A 3rd year medical student walks into a patient’s
room. His short, the pockets of his well-starched white coat overflow with
pieces of paper, small handbooks, his stethoscope, a reflex hammer, a pen light,
and 3 pens. He fidgets a little as he asks the patient questions. His questions
are staccato and rapid-fire. He has a long list of the questions he wants to
ask to make his history complete. Every few seconds, he looks down at the list
of questions in his hand. After about 15 minutes he walks out to present the
case to his attending. His presentation is a mishmash of facts the patient has
given him and a laundry list of physical exam findings. He lists 6 tests that
the patient needs. He stops, slightly
winded from reciting all of his findings, looking up to his attending.
His attending asks what he thinks is going on with the
patient. Caught off guard, he stammers an answer, then a second, and then a
third.
The attending gets up to see the patient. She strides into
the room. Her white coat is slightly wrinkled, has a pen, her stethoscope, a
pen light, and a couple, folded pieces of paper. She introduces herself to the
patient. Her voice is quick, but calm. She asks a handful of specific questions
in between examining the patient. In about 5 minutes she exits the room. She
goes to her student. She says, “We’ll recommend some ibuprofen and a couple
other over the counter medications for his symptoms.”
The attending explains her diagnosis, doling out a few facts
for the student, pearls for him to ponder over. The student is in awe, mind
racing, trying to figure out how his attending conjured up the answer,
seemingly out of thin air, wondering how he would reach such levels of expertise.
************
Regardless of specialty, most clinicians become an expert at
making diagnoses with time. Sometimes this takes a long time, but the clinician
gets there eventually. For most this is a gradual process that just happens
passively. It’s as if you wake up some day after graduation and clinical
competence come easier to you. You’ve become an expert, a master of your craft.
By some gradual and unknown process, you kind of just know.
How did this happen? Is there some magic sauce in the
process of medical education and clinical practice? After a certain point, the
experienced clinician just seems to find the diagnosis.
There is no secret formula to becoming an expert. It is just
experience. However, an astute student can take an active role and speed up
their way to expertise. How? By looking for specific disease patterns. If you
seek out the patterns specifically, you will recognize diseases more rapidly. As
a teacher told me years ago in medical school, “If you do not suspect a
diagnosis, you will not see it.” You have to think of a particular
diagnosis before you can see it. By practicing actively looking for certain
diagnoses, you will get better at finding them. Actively seek the diagnoses
out. Start with common ones, the high yield ones, and then move on to more rare
ones. By doing this, a student can improve their diagnostic ability more quickly.
By purposeful, directed history-taking, a trainee can more quickly build their
clinical acumen than by randomly asking questions until patterns emerge
subconsciously.
If you want to know more about the diagnostic process and
teaching trainees how to make diagnoses, please check out my book: A
Guide to Medical Decision Making
