Ambulatory

Ambulatory Medicine – adult outpatient medicine – taught me about patterns. At first it seemed that third year would be all about revisiting the facts I had learned during the first two years, but with patients to illustrate them. That would be interesting and rewarding; I certainly don’t know all the details of even the main diseases and disorders of each organ system yet, and I have definitely been looking forward to finally developing a working knowledge of the many drugs that I memorized for the boards, but whose names and side effects I still mix up (I’m looking at you, psych drugs). It turns out, though, that third year isn’t just about going over these things again in a clinical setting. It’s actually about gelling all of your knowledge (the facts you come in with and the many more that you learn along the way) about diseases and treatments into a form that is actually usable on a daily basis.

I did my four-week Ambulatory rotation with an endocrinologist. The downside was that I didn’t get to see the full range of ailments that bring people to the doctor’s office; no low back pain or upset stomachs or coughs. It did, however, give me the opportunity to really master the assessment and management of patients with diabetes and thyroid disorders. (Plus I got to see one patient with Klinefelter’s Syndrome, which is when a male has an extra X-chromosome. He was just there for follow-up, though; it would have been more exciting to be in on the initial diagnosis.)

What I learned through seeing the same diseases over and over again is that doctors function based on patterns. At first, when I would leave out some important question during my interview with the patient, I would wonder, How do doctors remember what all to ask a diabetic? And then it hit me: because they ask the same questions of every diabetic! They don’t go into a room and start from scratch, thinking, Let’s see, what are the effects of high blood glucose? It can hurt the retinas, the kidneys, and the peripheral nerves. So, I guess I should find out if this patient has had any trouble with vision. That’s a good start, right? And maybe ask about peeing and if s/he’s had any tingling in the feet. Same goes for a patient with hyperthyroidism; there are certain questions to ask, certain things to pay particular attention to on exam, and a certain way to adjust the medication as needed and a certain timeframe for follow-up.

Of course this is an oversimplification; doctors certainly need all of their medical knowledge on hand to figure out what’s going wrong whenever something doesn’t fit the pattern, or when they get an unexpected answer to one of their templated questions. But this realization was empowering in that it gave me a framework in which to start to organize my knowledge. Remember my little metaphor about the dewdrops on a spider web from my post about the boards? Well, grouping things into patterns allows me to continue connecting those drops and constructing separate little groupings of web for each area of medicine. It makes the entire endeavor of learning medicine seem just a bit more feasible. And I’ve already reaped the benefits: part of my final exam for Ambulatory was an encounter with a standardized patient. The patient had diabetes and needed an exam and counseling. And I knew exactly what to do.