Thread by @medicalaxioms

I used to hate it when I would present the case at the bedside and the attending would stare out the window at some shiny spot a half mile away. [thread]

At the end of the presentation they would ask me if the patient had a fever and I would say, “Like I said, the Tmax was 37.3C so no.”

Now I have become that attending physician and I understand completely. Doing this part of the job is very intense and requires parallel processing of a number of tasks including:

1. Hearing and processing the details of the case in real time without writing such that I can arrive at my prioritized differential diagnosis at the same time the resident finishes reading theirs.

2. I have to judge the patient and family response to this process. Having never met them before, I have to start to figure them out. Are they on board? Are they already soured to this hospital visit?

3. I have to judge the quality of all the information I am receiving. How well does this history seem to have been done? Does it ring true or are their gaps. Like a cop does when they hear a witness start talking. It eats up a lot of cognitive energy and requires intuition.

4. I search the room for clues. Shoes. Canes. Food. Bags of personal property. IVDU scars, fingernails. Dentition. Malnutrition. Plastic inserted by nurses and doctors. One ear is listening to the story and one eye is looking for clues.

5. I have to assess the storyteller. If I was a piano teacher, I would know the music and I could just judge how it is being played. In this case I have to hear a new song in each room and judge the technical performance at the same time.

So far this stuff is not to hard to do, simultaneously. Then it gets hard.

6. In the midst of all this information and assessment, there is a fairly high level cognitive process involved where the seasoned attending has to figure out what the residents in the room don’t know.

#findthegap

Noticing where the thinking is cattywompus or noting the likely diagnosis that is missing is a bit of a challenge.

Trying to figure out where the likely gap in knowledge is that lead to the error is hard.

I have to review my own education and training. When did I learn that? What experience or patient taught me that lesson? What stage was I in? Is it a lack of education, training, experience or basic principle? I may weigh 2 or 3 options while the presentation keeps going.

Should I teach to this gap with a reference? A story? Draw a figure?

Should I teach to the student? The intern? The resident?

Sometimes for this part I have to shut down my eyes so I stare out the window. I can never stop listening because the story is still unfolding. As I shuffle visual memories and consider different 60 second lectures, I stare at the church steeple across town.

7. We aren’t quite done though. Despite all these simultaneous tasks I am still a doctor and before me or next to me under the blanket is my newest patient.

I have only one chance to make a good first impression. I need to be soft. Attentive. Aware...

I need to notice tears and respond. I need to hold a hand when a hand should be held. Get a box of tissues before they are required. I cannot ignore how I appear to the patient and their family.

In summary, it’s very busy in my Brainy McBrainbox while the team is talking in the room. If there are times when I miss a datadotdetail it’s not because I was thinking about running in slow motion with my Special Lady Friend on the beach.

I have to turn down the senses when I turn up the CPU and it’s hard to see what in front of your eyes when you are seeing figures and mental photos of patients from the past in your mental visual workspace.

Practicing real time medicine with the patient in front of you is harder than collecting data and processing it in the calm spot in front of the computer.

Practicing real-time medicine with data of varying quality presented to you in front of the patient is a little harder still. No attending doctor ever told me what they were doing while they were staring out the window.

I hope you have enjoyed this glimpse into what may be your future. 🤓🤓🤓