The Interpreter of Facts

I remember feeling dumbfounded; perhaps dumb is a better way of putting it. A subintern, soon to be medical school graduate, I often sat in awe listening to Dr H, my medicine attending physician, as he expounded on various topics. One day he might be teaching about the streptococcal M types associated with pharyngitis and their relationship to rheumatic heart disease. The next day, while I was still trying to digest the information from the prior day, he would be lecturing about the interpretation of hepatitis B serology. Dr H seemed to possess knowledge beyond the scope of mortal me. Indeed, I had just subscribed to my first medical periodicals, so that I too could become a walking textbook, or at least become familiar with some of the literature that he and others were citing. Back then, we did not talk too much about “nonmedical” things like getting interpreters for those patients with whom we could not converse because of language barriers, end-of-life issues, or matters related to patients' spirituality. That said, one Saturday during morning rounds with a renowned division chief, I received my first lecture on professionalism when I was dressed down for not wearing a necktie. When the attending offered me his Royal College of Physicians tie, I remember feeling shamed, although tempted to take it.

I survived medical school to become intern, resident, then subspecialty fellow. At each stage of my training, the breadth of facts that my seniors possessed seemed remarkable. While I subscribed to increasing numbers of journals (many unread despite my best intentions) that lay scattered in my various apartments as I moved from city to city, I was still awestruck when I spent a moment in an attending physician's office engulfed by the volumes of textbooks lining the walls. At each step I suppose that I too was accumulating a grab bag of facts with which I could pimp and impress and at last impart to the students and residents under my tutelage. Before long, I became an attending physician too. Things ran fairly smoothly for the first dozen years of my academic career. My bookshelves blossomed with colored bands of a multitude of journals. Texts multiplied, and my office began to take on the air of some of my mentors. As I moved up the academic ladder, I became a wizened relayer of facts.

Some time in the last decade I noted a new phenomenon. It began with a smattering of students and residents surreptitiously glancing at medical “self-help” manuals during rounds while I was teaching. Although I was tempted to feel insulted by the fact that they might be checking up on my facts, I began to wonder about the rationale for my discourses when the factual content was at the trainees' fingertips. I asked myself about whether I was wasting their time during rounds. During the ensuing years, the furtive glances have become more overt; the books have been replaced by handheld devices in full view with full texts. A corollary to this phenomenon, not surprisingly, is that students and residents admit to reading fewer periodicals on a regular basis, and textbook ownership is all but a thing of the past.

The coup de grace occurred last year while I was rounding in an intensive care unit (ICU) with my infectious diseases consultation team. While the ICU team was querying me about the Vibrio vulnificus cultured from a patient's blood, I could not help but notice a computer with the latest Up-to-Date on the screen standing tall at the foot of the bed. These knowledge-hungry students already had several of the most recent articles on the subject downloaded from PubMed and printed using the equipment at the nursing station just a few feet away. Facts? At that moment these students and residents probably had more data regarding Vibrio species infection than I have ever known. Furthermore, given the medical scientific community's penchant for rewriting the facts with better and larger studies that have generated better data (think of menopausal hormone therapy, the interpretation of syphilis serology, or even the hazards of wearing neckties), my knowledge may even be out of date.

I was struck with a momentary flash of existential doubt. In horror, I posed a question to myself: What does a medical attending such as myself, not directly supervising a specific procedure, have to offer these people? It is clear that they do not need me or my years of data mongering to acquire nearly instantaneously a synopsized version of any subject; one that already has been digested and made user-friendly by an expert in the field. However, as I worked my way through the case in the ICU, I began to feel a bit better. Although the team knew about the relationship between the patient's HCV-related cirrhosis and this infection as well as the latest therapy, they had neglected to closely question her son regarding the likely source of the infection; he had brought her raw clams for dinner the evening before she became ill. I was also able to teach them that they did not need vancomycin to treat the lesions on the patient's legs that had developed while she was in the ICU. This is pretty common in disseminated V vulnificus infection. I left the ICU not totally dispirited but not entirely at ease.

It has become increasingly clear to me that with the information revolution in full throttle, the role of the clinical attending has changed drastically and continues to evolve. Besides using rounds to discuss many of the social, ethical, and professional issues surrounding a patient's care, I increasingly find myself teaching less about the current state of information and more about how things have changed and how our understanding of an illness or treatment has evolved to where it is currently. I teach about multiple portals—how there is no single way to approach a case and how the one we choose may not be the only or even the best strategy despite our attempts to get the facts right and review the relevant data. I have the distinct impression that my mentors possessed a degree of certainty that in hindsight I am not sure was warranted. In this era of evidence-based medicine, I am more likely to point out how scanty the evidence actually may be when making a decision. Although I may refer to the “classic” article in a particular field, all too often I will point out how in retrospect it looks much less convincing than when it was first published just 10 years ago. Rather than giving my team answers, I am more likely to ask them to formulate a question that interests them regarding a specific case, then investigate the data, and report back to the group. The group can then try to digest this information and place it in the context of the case at hand.

Perhaps most important, given the overwhelming amount of data that we receive about our patients (from both laboratory and literature review), I help to integrate and synthesize the data. Is a serum protein electrophoresis needed to evaluate an elevated immunoglobulin level in a patient with HIV? How does one proceed to work up all of the abnormalities in the complete blood cell count or chemistries of a person with AIDS? Is there some normalcy within the many laboratory value abnormalities that these patients demonstrate? When and which of the multiple positive cultures from an ICU patient with numerous invasive therapeutic and monitoring devices and open wounds does one treat? These are but a few examples of the types of questions for which there may be more than one approach to a problem and where medical attendings may disagree about the best approach to take or how to fully understand the data.

Although many have commented on the demise of the art of medicine in our increasingly technologically driven field, I would argue that never before has it been so important. What Albert Einstein said about a liberal arts college is also true in the realm of clinical medical education: “The value of an education . . . is not the learning of many facts, but the training of the mind to think of something that cannot be learned from textbooks.”¹ Indeed, I have become an interpreter of facts. I try to help my trainees wade through the morass of gray and paint a picture with some clarity that we can all live with, at least until the new data arrive.