Mentors and Dementors: The Knee Jerk

 

Dementor, Dr. Marion, sucking all that's good about medicine out of a resident

I, like most first year clinical fellows, felt a little awkward.  Just removed from the great unwashed mass of internal medicine residents, I was already  supposed to  exude rheumatology-ness when interacting with colleagues I had shared call with only weeks before.  It takes a bit of knowledge, a bit of show, but everybody generally plays along.  

I saw a floor consult on my own. An older women with a painful, red, tender knee.  It was right over the knee cap and extremely tender.  I thought it was an early pre-patellar bursitis, likely gout.  Unfortunately there was very little swelling and I didn't think I could get fluid.  She was on coumadin so I didn't want to muck about just to produce a crystal or two. I ordered some prednisone with a presumptive diagnosis of gout.

The following day we rounded with the consulting rheumatologist.  There was quite a crowd, which was exceptional for the times.  Two fellows, a resident, a med student and our staff rheumatologist, Dr. Marion.  It was my first time rounding with Dr. Marion and I wanted to impress her.  She was known by housestaff to be an excellent clinician and terrific teacher.  I presented the case with as much enthusiasm as such a mundane diagnosis could muster and we went in to see the patient.  I had not had an opportunity to revisit the patient since I prescribed the prednisone so I was a little concerned that we would find a massive oozing abscess leaking from a negligently  untapped bursa.  I was pleasantly surprised to find that not only was the patient not in septic shock, but had, in fact,  had complete resolution of the bursitis. Damn I'm good.

 Dr. Marion looked at the knee, flexed it a bit and palpated it unenthusiastically, like she was testing for ripeness.  

  "Mrs Johnson, your knee is fine.  There's nothing wrong." she said without discussion.

I thought it was a rather curt way of discussing the diagnosis but hey, I'm only a fellow.

  "We can stop the prednisone" said Marion.

"Do you want to taper it over a week ?" I asked.

 "No, just stop it, it's nothing."

Getting the gist of what she was saying, but not understanding why, I reminded her that just yesterday the knee was red, hot .

"She probably just had her legs crossed"

Beautiful.

Dr. Marion was telling me, with all the gathered housestaff as witness, that I must have mistaken the redness of acute leg crossing for an attack of a gout.  Silly boy.

Our relationship never did recover, although she probably didn't notice.  Fortunately my career was already decided by then and I subsequently discovered that, among rheumatologists, this kind of behaviour is extremely exceptional.  I can't help but wonder though, what might have happened  if I were an R3 at the time, trying to sort out my subspecialty options.  Residents work with but a  few staff in each field  and every personality reflects on their specialty.  Our  path to subspecialty is a crooked one, littered with anecdote; some gruesome, some wonderful.  You have to wonder whether our eventual choice is based more on the positive mentor experiences, or negative dementor types.

Comments

[MSII]

I'm only a second year med student, so I haven't settled on my path yet. I've been having fun shadowing physicians from all sorts of fields. It's interesting to observe the practice styles of different physicians.

I'm finding second year is a great time to get mentored. Last year I didn't know enough to really participate in conversations. I'm starting to understand things better now, and I'm listening to what everyone has to say. I'm finding physicians have a lot of good will towards second year students; we're still not at the point where we have to meet clinical expectations, but we're at the point where we can be introduced to a lot of things. I haven't met anyone grumpy yet (I expect that might change when I start my clinical education!)

[3+speckled]

Good, I hope you never do meet a dementor. Fortunately, while gruff, inconsiderate, and lazy docs are plentiful enough, the truly pathologic are quite rare. Enjoy the ride and don't forget to try out rheumatology.

[MSII]

Thanks! I was involved in a lupus project as a MSI, and this got me interested in rheumatology. Would you mind posting about "a day in the life of a rheumatologist"?

[Petra]

Yeah!!! THose dementors are out there!!! They did affect me once - two dementors - one much worse. the other itermittent.

Anyhow, they are there and if you are prepared, then the less effect it will have on you!!!

Don't let them stop you from loving rheumatology!!!