From Depth to Breadth

Originally published: November 4th, 2019

If I could sum up my Medicine ring thus far in one phrase, it would be “from depth to breadth”. Coming in to this set of rotations I was still very unsure of my career plan (and I remain so still). I was excited to learn medicine, or at least to apply my medical knowledge more intensely than I had sometimes in my surgery rotations. I wanted to see the whole patient, to be able to paint a picture of their human condition through a lens of illness scripts and treatment plans. And yet, I started on Infectious Disease consults, a rotation that in many ways was more hyper-focused than my surgery rotations. I quickly caught onto the flow – consult, cultures, sensitivities, antibiotics, sign-off. It was gratifying to solve a clinical question for the primary team so efficiently, and I really felt my depth of knowledge in that particular field increase. And yet, I still didn’t feel like I was capturing the patient as a whole. I would get a snippet of information about endocarditis and we would run with it, ignoring the heart failure or dementia or difficulty finding SNF placement. It wasn’t for lack of caring – rather, it was because our team was so dedicated to seeing every consult on time, and our service being so busy, that we had to ping pong from one to the next in succession. I felt able to add another tool to my toolbelt, so to speak, but I hadn’t yet begun that difficult task of seeing the forest through the trees (or in this case, the patient as more than just an infection to be treated).

Acute Coronary and Psych ED were another step forward in this process of learning. On the heart service, our patients were stuck with us for the duration of their stay. I felt a growing sense of attachment to their problems, and it was gratifying to integrate various organ system complaints into one cohesive assessment that I could present on rounds. In the Psych ED, I was explicitly told that my goal was to “describe the patient’s story” to my attending. This was my favorite type of presentation so far – leading the listener on a narrative journey, creating the patient in their mind’s eye before they ever set eyes on them. And yet still, on each of these services, my focus was on cardiac output and fluid status, or psych med history and social risk factors. I was honed in on these specific systems, and I could see how passionate my attendings were for their specific field, and yet I didn’t think that I had yet found a specific depth of knowledge that really called to me.

General Medicine the past two weeks has been the final step in this evolution of depth vs breadth for me. I feel like the quarterback of a patient’s care. All of the problems are ours to solve, or if we cannot solve them, to call in reinforcements in the form of consults. No longer am I able to separate cardiac from psych or surgical history from medication regimen. All of these factors form a latticework of information that is the sum total of this person as a patient. It is our job as the general medicine team to cover all of it, and more importantly, to know what kinds of questions to ask for the experts also involved in their care. I have found this incredibly instrumental in my growth as a clinician. We are constantly asking ourselves: what does my patient need, and how can I do that for them? I’ve seen firsthand the pitfalls of over-consulting, unnecessary tests, and waiting for the slow beast of the medical system to crank into motion for the care of the patient to progress. It’s been infuriating at times as we seek to juggle all of these conditions and external factors that affect the patient, but I feel more equipped to handle the rigors of residency and my career (whatever I end up in). I now feel comfortable with the idea of the art of medicine, and am continuing to work on seeing the patient as a painting, rather than staying focused on the individual brushstrokes.

The ED psych workroom after a patient presentation.