April 10, 2014

WHAT’S UP DOC?: Beyond the Test

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A patient is admitted to the hospital for management of florid psychosis. Several antipsychotic drugs are tried with little success. Finally, the patient is put on clozapine, a potent neuroleptic medication, but one that is exclusively used as a last resort due to its numerous and catastrophic side effects. (The FDA slapped on five black box warnings.) He begins to improve, but a few days into the hospital stay, he rapidly develops high fever, confusion and difficulty breathing. The list of possible causes includes several major side effects of clozapine, but the patient turns out to have aspiration pneumonia, likely caused by a strange drug side effect: excessive drooling.

Hypersalivation can drench pillows with saliva by the time a patient wakes in the morning, but for such a situation to lead to pneumonia is unlikely and was initially not seriously considered in this case. While this specific scenario is uncommon, the likelihood that a clinician will see a similarly bizarre presentation at any given time is actually not so rare due to the large number of cases seen every day. Statisticians explain this with the law of truly large numbers and the law of near enough. Tales of equally peculiar medical circumstances are told on a regular basis.

Fortunately, peculiarity is not a criterion for inclusion of subjects in medical curricula. At least in academic medicine, there is constant discussion of “high-yield” material — the stuff that is commonly seen or commonly tested. Since everyone wants to ace the exams to help further their career goals — and attain a medical license — much emphasis tends to be placed on such high-yield information. But what is actually seen everyday is often quite different from the “classic” disease presentations canonized in textbooks, or the obscure findings that are very characteristic but are so rare that they have never been seen by many seasoned physicians. The constellation of symptoms and findings in a given patient regularly escapes the simplified question prompt of the exam.

My friends and I will often joke around about this or that tidbit of knowledge as being “low-yield,” especially when studying for one of the barrage of standardized exams that we sit through. In this setting, it’s probably appropriate to forget minutiae in favor of overarching concepts. But dismissing the so-called low-yield becomes unfortunate and potentially detrimental to the health of others when the category of low-yield expands to include items integral to patient care. Can this medication be taken with a meal or is it only effective on an empty stomach? What should be done if a dose is missed? Is the drug covered under this insurance formulary? Medication compliance is a constant struggle in medicine, and effective counseling, including having answers to questions like these, is important in equipping patients with the knowledge and confidence to manage their health.

The real world isn’t an exam, and it takes everyday vigilance to assimilate low-yield information into a problem-solving strategy that best serves patients.

The real world isn’t an exam, and it takes everyday vigilance to assimilate low-yield information into a problem-solving strategy that best serves patients.  Learning material that will likely never be tested can still prove to be immensely beneficial, and may make the difference between a patient who recovers well at home and one who returns to the hospital shortly after being discharged with recurrent or unresolved issues. This is not so much a mandate to study and know everything under the sun as it is an admonition to remain engaged even in the face of seemingly mundane details. Prioritization is paramount and even cramming has an occasional role, but there is no good substitute for immersion to achieve mastery.

Knowledge of the basic foundations of medicine is essential and likely sufficient for the effective treatment of a population on the whole. But one must continue striving to obtain a depth of knowledge sufficient to treat each individual. A specific rare presentation may occur at low frequency in the general population and thus good management of this population can take place in the absence of certain specific knowledge. It may not mean much to a group that one individual will present with a particular uncommon condition, but you can bet it will matter an awful lot to the individual. And, at the end of the day, we aren’t treating populations so much as we’re treating a series of individuals who make up that population.

The truth about the example given at the beginning of this article is that it is not so low-yield as I may have led on. Knowledge of major medication side effects is stressed and most medical students will know that clozapine causes hypersalivation by the end of the third year. Given the clinical scenario, the jump to aspiration pneumonia is not that big after other things have been ruled out, especially in light of certain test results. But somehow I don’t think you would have kept reading if I regaled you with a story of performing medication reconciliation — a true tedium of life on the wards and something that is certainly not tested but a task of utmost importance. If you’re not familiar with a “med rec,” here’s your chance to engage and discover a new thing. Phoning a friend and asking Google are always acceptable starting points.

Justin Haseltine is a third year medical student at Weill Cornell Medical College. He can be reached at [email protected]. What’s Up, Doc? appears on alternate Fridays this semester.

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