April 2005

Decision time: Am I an internist in the making?

"He's been having pain in both hands for several months now, with occasional swelling in the MCP joints," the resident explains. "His past medical history was insignificant except for bad arches for which he is using orthotics and a pulmonary nodule that was found incidentally."

"Sounds like rheumatoid arthritis," Dr Alwin says. "A fairly straightforward diagnosis with respect to the hands, but what do you think about the feet?" he asks, turning to me.

"It might be a good idea to get an X-ray," I suggest.

"We did an X-ray which revealed joint erosions of the MTPs!" exclaims the resident. "It's amazing he didn't have imaging done earlier."

BY JOVE, WE'VE GOT IT
We all filed in to see Mr Escanla. "Tell me about this nodule they found," Dr Alwin asks the patient.

"I had an X-ray taken a few months ago and they found this mass in my lungs," explains Mr Escanla. "Strangest thing, because I haven't been coughing or had any symptoms at all. I've never smoked either. They took a biopsy of it and still didn't know what it was." He continues, "All they said was that it looked granulomatous or something like that."

Dr Alwin's expression brightened suddenly. Looking to the resident, I saw from his grin that he'd had the same eureka moment.

"Do you have any bumps on your elbows?" Dr Alwin presses. "Sometimes with rheumatoid arthritis, you get bumps under the skin called rheumatoid nodules, but there have been cases reported where they have shown up in the lungs. If the pathologist didn't know you had rheumatoid arthritis, granulomatous would be a word they'd use to describe it."

"Brilliant!" I think, absolutely thrilled that we, ok they had managed to sum up all of Mr Escanla's medical issues with one tidy diagnosis.

STANDING AT THE CROSSROADS
People say that medicine can be divided broadly into medical and surgical subspecialties. While I've never doubted my surgical abilities, I've always seen myself falling under the medical umbrella. My latest rotation in internal medicine served only to confirm this. I love the mental detective work and I love knowing something about everything. It's intimidating to see how much the senior medicine residents know, not to mention the vast knowledge base of the staff physicians. Yet it's inspiring at the same time. Someday and somehow, I think to myself, I might know as much as they do.

Internal medicine has easily been my favourite rotation so far. Coming out of it, I feel as if I actually know something. Through managing ward patients, being grilled by preceptors and reading, I managed to pick up enough 'voodoo' to be able to answer some of the seemingly random minutiae on the medicine exam and pass it.

But there are two things about internal medicine that worry me. Firstly, as medical knowledge seems to expand exponentially, how can a general internist keep up with all the literature? Secondly, while the medicine is fascinating, I have to admit I've found dealing with the equally important social issues and placement for some patients very frustrating.

Despite my search, I still haven't found the perfect specialty for me. The shift work and bureaucracy in emergency medicine seems to offset the diversity and excitement. Surgery is fun and hands-on, but the lifestyle is tough. Pediatric patients are great, but the parents can sometimes be overbearing.

LONGING FOR THE OLD WAYS
It's really too bad we don't have the rotating internship anymore. All the physicians I've talked to seem to agree that we don't have enough time to make an informed decision, that the experience provided by the extra year was invaluable, and it seemed that the decision to remove the rotating internship had little to do with improving medical education or healthcare in general. There's a lot of pressure on us to choose electives carefully and to make up our minds — now.

For the time being, I've narrowed it down to general internal medicine, pediatrics and family medicine. I just hope I don't enjoy my upcoming surgery too much as I've already aimed my CV in the medicine direction! (NB: Names of doctors and patients have been changed.)