Important Lessons Learned

By Gregory V. Smith, MD, FAAP

This is a story about some profound lessons I learned while in medical school.

I graduated from the Medical College of Georgia in 1974, trained in pediatrics, and then practiced general pediatrics for 28 years. This situation occurred in June of my junior year of medical school—our first clinical rotation. My group had psychiatry that first month.

About a week or so into that rotation, we were notified about an admission from the outpatient clinic. It seems patient X was a middle aged white female well known to the psychiatry staff. Such patients are often referred to as “frequent flyers”.

Ms. X had what today is called an anxiety/panic disorder. When she became anxious or any emotional situation arose, Ms. X would get progressively worsening shortness of breath. This often progressed into a full blown panic attack with Ms. X reporting she could not breathe and she was dying! She would become extremely agitated and was often verbally abusive to the staff. She had been admitted to the psychiatric ward at least 30 times and had been on multiple medications.

Ms. X had another problem which was frustrating to the medical staff. She was often non-compliant. She routinely missed out-patient follow-up appointments and rarely took her medications as prescribed. True to form, Ms. X had stopped her meds 2 weeks ago and was now in the outpatient clinic having a full blown panic attack and complaining she could not catch her breath. The physician in the outpatient clinic gave her a large dose of Thorazine and she was becoming calm enough to come to the floor.

The psychiatry resident saw patient X and then presented the patient to the Attending Psychiatrist. The Attending Physician saw Ms.X briefly and discussed the case with the resident. Finally the lowly junior med student had an opportunity to see the patient. (I was not that student. David T., a good friend who later trained in general surgery, was the student assigned to this patient.)

Being a junior medical student (JMS), David T. did what we had been taught to do. He talked to the patient and got a complete history—chief complaint, history of present illness, review of systems, social history, and family history.

Then, just as we had been taught, he began a complete physical exam. He quickly noted the patient was not only short of breath, she was cyanotic! Her jugular veins were fully distended sitting at 45 degrees in the hospital bed.

Future doctor David T also heard rales in her lungs, and on heart exam heard what he thought was a gallop rhythm. Her liver was palpable (even to a JMS!) 10 cm. below her costal margin. Obviously, this lady was in florid congestive heart failure. She was immediately transferred to cardiac care.

As one might imagine, there was considerable discussion of the case among our group of students.. It was pretty obvious that because Ms. X was a regular and her symptoms were generally what they had been in the past, the 3 physicians who had seen her did not do even a cursory physical examination! She presented with the same symptoms she had reported in the past and it had not occurred to any of the three physicians that something might have changed!

Our group of JMS students decided this was a great teaching case because we learned a couple of important concepts.

First, a good physician should never make assumptions! At the JMS level that means a thorough and complete exam on every patient because you are learning. But it also means in practice you need to examine every patient on every visit even if they are well known to you...

Second, we learned that crazy people do get sick! I imagine that’s why the psychiatrists in my town always want medical clearance from the ER docs or family doc before admitting a patient to the in-patient psychiatric ward.

I took these lessons to heart and I believe I was a better physician as a result.