An Opportunity to Publish Your Most Memorable Moment In Teaching Or Learning
Recall that unforgettable moment when, as a teacher or as a learner, in medical school, residency or fellowship, you suddenly appreciated something about teaching or learning that you’ve never forgotten. These truly are Memorable Moments.
As part of a major series of books on teaching, which the College will launch in 2010, the series editor, Jack Ende, MD, will collect these ‘moments’ and include as many of them as possible in Book One of the series. These vignettes should be brief, no more than 1,000 words in length. Some will be serious; some will be funny. All should be meaningful. Taken together, these stories will comprise a tapestry of teaching and learning in internal medicine. A sample Memorable Moment is provided below.
All submissions will be reviewed by the Book Series editor. Those selected for publication and commentary will include the author’s identity, although anonymous submissions will be considered as well. After reviewing the sample, please submit your most memorable moment.
Submissions must be received before March 1, 2009.
Sample Submission
Nodding Together
Rounds began as they always did, in the hallway, just across from the nursing station, informally. No conference room for this team. But this time the attending had a plan. Read an excerpt from a book about Osler. That’s how rounds would begin.
A few days before, the team, and particularly one of the interns, had sustained a terrible blow. A 94 year-old man whom they had anticoagulated for a pulmonary embolus was discharged to a skilled nursing facility, only to be rushed back to the hospital that very same day when he became somnolent. A head CT scan revealed a massive intracerebral hemorrhage. The last member of the team to see the patient before he was discharged was the intern, a ‘July intern’, who was devastated. He reported that, in fact, the man probably did not look “quite right” that morning of discharge. Perhaps, he wondered, he should have sensed that something was wrong before he let the patient go? The attending spoke to the intern. “Medicine is tough,” he said. “We are not perfect. We all make mistakes.” The intern nodded; but the attending knew. The intern felt no better. Words like these were ineffectual. What, the attending wondered, would allow the intern to feel less disconsolate, less alone?
A few days later that intern’s colleague presented a new patient to the attending, a 50 year-old diabetic man on multiple medications, including some with strong anticholinergic properties, who was admitted for acute renal failure. With the entire team at the bedside, the attending examined the patient. The neck veins were full; he was not dehydrated. There was nothing in the history to suggest intrarenal causes of acute renal failure. And he gave no history of benign prostatic hyperplasia. The abdomen was somewhat large, but whose wasn’t? Completing his physical examination, the attending led the discussion. Pre-renal? No. Renal? Maybe. Post-renal? Doubtful.
A renal ultrasound, of course, would be part of the initial work-up. It was obtained that very same day. And it showed a massively distended bladder, bilateral ureteral dilatation, and kidneys with impressive calyectasis. A bladder catheter was inserted and 1.5 liters of urine were drained. The attending was called about this that same afternoon. As he hung up the phone he asked himself, how could he have missed such a massively distended bladder? So much for his diagnostic skills. But remorse gave way to recollection as he recalled reading once about a similar error made by a physician who made very few.
So the next day on rounds, with the intern who probably had missed the early signs of an intracerebral hemorrhage standing right across from him, the attending read a short excerpt from William Osler - A Life in Medicine, Bliss’s wonderful biography of the nation’s most famous clinician. “Olser’s first patient in Baltimore,” Bliss wrote, “was an important elderly gentleman, a Hopkins’ trustee perhaps. Osler thought he felt a pelvic tumor, diagnosed it as an inoperable sarcoma, ‘and in as gentle a way as I could, told his wife, and advised that a surgeon see the case.’” The surgeon came the next day, drained the patient’s distended bladder with a catheter, and thus disposed of the ‘tumor’. Osler used the embarrassment as an object lesson in his teaching.” (1)
And when the attending looked up his eyes met those of the intern, and they both smiled ever so slightly. And their heads nodded, together.
1. Bliss, Michael. William Osler – A Life in Medicine. Oxford, Oxford University Press. 1999. p. 259.