Friday, July 18, 2014


A few years ago a group of recent medical graduates came to our house for dinner. An exciting conversation of their hopes and dreams followed. What would they do and where would they go in search of fulfilling their dreams. One wanted to go and serve in the rural areas with a large backyard where he could be “one with nature” and when duty called he would step into his home/office and care for the patient. Another wanted to follow in his father’s footsteps, become a sub-specialist and regale the specialty with new knowledge through discovery. A third quiet and more subdued graduate sulked in the background, not willing to express her desires.

As the dinner progressed the graduate magnetized towards the rural bent stated, “I don’t get it,” he said, “Why do I have to go see another surgical procedure?” He put his fork down with an emphasis. “You see one, you do one and you teach one!” There was a momentary silence. As a host, I asked, “don’t you think an aggregated knowledge would make for better decision making?” He fired back immediately, “Repetition is not necessarily the best education.” Not exactly true, but as a host, I volunteered,  “But more exposure leads to more information and that becomes a sort of experiential reference to draw upon, don’t you think?”

Ah but for the infinite regress of a mental intent...

 “A cholecystectomy is a cholecystectomy!” he stated with a smirk. “Fair enough,” I replied, “but each individual is different and each gall bladder therefore is different. You might find one gallbladder fixed from chronic inflammation to other tissues, another might be filled with stones, still another might have a nidus of gall bladder cancer in it stuck to the liver and so on, how can one know how to deal with all those contingencies?” He remained quiet for a moment and then not to be held down with a technicality suggested, “when you go in (operate) that is when you find the problem and you deal with what you find. The procedure of going in is the same!” This young Turk had a lot to learn and maybe he would in due course of his residency, only time would tell.

The sulking violet meanwhile quietly listened to the exchange and the cloud over her head seemed to darken. I asked her what was bothering her and she replied, “I wouldn't know what to do!” she said haltingly in veiled terror. “What do you mean?” I asked. “In the ER for instant a patient with abdominal pain, you cannot open the text book to look through all the differential diagnoses, how would one go about determining the diagnosis and the right treatment?” Ah, I thought from the bullish to the bearish the entire spectrum was covered here. “That is why you have the residency program to help you sort out the problems. It gives you the confidence based on the knowledge you accumulate from your peers, experienced nurses and attending physicians. That is the purpose for the residency, to help put the didactic into the practical format. Medicine is difficult both in the expanse of its knowledge-base and in its practice. The sorting and weeding out of what is right and wrong, is done early on in the residency to help gain confidence in one’s ability and in proper management of a patient’s illness when you embark on the life-long journey of being a doctor.” That might have sounded pompous, but it had the elements of truth in it. She sighed unconvinced and her head went back into the thoughtful repose. She would benefit from the experience of the residency “baptism under fire!” I thought. They had no idea what kind of an immediate future they were up against. Yet it would come and readiness was all they needed.

The night ended with laughter and fun. As we closed the door behind our departing guests, it struck me how arduous a path it is to becoming a doctor. All these graduates had their hopes and dreams, some had the arrogance of youth and others the timidity and fear of the unknown. Graduation from a medical school is only the first step towards the learning process. Residency is an important bridge between what one knows and how it is utilized. But learning goes on for the lifetime of a physician!

The recent legislation passed in Missouri to cover for the physician shortage is a bit discomfiting. Not only does it speak volumes about the expert policy makers but it broadcasts the potential future. What kind of impact would it have upon the actions of the “fearless” and the “timid” without supervision and their behavioral impact on patient care?

Maybe it will all work out. But in medicine, a lot of maybes can lead to a lot of oops!


  1. Well, I believe people have their own choices and refereance when it comes to profession as well as where they want to use their professional skills and sometime self satisfaction is more important than earning a big money. However, it was an interesting post.