I got a strange, but great, question from a new consultation client yesterday.
She’d sent over a DVD with a series of imaging studies from a potential case of a failure to diagnose breast cancer and, after reviewing them, I was satisfied that the work-up of an area of asymmetry had been appropriate, that it had been adequately cleared by both additional mammographic studies and by ultrasound so that although there was a cancer two years later I could call it as actually not detectable on the earlier studies and the asymetric area as likely just fibroglandular tissue serendipitously present. I explained to her that I would have done the same work-up and come to the same conclusions based on what I saw, both originally and on additional testing.
She kidded me that I had just screwed myself out of a fee and she offered to at least buy me lunch when I was next around. Then, as we were saying good-bye, she suddenly asked “How’d you learn to just do this?” “Medmal consulting?” I asked. “No – making decisions like this about real patients” she answered.
It got me thinking.
There’s a lot of talk about medical school and residency being exercises in abuse, intended to break you. The experience is often likened to Marine boot camp…but I think that’s wrong. Boot camp is designed to turn an individual into part of a unit but medical training is about creating someone who is actually ready, on their own, to take on the responsibility of another’s life since, well, on any day it may just come down to you alone.
When that clicks into place is the moment that you become a doctor.
I remember when it happened for me.
It was my first night of solo call in residency. Most of the work was pretty routine – pre-op chests for the next day, the evening batch from the ICU, ER cases that needed wet reads and none of which were particularly complicated or risky. Then an MVA C-spine study came up and it was my worst nightmare – seriously, these cases scared me crapless. The patient was – of course – in a collar and on a backboard and his shoulders covered far too much of his spine and his chin covered most of the rest. The request was – of course – “R/O fx for collar removal”. There was no one to ask and it wasn’t a conference case and if I missed a fracture someone I didn’t know could be paralyzed.
I took a deep breath.
I put up the films.
I traced the alignments.
I checked the vertebral heights and corners and the posterior elements.
I put a dash inside a circle – “Negative” – on the slip and I handed the folder back to the ER runner.
He said “Thanks, doc.” and headed out.
I sat back in my chair and said to the empty room, “OK – I can do this.”
I’ve seen a lot of cases since then that were pretty tough – certainly more than that one – and I’ve always been grateful for a colleague to consult with but that was the moment when I knew that I’d actually become a doctor who could do a doctor’s job.
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