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Learning The Textbook Case

Staring at each high-yield line in First Aid, attempting to commit every word to memory, hour-upon-hour, is the life of a medical student. The stress, isolation and over-caffeination, amidst the constant influx of information, is overwhelming and can cause even the most compassionate student to forget why they are studying.

At first, it may have been to learn medicine and then apply that knowledge to positively impact others’ lives. Unfortunately, it is not uncommon to inadvertently view the studies as a resented duty, dehumanized and far removed from patient care. However, this outlook is erroneous. Statistics to memorize are the condensed stories of individual lives. Each textbook case is somebody’s loved one from whom we have been afforded the opportunity to learn. The information from a textbook case — the classic symptoms, physical findings and disease sequelae — is highly privileged and life-saving.

In the library, feeling beyond fatigued, I came upon a list of risk factors for the development of deep vein thrombosis. My breath caught as a chill ran down my spine. My cousin died after a long car drive when she was 18 due to a pulmonary embolism caused by a deep vein thrombosis that had traveled to her lungs. She had all the risk factors identified on this list and yet was prescribed medication, which she was likely contraindicated for, less than a month prior to her death. I cannot help but wonder perhaps if those providing her care had recalled the list of risk factors in front of me. Had they applied it to my cousin’s case, could she have had a different outcome?

A few weeks later, I came across the classic description of renal cell carcinoma. Within that condensed paragraph, I was amazed to find the final years of another loved one’s life described. The high prevalence of recurrence — news that rocked my family — was printed clearly as an expected aspect of this disease. It dawned on me that, by learning textbook cases, medical training yields the ability to predict upcoming hardships of patients; along with this, there is the responsibility to guide patients and their families in navigating these hardships. What is not in the textbook is the perseverance, strength and love brought out by diseases. Further undocumented is the pain and suffering illness inflicts. Ultimately, the humanity of medicine remains unwritten amongst the high-yield facts and thus becomes the responsibility of the student to write in the margins as they advance in training.

Recently, I found myself acutely confronting this challenge as I walked down the halls of an unfamiliar hospital, looking for my first real patients’ room. This was the first time I was going to take a history and perform a physical alone — and I was nervous. Finally I found the room, took a deep breath, re-adjusted the strange clanking medical tools in the over-filled pockets of my short white coat, rubbed in the hand sanitizer and knocked on the door.

I began with a simple open-ended question and then listened to my patient talk. By the conclusion of the history and the admittedly bumbled physical exam, I felt I had learned a great deal about this patient and his life. I was surprised by how closely my patients’ disease mirrored what I had learned in class. I was also proud that, based on my patient’s account of “sky-high sugars” and classic symptoms of increased thirst and urination, accompanied by confusion upon admittance, I was able to deduce that he likely experienced a dangerous complication of type II diabetes: hyperglycemic hyperosmolar syndrome.

Later, I presented the case, sounding eerily like the automaton echo of the question stems that are cornerstone of exams, “Patient is a 78-year-old male…” At the conclusion of my report, the attending pointedly inquired, “What caused the patient to reach this point of uncontrolled hyperglycemia?” The attending was not referring to the pathophysiology that causes hyperglycemia but instead to the fallible life circumstances that unfolded into the patient’s state of deteriorated health. I did not know the answer to this question. I had not learned the most important information pertaining to my patient’s care at this point in time. Did an infection tip this patient’s homeostasis? Was there a breakdown in his social support system? Was the patient non-compliant due to lack of understanding, economic impediments or depression? The answer to the attending’s question was pivotal in understanding the patient, his current illness and identifying the most efficacious way to prevent this life-threatening state from reoccurring. I had failed to recognize how intrinsically human aspects of this disease amalgamate with its textbook description, and as a result I did not fully understand my patient’s story or how to best care for him as an individual.

This experience was a wake-up call; a true reiteration that medicine is more than the study of disease, but also the practice of discerning human nature. Therefore, it is the medical students’ responsibility to read the subtext of humanity amongst the high-yield facts. By learning as much as possible and unifying pathology with the person, students can become adept physicians able to apply this knowledge — not only to accurately answer multiple-choice questions, but to treat each patient uniquely and therefore correctly.

Kaitlyn Dykes Kaitlyn Dykes (6 Posts)

Contributing Author Emeritus

Georgetown University Hospital

Dr. Kaitlyn Dykes is an Internal Medicine resident at Georgetown University Hospital, in Washington DC. She completed medical school at Thomas Jefferson University in Philadelphia Pennsylvania and was a part of the clinical research tract. She completed her bachelors of science in Genetics, Cell Biology and Cell Development with a minor in Art History at the University of Minnesota, Twin Cities. She her most recent research is in the field of hematology oncology. Additionally she is actively involved in medical education. Hobbies include reading, painting, visiting museums (when they are open), and enjoying time with friends and family. She hopes to pursue a career in hematology-oncology.