January 28, 2011, 1:20 pm
A Life Lesson Learned in Medical School
By MAGGIE KOZEL, M.D.
Thomas Northcut/Getty Images

It was in my second year of medical school that I learned one of the most important lessons of my career: That it can be hard to distinguish truth from a perfectly good answer. Certainty was what I craved the most back then, poised as I was on the threshold of my medical career. But my first patient would cure me of certainty forever.

I had just started my physical diagnosis course and was teamed up with a classmate, Randy, for our first attempt at performing a medical history and physical exam. Our patient, admitted to the hospital with alcoholic liver disease, was dressed for company with crisp blue pajamas and a seersucker bathrobe tied neatly at the waist. He had white hair and white teeth, and his brown face was a little raw, as if he had just shaved. He looked pleased that we had dropped by.

We introduced ourselves and produced the clipboard that held our exhaustive list of questions. He remained as calm and patient as a snow-covered garden as we went through our checklists, assuring us he did not have facial pain or droopy lids, fruity-smelling breath or scrotal swelling. As I stood there perspiring, he calmly relieved us of any concern that his heart skipped beats or that pain radiated down his legs, before recalling what he could about his grandparents’ health at the turn of the previous century.

An hour later, it was time for the physical exam. We worked our way down his body, looking for malformations of the earlobes, listening to his heart sounds and noting every brown spot that had come to grace this man’s surface over the previous seven decades. We managed not to miss the yellow tinge of his eyes, or the rubbery edge of his liver, which we had first tried so insistently to locate at the bottom of the rib cage but which actually extended several inches below it.

A diagnosis of alcoholic hepatitis. Enlarged liver. Got it. Nothing in this world seemed as satisfying as having the puzzle pieces fit together.

The mental status exam came last. Having finished our four-week psychiatry course, we felt we knew a thing or two and conspired in advance to check our patient for alcohol-related brain damage. His unfaltering performance up to this point had not settled the question for us.

A supervising doctor had taught us a trick in assessing cortical function: pretend to hold up a string, and ask the patient what color it is. The patient should, of course, respond that there is no string there.

If he says it is pink or orange, he is confabulating, meaning his brain cortex isn’t working so well. So with thumbs and forefingers pinched together, Randy held up an invisible string and asked this man what color it was. We waited.

After some time, he gave us his considered answer: “It is the color of atmosphere.” A self-satisfied grin broke across his face.

Confused, I looked over at Randy, who was now frowning at the “string” himself, as if wondering if he’d missed something. We were suddenly a couple of rudderless ships, startled into the realization that all the facts in the world couldn’t protect us from uncertainty. Sometimes, it could actually blind us to the truth. After all, the string really was the color of atmosphere. Except, of course, for the fact that there was no string.

Of all the pearls that our patient offered us that day, this was the one I would carry with me throughout my career as a pediatrician, and the lesson never lost its relevance. Doctors, like anyone else, can get so comfortable with a routine that they neglect to question the questions, and we can all be misled as a result.

Clinical truth has only grown more obscure since my medical school days. Throughout the 1980s and ’90s, for example, pediatricians relentlessly used antibiotics to treat the middle ear infections so common in our young patients, as we waged war against the epidemic of hearing loss and delayed language we imagined would occur if we didn’t act. But the goal was invisible. No one had ever shown that not treating the ear fluid would cause long-term language delay. It would be decades before we realized that overuse of antibiotics caused us huge problems, while the drugs accomplished very little for our patients. We had devoured answers without asking the right questions.

Today, as we take on the hard work of health care reform, doctors continue to work under an avalanche of pharmaceutical marketing, malpractice threats and shortsighted health insurance strategies. Clinical approaches to conditions like obesity, for example, or mental illness or a learning disorder are hard-wired into current practice methods, even if those approaches don’t make sense.

And after decades of caring for patients in a complicated health care system, I have learned that if I really cannot see the string, I need to say so.

Dr. Maggie Kozel is the author of “The Color of Atmosphere: One Doctor’s Journey In and Out of Medicine,” published this month by Chelsea Green Publishing.

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