We make decisions every day, most of them without any consequence at all. What are you having for lunch? Going for vacation? Getting your friend for Christmas? These decisions may take a lot of our time, but the outcomes do not usually make a large difference in our lives. What happens when the decision has greater implications? What happens when your decisions may impact the health and welfare of others? How comfortable are you with the unknown? When you clearly do not know something does it make you uncomfortable? Does it make a difference if this is public or private ignorance?
In medicine we often have a chance to review these thoughts as we go in to the ‘office’. As a family physician, often you are seeing the undifferentiated, the patient who has not been seen before for the problem at hand. These patients could have anything, and often do. This is the heart and soul of family medicine, and more than anything else, it is this aspect of the profession that I often find the most difficult in the long hours of the night.
When students ask me what they should do for a living, I often ask them how much tolerance they have for the ‘gray zone’ of family medicine. By the time that they have spent six weeks with me in the hospital and clinic, I usually have a good feeling for their tolerance of the uncertainty that caresses every action of your day. Those with minimal tolerance are encouraged to pursue specialties where, to quote one of my local dermatologists, you can ‘know more and more about less and less’. This whittling of the number of problems that you are responsible for allows you to focus in on a subset of problems and become expert in these diseases. You learn to recognize the intricate variability of a presentation of each of those diseases, learning the common and uncommon presentation of ‘your special illnesses’. When a patient arrives in your office with a consultation, your role it to determine if this patient represents one of these diseases or not, provide advice on the management of the disease if it is in your realm, and if the patient does not have anything in your specialty identify what they do not have and return them to the referring physician. As a family physician, these patients are often back into you office with a long list of what they do not have and you are back to square 1.2 where you restart your diagnostic processes again, the gray zone of uncertainty has returned.
Students who truly relish the gray zone, exhibit significant comfort in the zone, and are willing to work hard to develop tools to improve their work in this zone become the rural physicians of old. These folks work on ‘gut’ instincts at times taking a chance on a hunch when the data is not always there, but the feeling that you have is undeniable. This is a skill that some are born with, but most develop over time as a side effect of lessons learned. These lessons come through every patient that passes through our clinic, every specialist report that lands on the desk, every specialized test that you have ordered. What is important is how you supplement this instinct, and that is something that has changed over the last years.
In 1996 I worked in a small rural clinic at Dugway Proving Ground in the west desert of Utah. I had received the minimum training needed to not be outright dangerous to people, but I had hardly received what would be called sufficient training. In this location I performed the duties of a rural family physician, taking care of any and all that came through my doors. In my examination room I kept a copy of the Merck Manual so that I had the best compact source of information to assist me with the diagnosis and treatment of my patients. It served to help me fill in the large gaps in my knowledge base as I saw my patients, and I often took it off the shelf while the patient was sitting on the table. I knew what my limitations were, and had no difficulties letting the patients know that my fund of knowledge had definite limitations. This was one of the driving forces behind my desire to expand my knowledge base, complete my training, and my enthusiasm for on-line evidence based medicine.
In order to work well in a rural clinic and do so without waiting years to develop the fund of knowledge that comes from practice, you must have a series of tools at your disposal to help you shrink this zone of uncertainty. For my part, DynaMed, PubMed, and ePocrates serve as my peripheral brain. They help fill in the gaps in my knowledge base, remind me of things I once knew, and help me to become a better physician. Despite these tools, there are still times when you find yourself faced with patients for whom you simply run out of good ideas. These patients are the ones who haunt you as you sleep.
As a family physician, even the presence of these tools may leave you with a patient for whom you still do not have an answer. These are the patients that drive you to study more, to deepen you fund of knowledge. These are the patients that leave you with a feeling of inadequacy as you pull on your hair at night trying to figure out what may ultimately be unknowable. In a rural setting, this absence of knowing can eat at you as you see the patient routinely and feel you inadequacy tugging at your sense of self. What is left is often something very different than you might want something somber and reflective as you look back on the day a thoughtful player in this world.
The beautiful flame fractal on this page came from the following website
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