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The Differential

The Doctor as Detective

Rick Tumminello, Medical Student, 09:23AM Aug 12, 2017

Rick Tumminello, MS, OMS-II, PCOM

Currently, I'm in the middle of the second rotation of my third year. So far, life is far better than what preceded the clinical years of my medical education. The learning is constant, you're in an environment you've wanted to be in since the pre-med years, and you're working closely with physicians, picking up tricks of the trade and seeing where the art of medicine fits into the mountain of textbooks and PowerPoint presentations.

The learning is different. It's fast, constant, applicable, remember-able, and rewarding. With every patient interaction and every question asked by a physician or nurse, you're learning. You're seeing how and why they ask the questions they do, building the differential in their mind. You begin to pick up the different physical exam findings you should be looking for to rule in and rule out disease. For the first two years, we've been scientists and students, but now we begin to practice the detective work that goes with being a physician.

Often the parallel is made between physicians and detectives. Many people know that Arthur Conan Doyle, the creator of Sherlock Holmes, was an MD; however, few know the great detective was modeled after a physician mentor of Doyle's. As part of the Engines of Our Ingenuity lecture series at the University of Houston, Bill Monroe shared the story of the creation of Sherlock Holmes, stating "[Sherlock's] propensity for close observation and his famous capacity for deduction derive from the medical practice of one Scottish physician." The Scottish physician is Dr. Joseph Bell, professor at the University of Edinburgh. Monroe continued, "...the magisterial teacher demonstrated dazzling powers of observation. As Doyle would later describe him, Dr. Bell "would sit in his receiving room" and with an impassive face would "diagnose the people as they came in, before they even opened their mouths. He would tell them details of their past life; and hardly would he ever make a mistake."

Nowhere is detective work in medicine more evident than in the emergency department (ED). Dr. Leana Wen wrote a piece for NPR, When Facts are Scare, ER Doctor Turns Detective to Decide on Care. She describes the challenges that come when you're met with uncertainty and absence of information with a patient in the ED; the classic example being an elderly demented patient who presents alone and is unable to express their chief complaint.

It is these skills we begin to learn in the third and fourth year of medical school and throughout the rest of our career. Learning how to uncover the facts and connections we've seen on paper and finding them in the patient in front of us.

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