The first year medical students at Baylor Med just embarked on their wonderful journey in medicine. I still recall how much fun I had at orientation and getting acclimated to “being a med student.” In retrospect, it’s clear that while the basic sciences and rotations at any medical school are vital in building a knowledge base, there’s an undeniable flaw – medical school teaches us answers before we even ask the right questions.
Med students are inundated with lectures about pathophysiology, how to work in a team, working up inpatients, etc. Much of our early training revolves around buzzword associations. “Brackish water”… something dealing with Vibrio bacteria. “Black urine”… gotta think about alkaptonuria. Fevers on post-operative day 1… does the patient have atelectasis/pneumonia? Diagnostics is not rooted in symptom buzzwords. It’s about asking the right questions to build a therapeutic relationship with our patients.
If a patient presents with low serum sodium, there are algorithms which break down etiologies based on volume status. One can probe through all the “answers” (the patient has cirrhosis, hypothyroidism, decreased oral intake, etc.) But what happens when everything is normal? The patient has a low sodium, and none of the common causes adequately explains the clinical picture. Why?!
Critical thinking is what patients expect from clinicians. No more buzzwords. No more “common things being common.” It’s time to drop all convention and take the workup from the top by constantly questioning our methods and tying together ideas.
In the aforementioned vignette, what if the patient didn’t have SIADH, but rather, an appropriate response to stress manifested by a release of vasopressin (ADH)? Nausea is one of the most potent stimulators of ADH release. This could explain things quite nicely. Let’s see if the sodium improves by controlling the patient’s nausea.
As a med student, I should have spent a little more time questioning the “why” more than spending time memorizing all eleven criteria for lupus. Diseases don’t read textbooks, and they often present outside the scope of buzzwords and guidelines. Gotta keep an open mind with every case and always question the “why” behind every symptom and diagnostic test.