bye bye baby

I left the wards today with a good feeling, recalling the hard work, happy outcomes, and good relationships. I had an urge to stay on after rounding this evening, just to see what's coming in. Will that urge be stronger or weaker on Emergency, where the variety of patients is so great and potential for calamity more likely?

But I was not that reluctant to go... because I was tired. And it got me thinking of the geneticist, and how Schmee approached college, compared to C.

I was impressed with shadowing the genetics counselor on Tuesday because I saw a kind of medicine (and research) that I had always suspected but had never actually witnessed: looking at a puzzling patient, ordering some labs, and trying to figure out what the kid has. Management is not the issue; there are neurologists and pediatricians working on that. Geneticists are doctors who diagnose, for the purpose of counseling on future pregnancy risks (and to better guide the PCP's management). They live in an interesting realm -- a huge chunk of diseases are readily diagnosable by any doctor, and perinatologists can pick up more in utero. The geneticists have to pore over those remaining malformations triggered either by spontaneous mutations, or extremely rare hereditary diseases.

How rare? OMIM on Jumping Frenchmen of Maine. I thought they were kidding.

So I guess a lot of times, geneticists have got to give up and say, "this collection of bizarre but nonlifethreatening malformations or reflexes are probably unrelated and may not pose much of a risk to future pregnancies beyond the background 3-5%". Other times, they can try to get insurance companies to pay for a $3000 gene test to rule out one possible cause of the child's symptoms.

But sometimes -- and maybe the bulk of a day is spent on these cases -- the doctor collects the observations and labs and experience and starts searching, online or in malformed facebooks -- for the variant of the extremely rare disorder already described. They can find the clues to management and future risk! Or describe all-new syndromes.

How rare is that? I used to think that physicians would be confronted with mystery on a more regular basis. When I was a first-year I wrote up a nice case on a mysterious rash that I concluded must be caused by Nickel allergy. But I understood that that case was one out of a hundred, maybe more. And so far in third year you don't see much that causes you to scratch your head and hit the books. All the decision-trees have been plotted, with percent likelihoods and odds ratios. If it were any other way, docs wouldn't be able to see 30 patients a day (unlike the four I saw on Tuesday. Just four!)

This relates to the contrasting approaches of Schmee and C. Schmee was a perfectionist and would rest up, mentally and physically, before tackling a big project. I do this too, and not just with academics -- housework, letter-writing, you name it. It's like I have to prepare my mind for the task. The bigger the task, the more rest and preparation is required. You can call it procrastination, and it might be that simple, but I think it's more nuanced.

On the other hand is C. C's mother once said if you've got to clean the kitchen, just clean a little of it, and soon you'll be "cleaning the kitchen" and it's easy to progress from there. It sounds ridiculously obvious but upon reflection strikes me as kind of radical. I can't tackle problems like this, or at least, not chores. Reading, studying, sure, maybe a little. But this is why C can study on a bus or while watching the game... while I need a good night's sleep and a full day at the library (and maybe not even then).

Medicine, it seems, is geared toward C's approach. You have to see these patients, because they're coming. You have to write her up, and quickly, because she needs her meds and orders and the next patient is on the way. My notes still often look like crap; I could have done a better job with a bigger template and infinite interview time. I didn't have that time, or that template, so I asked and wrote what I could remember and got it signed and moved on.

Would my old lab have been like this, if we had free coffee and call rooms? Probably not. Medicine wouldn't even be like this, if it wasn't for the onslaught of patients and paperwork. And the free coffee, and call rooms. There's something about working on just a few hours of sleep that forces you out of the Schmee mode and into the C mode. If you're a little tired, and faced with new tasks, you just leap into them, like C's mother advocated.

It was when you were too-rested and had time to think, that's when the perfectionism creeped in. Notes wouldn't be written unless they were perfect. I guess even the geneticist, with her seemingly luxurious one hour per patient, must eventually assess and plan and move on to the next one.