Why do they call it practicing?
If you become ill do you really want to go to someone who is just practicing? Don’t you hope that the person you are seeing knows what they are doing and has it down?
I was puzzling over this the other day.
Then I remembered.
It was July of 1992. I had just graduated from my one-year Navy internal medicine internship.
Suddenly I was in an office seeing patients. It was just me and the patients.
When I graduated from medical school at the University of Michigan, we moved to Virginia. Sarah and I were newly married and we settled into a nice apartment in Chesapeake, VA. I did my internship in internal medicine at the Naval Medical Center Portsmouth, VA. The usual routine for US Navy physicians (at least at that time) was to do a 1-year rotating internship and then go serve in the fleet for a couple of years as a General Medical Officer (GMO). Near the end of my internship, I applied to do the flight surgery training program and I was accepted. I opted for the January training session. That left a gap of 6 months between the end of internship and the start of my next training. I was assigned as a GMO to the Admiral Joel T. Boone Clinic at the Naval Amphibious Base in Little Creek, Virginia.
On June 30 I was an internal medicine intern working in the hospital with a resident physician and an attending physician supervising me. The next day I was sitting in an office with my name on the door and patients waiting to see me. I no longer had a resident or attending physician to supervise me or verify my decisions.
It was mildly terrifying.
It was not that I hadn’t had good training. I had good training. The clinical training at Portsmouth was amazing but it was almost entirely hospital based. I was really good at managing critically ill patients. I could easily take care of diabetic ketoacidosis, intubate a critically ill patient, put in a central line, or manage a heart attack. But I was not quite so experienced at treating a sprained ankle or a sinus infection.
I quickly learned that physicians develop practices that they follow. In other words, I have certain ways that I do the work that I do. For each potential complaint or problem that a patient has, I have developed “my way” or “my practice” for how I handle them.
Yesterday in clinic I saw some amazingly complicated heart failure patients. Unlike my first days at the Boone Clinic, however, it was not stressful. Years of experience have allowed me to develop and refine, multiple times over, my approach to their management. I could confidently move from talking to them, to an exam (inwardly figuring out what I was going to say to them and what my plan will be while I listened to their lungs), to executing a logical plan that I have confidence in. Phone calls and patient questions between patient visits could be dispatched reasonably quickly because I was not having to reinvent the wheel every time. I have ways that I like to take care of certain conditions or problems.
That is, I have certain practices that I use to treat my patients. I keep using these practices, and every time I do, I keep looking to see if there are better and better practices that I should be using. To put this another way, practicing medicine means applying all my past training, experience and clinical patterns to manage their care.
But on day 1 at the Boone Clinic my practices were not very developed yet.
A patient presented with a twisted ankle. I brought him into the exam room. I took a history (asked him what happened). I examined his ankle. It was swollen and tender. It felt warm. I had a little bit of experience with this from my one-month mandatory orthopedic surgery rotation during internship at the Naval Hospital. Most of that rotation, however, was spent on the serious cases that needed surgical care. On this first day in the Boone Clinic, I would have been more comfortable if my patient had a broken ankle and he needed me to prep him for surgery.
What should I do? What should I tell him?
X-rays. That made sense. I wrote out the request (“chit” in military jargon) for ankle x-rays. I sent him to x-ray.
This was a blessed reprieve! It gave me some time to think. I grabbed my, “Roche Practice of Office Medicine,” textbook. I flipped to the index, “ankle sprain” and then a nice discussion about RICE (Rest Ice Compression Elevation) along with the debates about rest vs. early mobilization and physical therapy. I remembered providing this sort of care during my Emergency Department (ED) rotations. By the time my patient came back I confidently shared my plan for him. I wrapped up his ankle in an ACE wrap and gave him a limited duty “chit” and asked him to come back the next week for me to recheck his ankle.
