Wednesday, September 30, 2009

A Clockwork Orange Tonsils

The title will make more sense later. Bear with me for a minute, as I have two topics to touch on. After a particularly difficult exam on Tuesday (and a few classes), we had the opportunity to participate in what our Essentials of Clinical Reasoning professors call Patient Day. I described, earlier, the process of taking a History of Present Illness (from here on: HPI) from a standardized patient. Patient Day involved three real patients, sixteen white-coated M1s, and some other form of medical professional to moderate. For each of the three patients we talked to, we were tasked with eliciting an HPI, a medical history, and a psychosocial history. As there were sixteen of us at a time, we were supposed to take turns asking appropriate questions and follow-ups in the general order in which we were taught. That has to be disorienting for the patient, or at least reminiscent of a firing squad.

So why Anthony Burgess? As the first patient described her symptoms (achalasia) and we asked about discomfort, she said that she occasionally had "The Sickies". Viddy this, my droogs. I then spent one of my precious questions attempting to, in a roundabout manner, get the patient to explain The Sickies without my having to ask directly. Turns out that The Sickies are nausea. Add another hurdle to the process of extracting information from a patient: deciphering their personal lexicon. Hopefully that will also serve as a reminder to make sure I'm translating my thoughts back to them as well. May I share another vignette? You're nodding slightly, so I'll continue. This also involves a guessing game for those with medical background. Answers provided later. I once had a discussion of a similar nature with my parents about their patient population while in residency at LA County Hospital. I may be smudging some details, but so be it. They would see patients who, when asked about medical history or current illness, would say they had Smilin' Mighty Jesus* or Fireballs in the Ucherest**. After consulting with people who had been around LA County for a longer period of time, they realized what their patients were telling them. Even though early medical students have limited exposure to patients, it's clear we not only have to understand our patients but make sure they understand us.

Another interesting part of the medical education process? The blurts. We see a lot of PowerPoint slides in lecture every day, on the order of hundreds. Most classes make a point of adding in clinical correlates so that we have some idea why we should care about Type I collagen or Superoxide Dismutase. A byproduct of the way my brain works is that I'll link inexorably two facts to the degree that I'll see one somewhere and my brain will blurt out the other. Case in point? Tangier Disease. Learning about lipid metabolism, we learned that a mutation in a particular gene causes a defect in cholesterol transport, eventually leading to buildup in the tonsils (and other organs) that gives them an orange color. A day or two after that lecture, I heard someone say "tangerine" and my brain tripped over itself rushing "orange tonsils" to the tip of my tongue. I'm sure this is healthy and not in any way a sign of insanity. Also, did you know that your brain literally sends words to your tongue via a series of tubes like at the bank? Anatomy is neat.

* Spinal Meningitis
** Fibroids of the uterus.