Once again I am in the unfamiliar waters of not having a solid answer at my fingertips. So much in medicine is evidence based - we know that if we give you antibiotics (the right ones) you will be cured of your pneumonia. We know that if we sew your wound closed within 6 hours (newer studies are saying 24 hours for clean wounds), your chance of infection is only about 5%. These are facts as far as we're concerned. No more debating to be done. As students, we learn myriads of these facts and are armed with solid answers for a multitude of medical complaints. And then comes clinical year and we realize that so much of actual medicine is far less certain than we were initially taught. Does this wound need a two layer closure, or will just one do? How many sutures does it need? Is this viral, or bacterial? Will chronic tonsillitis cause a child to have paroxysmal nausea with vomiting? Is this patient septic? Does an elevated carboxyhemoglobin explain all of these symptoms, or just a few? Should this patient be admitted, or not? Many of the questions that we have can only be answered after a lab has had a chance to run certain tests, which often take a day or two. Thus we make treatment decisions based on probability, or more plainly put uncertainty. This is medicine, take it or leave it.
I have spent much effort getting comfortable with this. As a clinical student, it is my job to learn to operate in this world of incomplete certainty - "Mrs. Smith - you most likely have a viral bronchitis and will not need antibiotics for this condition. Use symptomatic treatments like cough syrup and throat losenges. If you're not better in a week, come back and see me and we'll see if we need to do something different." In this case, the most likely diagnosis is a viral illness, but it could be bacterial. We can't be certain without expensive and, sometimes, inaccurate tests. This case is a simple one but they can be much more complex and serious such that if we don't have a grasp of operating in uncertainty then we may end up contributing to a patient's demise.
In the ER it comes down to a relatively simple problem - what could this be that might kill the patient? If we can rule all of those out, but still don't find an answer to exactly what's causing the symptoms, then so be it. We'll have them follow up with their primary care provider later. But when I was working in internal medicine, we were the primary care providers. Here's an example: "I went to the emergency room over the weekend because I was having a lot of trouble with pain in my legs - so bad I couldn't walk. What do you think it is?" In this case, the ER has ruled out the "Big Bads" - things like PE, cancer (sometimes), fractures, and the nasty bacterial infections. But they didn't give the patient an answer - they were only able to treat the symptoms (make the patient functional again, which is always a win in my book), made sure it wasn't anything "serious" and let him go on his merry way. But then in internal medicine we were expected to come up with the answer - this is our job, so I'm not complaining. Yet the patient sits in the examining room and we, without certainty, begin the workup again (usually we don't get the results of all of the tests done in the ER). So from an uncertain footing we begin and we do all the same stuff as the ER docs/PAs/NPs perhaps with the exception of x-rays at first (though, of course, repeating an x-ray after a week can show occult fractures - something to keep in mind). We repeat the physical exam, trying to be perhaps more thorough than the previous provider, and hope to come up with some more clues. Sometimes we get the answer from a test or a physical exam maneuver, but sometimes not. In that case, we have to say something along the lines of, "This is most likely [you fill in the blank]. We'll treat you much as they did in the ER, but we'll try something new that will cure it if it is what we think it is." Talk about uncertainty...
This is generally not how we are taught to practice medicine. In classrooms, we are taught the typical prodromes and clinical pictures of disease - a patient comes in with chest pain when taking a deep breath and his EKG shows a deep S wave in lead I, a pathologic Q wave and a flipped T wave in lead III - what is it? This would be a "classic" presentation of pulmonary embolus (PE) but truth be told, it is nearly never that clear cut. One preceptor notes that in all his years of practice, he has never looked for that classic "S in lead I, Q and flipped T in lead III" pattern for PE. Thus classroom learning, though undoubtedly beneficial, does not reflect real world situations as well as we would like. In my recent (though short) experiences, I would have to say that probably 1/5 or even 1/4 of the patients I have seen have not had "classic" symptoms of the conditions with which they end up being diagnosed. Though this is not news to anyone, I think it highlights the value of clinical experience - both before PA school and our clinical year. In some ways, I believe this year is my true medical education because I not only learn the facts of disease but I learn the uncertainty of medicine as well.
Perhaps if we designed a new curriculum to address uncertainty a bit better, we would all be better off. Of course, whoever can figure out how to do that will be a millionaire and won't ever have to work again. Where would be the fun in that?
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