The next patient presented with a runny nose over the past week and now was having progressive sinus pressure and pain, thick colored nasal drainage, and a post-nasal drip that made him cough. It was the usual pattern: (1) history, (2) exam and then my plan. Some tenderness and pain on the maxillary sinus region. Hmm. Maybe a sinus x-ray could help? It would also give me a chance to think. I had done some of this type of medical care also on my ER rotation but what was my own style for managing a sinus infection? I went back to my textbook: (1) Discussion about whether or not antibiotics are indicated. (2) Decongestants to help the sinuses drain. (3) Choice of antibiotics. (4) Debate about whether x-rays are really needed or not. Patient returned. I reviewed the x-rays. They did show some sinus haziness. I gave him some prescriptions.
Ok. We were making progress now. I could handle an ankle sprain and a sinus infection. As time went on my patterns – or my practices – got refined. I got more and more comfortable with each problem that presented to me.
Next came a patient with rash. I did a month of dermatology training in my internship. That rotation was in a busy military clinic that served active duty and retirees. In that rotation I got pretty good at recognizing skin cancers and doing some minor surgeries. I could freeze an actinic keratosis, do shave biopsies, and even do electrodessication and cautery (EDC) to a basal cell carcinoma. There had been no way in just a 1-month dermatology rotation that I was going to be able to learn and know every possible rash. I knew in advance the challenge of figuring out rashes. I invested in a fabulous book with lots of pictures, “Habif’s Clinical Dermatology. A Color Guide to Diagnosis and Therapy.”
Back to my patient. History. Exam. Hmm. Nothing to x-ray. I asked the patient to wait for me. I excused myself from the exam room. I moved back to my personal office where I had a small desk and where I kept my key reference books. I grabbed my Habif. I started guessing as to what rash my patient had. I flipped through page after page of disgusting pictures until I found what looked like my patient’s rash. I jumped to the text below and read through an organized plan. Ok. That is what we will do.
Next came a patient with a possible STD (sexually transmitted disease). Same thing. History. Exam. Some memories from ER rotation. Verify in the textbook. Treat.
But what was I to do when the textbooks didn’t provide an answer?
I had some other very important tools. One key tool: Greg. Greg was another GMO in the clinic. Greg was really experienced (to me) because he had been out of internship for a full 3 years. He had come back from serving a tour on an aircraft carrier and was used to the daily deluge of sailors coming to “sick call”. Greg was a great guy and took me “under his wing.” He had developed a lot of practices that he had developed over those 3 years. His help was enormous.
History. Exam. Excuse myself to my office. Think, think, think. Go to Greg. Ask for help. Return to the patient with a plan!
The other help came from an even more experienced older civilian contract physician. He had more than 30 years of experience. When Greg didn’t know what to do I would walk over to the other hallway to find him. He also was a great guy. He never complained or belittled me. He would think through my patient problem with me. He rescued me and provided me answers numerous times.
They were not able to rescue me every time. Sometimes even my two more experienced physicians didn’t know what to do. That was when we ordered a consult from the specialists at the nearby Naval Hospital.
My first day in the clinic was exhausting. As time went on it got easier and easier. I learned and refined my practices, or my “practice of medicine” with each passing day.
One day I was to see an entire group of sailors with intense itchy rashes (red bumps all over.) They had been on a military field exercise together. I had no idea what was wrong with them. Greg laughed. He told me they had red bugs (chiggers). Greg was surprised that I didn’t know about red bugs. I didn’t grow up in the south. It was my first experience with this problem. Hydrocortisone cream for all of them and on we went.
DUI (driving under the influence). A sailor got drunk on the weekend and got in trouble. Their commanding officer sent them to me. This was a new one for me. An 18-year-old sitting in my exam room in trouble.
I ran to Greg, “Greg – What is the deal with this?”
