I like general medicine because we use our brain to work out problems. Surgeons always say they are not in medicine because they are not clever enough. That's partially true. The physician's brain needs to think systematically yet in multiple layers in different directions in order to know what's actually happening to give the right treatment (as oppose to surgery, where the question is usually just to cut or not to cut). I don't want to be perceived always complaining, so will tell you something nice about the two spot-on diagnosis I made.
The first one was about a young man who came in when I was oncall. He had 2 weeks of very bad headache and 2 episodes of seizure. The diagnosis made by the ED medical MO was '1. first seizure for investigation ?epilepsy; 2. ?migraine'. When I asked him about the headache, fair enough it was vague, but there was a hint of the classical 'hit on the back of the head' and 'worst headache in my life' story. Neurological examination was unremarkable apart from a left sided ptosis, which itself was a good clue towards a posterior circulation aneurysm. Then I saw the CT brain (which no one had reviewed and not reported yet) - there were white stuff around the area where subarachnoid haemorrhage frequently occurred. I've seen quite a few of those scans when I was doing neurosurgery in Manchester but I forgot the name - later remembered - it's called the sylvian fissure. So my diagnosis was 'TRO Subarachnoid Haemorrhage'. Overnight, he was seen by the specialist oncall and we referred to neurosurgery and they all agreed. By morning, the formal CT brain report has come out and it confirmed my diagnosis of SAH. I was so happy eventhough it means that the patient is no longer a medical case and would be transferred off to neurosurgery.
The second one was about a man was a new elderly patient in my ward. He has just been discharged 7 days ago to a nursing home and sent in overnight because of poor oral intake and less talkative. When I see presenting complain like this my heart always sink, because often no clear diagnosis is made and the diagnosis would invariably be something like pneumonia (due to some 'hazziness' on CXR) or UTI (based on 1+ leucocyte on dipstick). Admission clerking was rather pathetic - vague, no clear history from reliable source. I phoned up the carer from the nursing home to find out what exactly happened. It turned out that over the last week, he has been vomiting after every single meal and eventually not eating at all, and also been passing black loose stool for a week. I also noticed that Hb dropped from 15 to 11 in one week. On examination, there was tenderness on the epigastrium and PR showed malaena. So, worked out that the patient actually has upper GI bleed. Seems like a long grandmother story but all the talking, examining, thinking and solution happened perhaps over 5 minutes. So again, was pleased with myself because I made a diagnosis that at least 3 doctors (more senior than me) missed.
I'm not sure about other hospital, but in my hospital, patient from the ED are first seen by the ED doctors, then reviewed by medical MO in the ED, sometimes seen by medical registrar and specialist before being formally clerked in by the house officer on-call. Then, we are supposed to inform our MO oncall to review the patient's we've clerked. So, house officer can be rather complacent about doing a full history and examination as they have been seen by all the senior people already. That's just safety nets put in place so the patient gets the best care possible during the critical first 24h of admission but I don't think that's good for our training. For me, it's not that I don't want to do proper clerking to everyone of my patients when I'm oncall, it's just circumstance. Firstly, I am exhausted - by the time I clerk in the new patient (usually well after midnight) I would have been awake and on my feet for 18 hours already. Old notes would not have arrived, there's not likely to be relatives around to take collateral history and I have another 10 IV lines and 4 new patients to look forward to seeing (waving good bye to my sleep). I only wish that I am able to have time and mental space to think and review all my patients this thoroughly. This can be achieved by having 1 more HO to cover passive calls or having the day before or after on-call off. But I think I am just dreaming and will do my best in the mean time.
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