..I don't count Jennifer among my mistakes. She had a severe infection and precious little reserve. Nevertheless, I think of her often. Those minutes of terror and confusion I felt standing powerless in her room served as a visceral reminder throughout my training... that the big picture isn't enough in medicine...
Lisa SandersThe basic sciences of anatomy, physiology, biology, and chemistry are linked to a patient at the bedside through very specific stories that doctors learn and eventually create. These stories, what researchers now call illness scripts, contain key characteristics of a disease to form an iconic version, an idealized model of that particular disease. … It is the story that every doctor puts together for herself with the knowledge she gains from books and patients. The more experience a doctor has with any of these illnesses, the richer and more detailed the illness script she has of the disease becomes.
Lisa SandersA lot of the appeal of internal medicine is Sherlockian—solving the case from the clues. We are detectives; we revel in the process of figuring it all out. It’s what doctors most love to do.
Lisa SandersMuch of the education doctors get in their four years of medical school and subsequent years of apprenticeship training is focused on teaching this skill of identifying and shaping those aspects of a patient’s life and symptoms, exams and investigations that contribute to the creation of a version of the patient’s story that makes a diagnosis possible. Indeed, the ability to create this spare and impersonal version of the patient’s story is THE essential skill in diagnosis.
It’s also one of the aspects of medicine that can seem the most dehumanizing.
If a doctor has worked through the problem well, there’s a very good chance that one of these possible diagnoses will be right. The rest though, by definition, will be wrong. We are regularly wrong in the pursuit of being right. … The question we are taught to ask ourselves is, if it isn’t that, what else could it be?
Lisa SandersIn medicine, uncertainty is the water we swim in.
Lisa SandersBut then there are other cases… Cases in which the narrative of disease strays off the expected path, where the usual suspects all seem to have alibis, and the diagnosis is elusive. For these, the doctor must don her deerstalker cap and unravel the mystery. It is in these instances where medicine can rise once again to the level of an art and the doctor-detective must pick apart the tangled strands of illness, understand which questions to ask, recognize the subtle physical findings, and identify which tests might lead, finally, to the right diagnosis.
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