The Dragonfly Initiative suddenly took me back to those halcyon days of yore, when I could just sit for hours studying things that I find are of little-to-no clinical relevance. Chronic renal failure? Obsolete. It’s Chronic Kidney Disease. Congestive Heart Failure? Obsolete. It’s just Heart Failure, or Decompensated Heart Failure, now. There is no such thing as Non-Insulin-Dependent Diabetes Mellitus, either. It’s either DM type I or type II. Beta-blockers are standard of care in Decompensated Heart Failure. Digoxin is almost useless, except as a way to achieve rate-control in atrial fibrillation. The difference between Q-wave Myocardial Infarctions and non-Q-wave Myocardial Infarctions are academic and don’t make a difference in terms of treatment. What we care about are ST-elevations: STEMIs vs NSTEMIs/unstable angina. And it’s all called Acute Coronary Syndrome now.
Hell, I’ve had to unlearn things I’ve learned during residency already! Erythropoietin can cause serious problems. COX-2 inhibitors are a marketing ploy more likely to cause Acute Coronary Syndrome. LDL is not the end-all, be-all of risk stratification for Coronary Artery Disease. No one I know has actually ever seen warfarin cause a thromboembolism, and it’s standard-of-care to just start it without bridging as long as you know they don’t have a hypercoagulable condition and aren’t a super-high stroke risk.
I’m trying to think of a situation where medical student syndrome became an issue.
All I recall a couple of cases that my friends and family tried to get me to diagnose over the phone, knowing full well that I was just a mere medical student, and that diagnosis without actually seeing the patient is fraught with massive amounts of danger.
My sister develops severe right lower quadrant pain randomly in the middle of the night. She’s puking her guts out, and one of her roommates tries to describe everything to me over the phone. She also has a fever. I’m thinking that it’s probably appendicitis. She ends up in the emergency room, and the urinalysis is consistent with kidney stones.
My friend A calls me up and reports that she gets right upper quadrant pain about 30 minutes after eating meals, and that she ends up feeling bloated and nauseated. A diagnosis of gallstones flits through my mind, but it doesn’t make any sense. The mnemonic for gallstones is 40 years old, female, fat. A is (or was at the time) in her mid 20s and barely weighs 100 lbs. Gastroesophageal reflux disease (GERD) also floats through my brain. But why now?
Then I remember the old dictum: every female of child-bearing age is pregnant until proven otherwise.
I ask her when her last period was, and it’s like three months ago, and I’m like, “What?”
A laughs and tells me she and E are expecting. Now that was a forehead slapping moment that I won’t ever forget.
My dad starts having bright, red blood in his stool and my mom is a little agitated by this. My dad, who is excessively fatalistic, doesn’t seem to care. He says it’s his hemorrhoids. My mom retorts: Didn’t you have surgery done on them? My dad laughs mirthlessly. We both know that surgery for hemorrhoids is no magic bullet. He eventually gets a colonoscopy, and, what do you know? It’s his hemorrhoids. At least he won’t have to have that done for another 10 years.
I’m glad I wasn’t in medicine yet when I had my chronic cough. I mean, this was really a chronic cough. It lasted from September to March. Non-productive. Non-bloody. No shortness of breath. Just this irritating cough that wouldn’t go away. I don’t really think anything of it at the time, but my mom freaks out and demands that I get a chest x-ray, which, predictably, comes back negative. And yet, for some reason, I didn’t get a TB skin test done.
In retrospect, it turns out that it was probably a combination of a post-viral cough and my latent asthma. This is when I realized that there is no such thing as outgrowing asthma, and I’m going to have bronchospastic airways until the day I die.
Oh, now I remember. I got my testicles checked because I have this lump that turns out to be probably a spermatocele. At least, the urologist didn’t seem concerned.
I got my salivary glands checked out by two ENTs because I kept having (and keep having) face pain. One of the ENTs diagnosed me with sialolithiasis and extracted two stones from my Wharton’s duct. That’s probably what it is, and I’m not sure if I should get anything else done about it. The idea of injecting iodinated dye into the ducts to do a sialogram sounds unpleasant, and knowing my atopic history, I may even run the risk of having a contrast reaction, but I should probably get this taken care of while I have insurance.
Lastly, I remember getting motion sickness and feeling nauseated for days and days, to the point where I was basically just going to sleep after coming home from my rotation. I even saw a neurologist, and they found my exam completely normal, and chalked it up to some form of viral labyrinthitis that should wear off in another week or so. In retrospect, I realize that this was probably venlafaxine withdrawal. Damn that drug.
It’s funny how I feel reassured when the so-called experts can’t figure out what’s going on. Unfortunately, this also means that they can’t figure out how to make me feel better. I’m wondering if I should just get empiric treatment with parenteral penicillin, in case this really is an smoldering case of actinomycosis that’s causing sialolithiasis, although this seems pretty damn unlikely. Although it could explain some of the night sweats. (And, no, my last PPD was still negative, and while I may have converted sometime this year, the night sweats would pre-date the point of conversion. And my last CBC was perfectly normal, so I seriously doubt this is leukemia or lymphoma. But, you know what? You never know. How reassuring is that?)
Bayes Theorem is a powerful, yet oft-misunderstood, tool in medicine. Physicians are probably slightly better than average people at estimating probability, but we’re terrible at adjusting these probabilities in light of data accumulated from clinical diagnostic testing. So, despite the fact that very few people, even when considering people with hypercoagulable states, even when considering people with cancer, develop pulmonary embolisms, anyone with chest pain and shortness of breath that can’t be ascribed to Acute Coronary Syndrome, has a pulmonary embolism, no matter what the tests say. D-dimer negative? I don’t care. Get a CT angiogram of the lungs. CT negative? I think it’s wrong. Get a ventilation/perfusion scan with xenon and technetium-tagged macroalbumin. V/Q scan negative? Who cares. Let’s just anticoagulate the guy. This kind of flawed thinking goes on everyday, at the tune of hundreds of thousands of dollars. I think if they just taught Bayes Theorem for an entire year, we might get better at this prognosticating racket. But maybe not.