My patient had a hyperbilirubinemia, not sufficient to cause jaundice, but it was definitely abnormal. To investigate, his previous physician ordered an abdominal ultrasound. His liver appeared unremarkable, but curiously, his spleen was enlarged. Those clues and the presence of a longstanding microcytic anemia prompted me to suspect that the patient was afflicted with a particular type of hemoglobinopathy. This diagnosis was later confirmed by an electrophoresis. The pieces of a puzzle fell neatly into place, and yet the process felt oddly incomplete; there had been no resident or fellow with whom to reason it out. For junior trainees, I could conceive of several teaching points, such as the proper hand placement for detecting a slightly enlarged spleen, but I no longer supervised any.
I had been a clinician-educator for nearly 30 years. Following my retirement, I continued to practice medicine as a volunteer at a clinic for the underserved. I did not miss the long commute to my former job or some of the administrative responsibilities, but I grossly underestimated how much at a loss I would feel, bereft of the intellectual ferment of interacting with my fellows, residents, and students. In fact, they were indispensable to me.
I thought back to some earlier teaching experiences. During morning attending rounds, the ward team presented a patient to me who had been admitted overnight with presumed pneumonia despite the absence of a discrete infiltrate on his chest radiograph. Antibiotics had already been started in the emergency room and the team continued this course. I was not convinced, but rather than advance my own hypothesis I summarized the patient's history back to the team: “So you have this very sedentary patient who develops sudden onset of dyspnea with normal breath sounds, and his chest x-ray is equivocal….” The resident interrupted me, saying “Well, since you put it that way….” Upon hearing the most salient information, stripped of distracting, irrelevant details, she realized that she should have considered the possibility of a pulmonary embolus, which proved to be the case. According to Sherlock Holmes in “The Adventure of Silver Blaze,” “…nothing clears up a case so much as stating it to another person.” Over the years, I found this to be a useful technique to organize my thoughts, as well as to promote the development of residents' independent judgment instead of having them simply accept the pronouncements of others. Thinking out loud, as Sherlock Holmes understood, was indeed clarifying. However, this method is much more effective and less eyebrow raising with a team of residents and students than it would be in a room by myself.
One afternoon, I was instructing 2 second-year medical students in the basics of a physical examination. They were practicing on each other when a gentleman with curly white hair poked his head through the door. He asked if I would be so kind as to write him a prescription; his regular physician was not available, and he had run out of refills. I recognized a golden learning opportunity. I said that I would be glad to help him if he would consent to be examined from head to toe by my students and me. Mr. C graciously agreed, and we shook hands to seal this providential bargain.
With textbook thoroughness, we palpated, poked, and prodded a very accommodating Mr. C. While on the subject of peripheral pulses, we were surprised to find dilated and bounding femoral and popliteal arteries, of which he had not taken any previous notice. These observations soon led to the discovery of a sizable abdominal aortic aneurysm, ripe for rupture. Mr. C expeditiously underwent repair of his aneurysms, without any complications. In “A Case of Identity,” Sherlock Holmes asserted, “It has long been an axiom of mine that the little things are infinitely the most important.” The students heightened my attention to these “little things”; without them, I doubt that I would have come across the aneurysms. Mr. C thrived for many more years free of any problems from his aneurysms or the surgery.
On another occasion, the fellow and I were rounding in the rehabilitation department to directly observe our patients' progress. One of our patients was there for generalized weakness attributed to deconditioning following a prolonged hospitalization. He had recently been started on hemodialysis, performed through a temporary catheter. We watched the patient labor to walk between the parallel bars. Rather than improve with therapy, his legs were growing weaker by the day. I was concerned that an epidural abscess, seeded from the dialysis catheter, was causing cord compression. The fellow was skeptical because of the absence of pain, fever, or leukocytosis. This gave me a chance to reinforce some principles regarding the significance of demonstrable functional decline and the absence of the typical signs of infection in some older patients. I could sense that his doubts persisted, but he humored me anyway as we brought our patient for an MRI scan. His eyes widened as the images appeared on the monitor, revealing an abscess impinging on the spinal cord. I had encountered this uncommon phenomenon before, and it was gratifying to have the fellow with me to share in making this diagnosis—to pass the torch. To paraphrase Sherlock Holmes from The Hound of the Baskervilles, “It may be that you are not yourself luminous [yet], but that you are a conductor of light.” As with all clinician-educators, I hope that my trainee-conductors go on to illuminate others.
In an empty office, I contemplated the contributions of trainees to my career. They compelled me to be thorough and systematic, to sharpen my focus, to justify my decisions with evidence and logic, and to strive to set a good example as a professional. Moreover, the wide-ranging discussions, the debates over the best approaches to complex patients, the open airing of the risks and rewards, the constant back and forth, was all akin to honing a knife to keep the edge keen. But most of all, teaching was fun, greatly enhancing my enjoyment of patient care. Oh, I still give a lecture now and then, but that is a thin gruel compared to the previous daily feast of facing clinical challenges with my trainees. I acknowledge an essential truth, that I needed them as much as they might have benefited from me.