The third year of medical school is a lesson in humility. In the OR, you’ll invariably cut the suture too short, or too long, or too slowly. On the floors, the one laboratory value you haven’t checked is the only value vital to the patient’s survival. And just when you think you know everything there is to know about a disease, the Attending Physician will keep asking you questions until you’re stumped, a fun game known colloquially as “pimping.”
The goals of pimping, to me, are three-fold in nature. In order of importance, they are:
1. To make the attending physician look/feel very knowledgeable.
2. To make the medical student realize how little he/she actually knows.
3. To teach the medical student something useful.
On rare occasions, however, pimping a student can actually backfire on a doctor. Who knew?
During my family medicine rotation, a 60-year old woman came into the doctor’s office with her sister. She had spent the previous week in the hospital, being treated for a tubo-ovarian abscess (TOA). A TOA is an inflammatory mass involving the ovary and fallopian tubes. The TOA was confirmed with an abdominal CT scan, and she was given intravenous antibiotics. She came to the office to make sure her white blood cell count was dropping. She also still had some right lower quadrant (RLQ) tenderness, and was worried that the TOA wasn’t fully treated. Overall, she seemed very jumpy, as did her sister.
The doctor figured this patient’s case would make a good teaching lesson, and started to ask me some questions about it.
Doctor: “What else can cause RLQ pain?”
Me: “Well … appendicitis would be my first thought.”
At this point, the patient helpfully chimed in, “I’ve already had my appendix taken out!” The doctor disapprovingly shook his head at my history-taking skills.
Me: “RLQ pain can also be caused by an ectopic pregnancy.”
Doctor: “In a 60-year old?”
Me: “Meckel’s diverticulum could do it.”
Doctor: “Maybe if she were 2 years old.”
Doctor: “That’s more common in the LLQ, but I guess it could.”
The only other differential diagnosis I could think of was colon cancer, which I definitely was not saying in front of the already nervous patient, so I just kept quiet for about 30 seconds. Finally, the doctor said aloud, “Have you thought about mesenteric adenitis?”
I had heard the term before, and knew it had something to do with lymph nodes, but before I could say anything, the attending said, “Ok, that’s your homework for tonight- look up mesenteric adenitis and present it to me tomorrow.”
The patient’s sister couldn’t handle the suspense, however. “Doctor, if you don’t mind, could you tell us what mesenteric adenitis is? It sounds really bad.”
Doctor (looking upset that my homework was ruined): “It’s when the lymph nodes in your intestines get bigger, usually from an infection. It can cause abdominal pain similar to a TOA.”
Patient: “I knew it! I knew I didn’t have a TOA!”
Doctor (looking alarmed): “No, no, it was definitely an abscess, the CT …”
Sister: “We should go back to the hospital now. I had a feeling this was going to happen.”
Patient: “Am I going to be ok?”
Doctor: “Ladies, I was just trying to get the student to think of some other …”
Sister: “This is why your pain hasn’t been getting better. You were misdiagnosed!”
This discussion continued for another five minutes, until the doctor finally convinced the patient and her sister that she without a doubt had a TOA, and was diagnosed properly. Even then, one could tell that they weren’t buying it. I tried to keep a smirk off my face, but it wasn’t working, so I pretended to read a poster on the wall about ankle injuries.
In the hospital, the medical student is usually the one made to feel uncomfortable by pimping. For once, it was nice to see the attending physician share the feeling.
Collin Creange is a medical student who blogs at The Human Fabric.
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