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People Not Pathology

It took a dermatology rotation to remind this med student exactly why he was going into family medicine.

By Michael Richardson

“What am I doing here?” I asked myself as I sat through the weekly journal club at the clinic during my dermatology rotation, a presentation on some histological finding.  I was just a few months away from finishing med school and was on the last week of my dermatology rotation, anticipating Match Day and entering family medicine.  I had arranged the dermatology elective, along with several other subspecialty rotations, to build my medical knowledge and become a well-rounded family doctor.  But that day, all I really wanted to do was go home.  Everyone had been kind and respectful. Residents and attending were willing to teach and share interesting pathology, but I just wasn’t happy.  I actually couldn’t remember the last time I was happy to come into work.  How could I be burnt out and not even be done with medical school?

The clinic day continued, with residents and attending pointing out cases to me that they thought were interesting. “Warts are in room 5.  Acne in room 2.  Sarcoidosis is in 3!  That’s exciting!”  Rooms full of pathology are not necessarily my idea of a good time, but I appreciated the doctors’ attempt to involve me.  After the morning session, I had lunch and rallied myself for the afternoon clinic.  I would be in a clinic without residents, which would mean I would have a lot more hands-on involvement.

I was sent to interview an elderly couple, both in for their annual skin checks.  These visits are usually very quick as we take only an abbreviated medical history when we do a quick skin exam.  When I asked about any recent medical changes, the husband informed me that his wife had just been discharged from a two-week stint at our neighboring hospital.  “She was admitted for hyponatremia and was diagnosed with SIADH [syndrome of inappropriate antidiuretic hormone secretion].  They also found a lung nodule.”  I was taken aback by the husband’s fluency with the medical terminology for his wife’s condition. 
“I don’t know why they won’t let me drink very much water. I’m so thirsty,” said his wife. 

Soon I was explaining her predicament in very basic terms. Usually the body does a good job regulating water, but her nodule is sending signals to retain more water than she needs, leading to her salt problem, which could happen again if she drinks too much. 

“Wow, I get it now.  I’ve never heard it explained so simply before,” the husband said. This elderly couple whom I had thought had remarkable health literacy actually had no idea what was going on with their health. They had received extensive medical care, were informed of the diagnosis, but no one took the time to see if they truly understood it. The husband repeated the words the doctors had said to him, but he didn’t know what they meant.

The skin exam was now the last thing on my mind. I wanted to help them understand their predicament and coach them through the next steps in care.  I wanted them to know I cared about them, that I would be there for them and help them navigate our amazingly complicated health care system. My mind was racing with all these thoughts until my attending came in, performed the skin exam, and sent them on their way to follow up in a year. 

I knew then what I was missing. I missed taking care of people. For the past few months, rooms had been filled with pathology instead of people.  Instead of focusing on a nervous young boy, for example, whose confidence had been plummeting since puberty, I was supposed to focus on acne. Or instead of an elderly couple confused about a new diagnosis, I was supposed to focus on irregular moles. In medical subspecialties, there is a tendency to place a heavy emphasis on pathology. A specialist is asked to manage the diagnosis; I want to manage the patient.

Much of our value as future physicians is determined by exam scores and how well we understand the biological processes of disease, which are the focus of extensive lectures, journal clubs, and rounds. The patient’s thoughts and feelings and the underlying factors that affect medical self-efficacy are rarely the topic of discussion. We are quick to label patients as “nonadherent” because we have immersed ourselves in a world that has us believe that our advice is self-evident, not realizing that we need to bridge the gap in knowledge through more effective communication with our patients.  It is far easier to blame our patients for not listening, than to ask ourselves if we are the ones mishandling the message.  

I chose family medicine as a specialty because of its emphasis on people over pathology. By giving a person’s biological, psychological, and social health equal gravity in developing a treatment plan, we can make a remarkable difference in a person’s life. After meeting with the elderly couple, I remembered why I was in a dermatology rotation. I wanted to be a better doctor. I wanted to improve my knowledge so I can become a better communicator and guide my patients through their lives, not just periods of disease. Primary care will let me to do that. 

Michael Richardson is a 4th-year medical student at the University of Massachusetts Worcester. He plans to enter family medicine residency in the summer of 2014. Michael’s research interests include social determinants of health, obesity prevention, and redefining primary care delivery. 

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