Notes from a med student

Jason Faber

The questions come flowing out of my mouth more quickly than I can actually consider them, in light of the chief complaint. Here I am, standing over this man on the stretcher in the emergency room, asking him the questions I have asked countless times.

"So tell me ... why did you come into the emergency room today?"

I'm articulating my voice, trying to convey sympathy and compassion for the patient's plight. I already know why he's here ... shortness of breath. I know this because I read the ED physician's note, because I've looked at the EKG and the chest X-ray before I even appeared beside this man's stretcher.

In fact, I have an excellent idea why he's here today. I could tell you what the story would probably be, what his past medical history has probably been like before he walked through the sliding doors with the big red EMERGENCY sign over them. I could hazard an educated guess on what past virtues and vices he's had. All these things I could likely guess at before I could tell you if he had any tattoos or identifying markings, before I could tell you what his voice sounds like or if he came with or without his wife.

I'm articulating my voice because I have a good idea what he's about to tell me. You can always tell how strong a hold a physician has on a suspected diagnosis by the voice: compassionate with inflection on the middle of the sentence if there's a good idea what's going on, flat and bland with the inflection of interrogation at the end of the sentence if there's doubt and uncertainty.

The story runs then as I suspected: increasing shortness of breath, history of heart failure, no fever, no cough, stopped smoking years ago, smoked for 30 years, and on and on. What's changed over the past few years is not that I've become more correct in what I suspect as the chief diagnosis, but in my expectation of how recovery should be once we institute therapy. This is the defining characteristic between medical school and residency: the ability to foresee and adapt to what is expected and what is not expected. It's something dependent on experience and the ability to remain in the learning frame of mind.

Three days later, I'm standing over the same patient, who has only gotten worse over the past few days. I revisit the questions I asked on the first day. This time, I'm not running over the end of his sentences with more questions. This time, I'm not nodding my head when he's half done with his descriptions. This time, my sentences are flat, bland and more questioning with long pauses between to collect my thoughts and clarify the answers. I'm adapting, albeit slowly.

I redo my physical exam, looking closer. With my stethoscope, I listen closely. The resident looks at me and asks what I hear. I don't answer, I just keep listening. Last year, I would have said, "I'm not sure." I would have felt that sense of prodding that students get from residents to start moving faster. Now, I wait to answer.

In the third year clerkships you don't trust your ears, your eyes, your hands. You rely more on what book knowledge you have, as you have no experience with examination. You answer based upon the likelihood of the answer being benign or serious. Now, I take my time, listen for a minute and then look up.

"There's a systolic ejection murmur ...and it's new."

"Are you sure?" the resident asks, grabbing his stethoscope for another listen.

"Yeah, I'm pretty sure." A few seconds later the resident sits up, and nods.

"You're right; there is one there...it's soft but there."

Now we have direction. We walk out and redirect our work-up. It's the last day of my junior internship in Internal Medicine; tomorrow I'll start the last of two electives and graduate from medical school in May.

I'll be starting my residency in internal medicine at Kettering Medical Center. I walk through the hospital going from room to room to say goodbye to my patients ... to my patients. Two more months ... that's it. I don't know if I'm ready to be an intern yet, but I do know I've gone as far as I can as a medical student.

Jason Faber is a fourth-year student at Wright State University School of Medicine. He graduated from Xavier University with an honors Bachelor of Arts degree, with concentrations in philosophy and classics. He is originally from the Cleveland area.