It takes more than medical school to make a good physician
It is often said that one of the best ways to truly learn something is to teach it.
In my role as director of the Maine Medical Center Emergency Medicine Residency Program, I came to believe that saying, and one thing I learned while working with young doctors in the chaotic setting of an emergency department is that while medical knowledge is vital, it is only part of what it takes to be effective.
A good emergency physician needs to be able to pick up on the nonverbal cues that can indicate when a patient is in pain or anxious or is trying to avoid telling you something. The ability to interpret those cues can help a physician ask the right questions and quickly get the information he or she needs to make a diagnosis.
Residents who have this ability are usually able to arrive at a correct diagnosis fairly quickly. Those who don’t have these skills are likely to develop them with experience, but until they do, they are often much slower at reaching a diagnosis and they may miss something important.
A resident who trained with us several years ago illustrated this better than most.
“Steve” was a Minnesota farm boy right out of central casting with blond hair, blue eyes, and an aw-shucks manner. He was an incredibly nice kid, and to top it off, he was both very good-looking and incredibly book-smart, ranking at or near the top of his medical school class with phenomenally high board scores.
He had not had an easy life, however. Both of his parents had died when he was still in high school and he and his sister had kept the farm going with the help of relatives, getting up every morning and milking the cows before school and helping to raise younger brothers and sisters.
I sometimes wondered if having to take on adult responsibilities so early in life while growing up on a farm had limited his opportunities to develop social skills in new and challenging situations. Despite the fact that he was incredibly intelligent, Steve took a little longer than the average bear to get to the diagnosis.
What most residents could do almost without effort was laborious for Steve. His questions seemed to come right out of the textbook and he couldn’t take those intuitive shortcuts that other residents often used to reach a diagnosis more quickly.
Case in point was a young woman, about 17 years old, who came into the emergency department suffering from gastroenteritis. She had been sick for a while and was weak, dehydrated, and anxious, with a relatively high heart rate of about 120.
We started an IV, gave her two liters of saline solution and some anti-nausea medication, and it wasn’t long before she was feeling much better.
It is not unusual for patients with gastroenteritis, especially when they are young and otherwise healthy, to make a relatively quick recovery after they have a chance to rehydrate.
But just as we were getting ready to send her home with her parents, we picked up on an anomaly in her heart rate. Most of the time her heart rate was in the normal zone – under 100 – but every once in a while it would shoot up to about 180 on the cardiac monitor in the nurse’s station, well outside normal and high enough that it could be an indicator that she was a lot sicker than she appeared or had an undiagnosed cardiac disorder.
Wolff-Parkinson-White syndrome is one condition that can cause an abnormal heartbeat. Wolff-Parkinson-White is usually asymptomatic but in some situations can cause sudden cardiac death.
We ordered an electrocardiogram, which is a noninvasive and fairly cheap test of the electrical activity in the heart.
That came back normal, but we weren’t ready to send her home until we had a better sense of what was going on. Although she was feeling much better, every once in a while her heart rate continued to spike. Steve and I worked with the patient and her family, asking about periods of dizziness or shortness of breath, but we couldn’t find anything that could explain her symptoms.
It was the nurse who finally noticed that the spike in the girl’s heart rate only happened when Steve was in the room. She told him to leave the room and after a while the girl’s heart rate returned to normal. Then the nurse sent Steve back in. Again, the heart rate spiked.
Case closed. The girl was recovering nicely and showing an interest in her surroundings.
The nurse and I stood back and laughed as the whole scene unfolded. Even after we had sent the patient home and moved on to the next patient, Steve still seemed a little confused by the whole thing. Eventually, he became much more efficient at making diagnoses and is now a very successful physician and administrator in another part of the country.
We all learned something from the experience. One thing I learned, or re-learned, is how important a team approach can be in the emergency department.
Steve and I had many years of medical training between us, but it was the nurse who saw her not just as a patient with gastroenteritis, but as a 17-year-old girl.
(Dr. Mark Fourre is an emergency physician and the chief medical officer of LincolnHealth. He also sits on the LincolnHealth Board of Trustees.)
