I learned how to perform a pulmonary exam today. Now, I've found that I'm decent with the actual examination part. I can go through the motions pretty well (take a deeeeep breath in, hold it, breathe out, good), but when it comes to knowing what I'm seeing, I fail miserably. My patient's lips looked slightly blueish to me, but not enough to call them "cyanotic". He was a little on the heavy side, so his chest was big, but he wasn't "barrel chested". He got slightly out of breath when he talked too much, but his breathing wasn't "labored". His fingernails were a bit rounded, but they didn't exhibit "clubbing".
All of those are pathognomonic findings that show up on tests and boards, so you can say "ah HA! They said clubbing, which is usually associated with lung cancer!". But what if you can't see the symptom? They make this out like it's a cakewalk - patients with EMPHYSEMA present with nicotine stains on their fingers, labored breathing, and a barrel chest - but I'm starting to get the sinking feeling that all of these symptoms are shades of grey.
After the exam was over I had to document my findings. He had an obvious wheeze upon expiration on the anterior chest wall, but that was the only thing I was 100% certain about. I threw in some other "findings" that I didn't really find - which we are told NEVER to do - because just one finding didn't seem like enough. Cyanosis, clubbing, barrel chest, and labored breathing all went on the sheet. I was then asked to make a diagnosis, which I hesitantly called chronic asthma. I had noticed that he was short of breath upon exertion and that he was wheezing at the very end of his exhalation. That's all I had to go on. Then he took the sheet and corrected it. Turns out he did have asthma and wheezing, but that was about all I got right.
I'm feeling a bit unnerved by the whole experience. This time around I had someone to tell me what the correct answer was, but now I'm thinking back to this post and putting myself in the place of the doctor who doesn't know what's causing the woman's abdominal pain.
Can I really tell a patient "I don't know what's wrong with you"? I've done it before, but I'm a medical student and there is always someone above me who can catch my mistake. I remember looking at docs in the ER who would say "we don't know what's wrong with you"... and I always nodded my head sagely and thought "medicine doesn't know what's wrong with you". But now, I'm thinking that when I'm there, I'll realize that "We don't know what's wrong with you" really means "I don't know what's wrong with you". Me, personally. My fault. My failure.
I remember the doc I worked for this summer said something that struck me. "Zac, you keep thinking that as you advance in medicine, things will get more and more clear. They don't. Medicine is always murky and confusing, and you hope to god that you're doing the right thing for your patients, but you never know".
That is one scary thing to have a 50-year old, phenomenally successful physician tell you.