despite the grueling hours and heavy workload, the experience was exhilarating. I watched with awe as a woman’s chest was opened, exposing a gritty stenotic aortic valve, which was replaced with a functioning prosthesis. The procedure took many hours, and demanded a precise choreography of care among the heart surgeon, anesthesiologist, and cardiologist. As the last sutures were placed, the resident remarked how it was “a great case.”
While surgery offered the drama of dexterous skills, my next assignment, to internal medicine, prized broad thinking. The aim was to generate comprehensive lists of possible causes for the patient’s symptoms and physical findings, so-called “differential diagnoses.” It was like assembling a large jigsaw puzzle, but you did not receive the pieces all at once: rather, you had to guess which next piece to seek by ordering one diagnostic test or another—should it be a certain X-ray, or a particular serology, or a tissue biopsy? Then you evaluated whether the new piece of data fit and solved the puzzle, or whether more was needed to form a coherent picture. “Great cases” on the internal medicine ward were ample. I recall how our team of residents and students identified a rare form of malaria in a botanist with raging fevers who recently had returned from Africa, and discovered an overlooked lymphoma that was the cause of a patient’s kidney failure. After surgery and internal medicine, I was assigned to pediatrics, and there became frozen in my tracks.
Some of my day was spent in the outpatient clinic, where mostly healthy children arrived with sore throats or ear infections, and our prescriptions for acetaminophen or antibiotics were rewarded by a parent’s relieved smile. But the other part of the day was on the wards, among scores of children with incurable illnesses. There were listless babies with a dusky hue whose malformed hearts defied surgical repair, toddlers with cystic fibrosis struggling to breathe through airways encased in cement-like mucus, middle-schoolers with brain tumors that blunted their vision and unleashed violent seizures.
In the evenings, the images of these children could not be moved from my mind. I was unable to concentrate on the medical articles assigned for reading, or prepare presentations for the next day’s rounds. I could not summon the cognitive dissonance that allowed labeling a patient “a great case,” and had no capacity to marvel at the complex biology of a child’s disease. As I looked at these suffering youngsters …