Tuesday, December 6, 2011

Boring patients

One morning when I was a medical student on inpatient pediatrics, there were two admissions from the night before and I was told to pick up one of them.

One of the patients was a little girl who had some "interesting" disease, something rare that I might never see again.

One of the patients was a ten year old boy with periorbital cellulitis.

I wanted to take the boy with periorbital cellulitis, since the girl seemed more complicated and I wasn't interested in pediatrics. But the chief said to me, "Why don't you take the girl. She's very interesting."

"I'd rather take the boy," I said. "Isn't that something I'm more likely to see again in the future, so it's more relevant?"

"Fine," she huffed. "You take the boring periorbital cellulitis and I'll give the interesting patient to someone else."

Of course, it later turned out the boy had a brain abscess and became a much more "interesting" patient, unfortunately.

Regardless, I don't agree with the practice of finding "interesting" patients for medical students. I feel like interesting patients are great for attendings who see tons of patients and experienced residents, but for med students and new residents, even the bread and butter stuff is interesting because they've seen so little. Plus it's important for them to learn to treat bread and butter stuff, not rare diseases that they'll likely never see again.

For example: Say you have a med student on the renal service. Is it more important that they learn to manage a "boring" patient with diabetic nephropathy, a common disease that will be relevant in the future in almost any specialty, or an "interesting" patient with diabetes insipidus, a disease most doctors never or rarely see.

I mean, is the purpose of medical school to train students or to entertain them?

(Answer: Neither. It's to learn to pick up residents' drycleaning.)


  1. That is the best take on medical education i have ever read. To be honest, i m one of those students who used to run after interesting cases. I think it's time to reevaluate my priorities..

  2. Excellent observation!
    The little AIDS-orphan I lost my heart on during my Paeds rotation this year was at one point deemed "boring" because he was improving so well.
    I was peeved, partly because if being healthier was boring then I didn't want him to be interesting, and partly because it was a prime opportunity to learn about management of the disease in such a tiny person.

  3. totally agree. i'm a pediatrics resident now, but i remember doing my peds rotation in medical school and having residents constantly saying, "oh, don't take that one, it's just a hyperbili baby, asthma exacerbation, bronchiolitis, dehydration, etc, it's not interesting." and then i'd end up with no patients just because no kawasaki kids came in. the boring stuff is the stuff i needed to learn!

  4. It's always a bad idea to try to cherry pick cases for students. Why? The interesting cases always end up boring, and the boring cases always end up interesting. Most patients will give you something to learn about even if it's not what you expected when you picked them up.

    FWIW -- I've seen DI twice in med school. Here's it's handled by endocrine rather than renal though.

  5. I'm on peds right now, and on my inpatient weeks they would give me the "bread and butter cases." The "interesting" cases always went to the intern, which was fine with me. I agree with you and I've decided I don't want to do peds, so I'd rather see something I might come across in the future :)

  6. If it makes you feel any better, they do the exact same thing in nursing school as well only nursing is much more skill based and we don't get the residency after we graduate.

    I got so much shit for wanting to put in foley or do a blood draw over accompanying a patient to IR for some weird-ass procedure that I'd never, ever see in practice.

  7. Exactly, exactly, exactly! Just this morning I informed my attending, who was whining about/ apologising for the lack of "good" surgeries for the day, that I was happy to see the "boring" EGDs and colonoscopies and skin grafts because I'd never seen them before and wanted to know the processes. And I had good learning today.

  8. My father was hospitalized recently and wondered why he was getting visits from so many med students and residents. I explained to him that, with sarcoidosis and pulmonary hypertension, he was a huge double coupon for the U of FL med school. :)

  9. As a "special needs" parent... Ya, I want the attending as even the primary (double boarded pedi neuro) says my son is a puzzle to figure out.

  10. seeing the routine stuff is important, of course, but I feel students should jump on the rarer conditions when they are there. You see one patient with Kawasaki etc. and it locks into your memory. Half of us will end up as GPs, and the next time you see the rare condition could be 15 yrs down the track when it walks into your practice.

  11. Becky: Well, there would never be a situation in which your son would be cared for by just a med student.

    nd: I'm not sure if I agree that seeing one patient with a disease 15 years ago will help you remember enough to provide better care 15 years later. Regarding the case I DID take, the periorbital cellulitis, I don't remember anything about that illness that I couldn't read in a pocket pediatrics handbook.