Medical Student Perspective: Medicine-The Science and the Art: My Internal Medicine Clerkship Experience
Merriam-Webster defines medicine as "the science and art dealing with the maintenance of health and the prevention, alleviation, or cure of disease." I started my third year of medical school with that in mind. After two years of being exposed to the "science" of medicine, I looked forward to observing first-hand and practicing its "art." As my internal medicine clerkship approached its conclusion, I realized that this definition of medicine is by no means all-encompassing. It does not convey the business side of the profession, the unpredictability of the course of disease, the implications and complications of the electronic medical record, or the surprisingly egalitarian environment of a physician's office, among many other things. As I delved into the world of hospital wards and clinics, each day I learned more about the nuances of this noble field and became more mesmerized with the vastness of medicine.
The pathogenesis of illness can be enthralling: piecing together the relevant information from the patient's history with the pertinent exam findings and lab abnormalities in order to make a diagnosis can be challenging and at the same time fascinating. Figuring out an elusive diagnosis is much like a detective solving a difficult case. The intellectual exercise involved made it easy to become caught up in attempting to diagnose and treat the illness and, at times, to forget about the actual patient. Often in rounds I found myself and other members of the team engaged in establishing differential diagnoses for unclear presentations, or trying to determine whether a case was worthy of a report. I had to force myself to come out of that analytical state of mind and think of what the illnesses included in the differential could mean for the patient.
Besides being interesting-albeit terrifying-for their pathogenesis, illnesses are remarkable in that they do not discriminate. And neither should medicine. Although it is true that the benefits and access to care patients receive often depend on their socioeconomic status and type of insurance they have, within the walls of a physician's office, all patients can receive the same care. For that to happen, the physician needs to be aware of personal biases and determined to overcome barriers to the provision of equal care. During a single morning in the clinic, my preceptor and I saw a great variety of patients, from a neurologist, to a recording artist, to a single mother struggling to raise her disabled daughter. All were asked the same questions, received the same physical exam, and were offered the same level of treatment. Despite their differing circumstances, all were seen as "fellow creatures in pain."
What I was soon to find out was that, unfortunately, just as medicine can be a great equalizer, death also does not discriminate. I had always wondered what it would be like to lose my first patient. Although I had tried to imagine what it would be like, I was not prepared for it when it happened. I met Mr. K on the morning after his admission for a COPD exacerbation. He was a vibrant elderly man who eagerly told me about how the best thing that happened to him was moving to his son's house after his wife had passed. He spoke with pride about his grandchildren and his dog, and how he was hoping to be home soon to see them. He seemed to be recovering, and I thought that he would probably be discharged soon. The following morning, however, when I went to pre-round on Mr. K, I found him lying in bed motionless except for his labored breathing, with eyes once full of life now dimmed and half-closed. He struggled to muster a few words and politely asked if I could get him something to drink. Overnight he had had a recurrence of C. difficile colitis, and was extremely fragile. Suspecting the severity of the situation, I hurried to find my residents. The family was notified, and after visiting with Mr. K and being informed of the situation, they realized that it was too late for medicine to provide "the maintenance of health" or "prevention" and "cure of disease." We had to focus on the mere "alleviation" in Mr. K's final moments. Mr. K passed that night. I spent the next day reviewing his chart and thinking of all of the things that we could have done differently to prevent his death, only to come to terms with the fact that medicine, although powerful and effective, is not infallible. This taught me to have humility in the face of an unexpected turn of events and to be aware that I would have to go through similar situations in the course of my career.
Just as one cannot predict when medicine will fail, there are times in which the science and art of medicine surprise us with unexpected favorable outcomes. I had the pleasure of meeting Ms. G, a woman with AIDS, hepatitis C, pulmonary hypertension, and innumerable other comorbidities during one of my rotations in the wards. Ms. G had presented to the hospital for symptoms consistent with pneumonia. Upon arrival, she had rapidly increasing requirements for supplemental oxygen, and had to be intubated and taken to the ICU, where she had a complicated and prolonged stay. The ICU team was convinced that Ms. G would not survive this illness. Her son was consulted regarding her full-code status, and he decided that he would not change it, as his mother had been through similar situations before and had recovered. After an ICU stay complicated by refractory hypotension requiring multiple blood transfusions and administrations of albumin and vasopressors, Ms. G recovered somewhat and was able to be extubated and transferred to the floor. When I met her, Ms. G had severe anasarca and dyspnea. Members in my team commented that based on her appearance and lab values she would probably not make it out of the hospital this time. We persevered in providing the best care as she continued to fight for her life. It all paid off as, despite the odds, Ms. G responded well to diuretics, returned to her baseline, and was able to be discharged home. This incident, although exhilarating, made me uncertain of our ability as providers to determine the course of disease, and caused me initially to be worried about discussing end-of-life issues with patients and family members. How were we to account for all of the variables and uncertainties of the fight against disease? My rotations since then have helped me understand that the physician's role in end-of-life matters is not to advise or speak of unchangeable truths, but rather to inform the patient's family members of the patient's situation and its possible outcomes to the best of one's knowledge, and to hope that the family will come to a decision that is right for the patient.
As I continue my journey and quest to perfect the science and the art of medicine, I will continue to be intrigued about the pathogenesis of illness, while applying the many lessons learned in my clerkship. I will remember to care for the patients as human beings, with lives and feelings of their own, and not simply as a disease. I will seek to provide equal care for all patients and try to keep in mind that medicine is not infallible but can always surprise us. And every day I will learn from and be thankful for those who are already much farther in their journey, master scientists of medicine, who dedicate their time to teach us the art.