He told me. It was my job to meet with them and give them a diagnosis. If I said they had “alcohol abuse” they would get sent to a 4-week outpatient class. If I said they had “alcohol dependence” they would be sent away to a 6-week inpatient class. None of the sailors wanted the inpatient class. Most of them hoped to convince me there was no problem whatsoever. At a bare minimum they hoped to keep it to just the outpatient class. I had studied about alcohol disorders. During my internship we spent time visiting various AA and NA meetings to help educate us on substance use disorders. Those were interesting experiences, but did that really qualify me to make these judgments? From a military perspective, someone had to do the job and who was more prepared than the doc? At first, I was uncomfortable doing these evaluations. Over time however I got better. I practiced. I read. I learned questions to ask and how to probe and find out what was really going on in their lives. I still didn’t like those exams. It was always a bit awkward and uncomfortable how much power I had over what happened to them. With time it got easier. I developed “practices” that I could use to work through things.
A few years later as a flight surgeon my commanding officer (CO) sent over a young man after a DUI. This time the CO called me. “Mike – check out this guy. Let me know what you think. Is he a dirtbag or just a confused kid? If he is a dirtbag, I will kick him out of the Navy. If he is a confused kid I will be a firm father and try to see if we can get him to shape up.”
Wow. Really? Me to decide this? I was just a few years out of medical school and internship? But then again who else in the squadron should decide this? I guess I had more training than anyone else in the squadron. So how do you decide if someone is a “dirtbag?” I am not sure that is really an appropriate medical assessment, but I did my best to sort through things. I guess I was learning another new practice.
It amazes me how much I had to learn in those first few weeks at the Boone Clinic and my first few years of clinical practice. Most of my training before that had been on complex hospitalized patients. I learned quickly with the help of some key books and the other physicians. They helped me get better. Eventually the other physicians even began asking me questions about the more complex internal medicine related conditions.
So, are we practicing medicine? If that means that we are applying or following a set of practices that we have learned, developed, and continually refined through the years then absolutely we are practicing medicine.
Beyond what we do in medicine, are there any life lessons related to this? I think so.
We are all practicing at life.
What do I mean by that? We do our best to apply the lessons we have learned through our lives to cope with the issues that come up. We all have practices that we follow. We get through life by learning patterns that we use to cope with problems. Whenever we are faced with a new problem it can be a bit overwhelming. We go to the computer database in our brain searching for a programmed response. If there is nothing there, then we must invent or figure out a new practice. That can be stressful.
Going back to fresh out of internship me:
- Recognize that the situation is new. Acknowledge the stress and the need to have some time to figure things out. As I learned in the Boone Clinic, it is okay to excuse yourself to your office to have some time to think.
- Read or search out data from reliable references. This might be practical stuff or scientific stuff. Sometimes it means going back to the Scriptures for wisdom on living your life.
- Seek out advice from people with more experience. Find your “Greg(s).” Look for reliable experts.
- Implement a plan but always be open to changing and improving your plan. You will likely not be perfect right away. If you keep “practicing” you can and will get better and better.
This is all common sense, right? But in the moment, it may be not so easy to do.
I can remember when we had our first baby. There were lots of practices to learn and figure out for how we were going to do things. Maybe not as extreme as a new baby there is similar stress with a new puppy. There are a lot of key life events that can trigger this cycle of change including things like marriage, new city, new job, retirement, etc. Even something as simple as summer vacation can seem to initially throw things off balance. What are the norms and expectations? How are we as a family going to do things?
Social distancing, masks, whether to see your family members, how to go to work, how to get groceries, whether to go on vacation, and a whole lot of very basic stuff got messed up in March 2020. Just like my 1st day at the Admiral Joel T. Boone Clinic, going to the grocery store was something that I didn’t know how to do for sure. Over time most of us have developed practices that we are using, and it has gotten easier. I still would like for it to get a lot easier (like maybe go back to what it was before COVID 19). But I don’t get all that I want. It is getting easier. We are learning. We can adapt and grow. Did we get it all perfect? Of course not, but we keep learning and refining and practicing. New variants (delta, omicron) have tended to confuse and shift things again.
Beyond that, do I really know what I am doing in my life or am I just practicing?
To be honest it is always a little bit of both. I have a lot of practices I have developed and refined over the years that serve me well. I am clearly far from perfect. I will always have things that I could stand to change or improve.
Maybe there is real value in the term “practicing”? There seems to be wisdom in understanding that all of us are just doing our best (based on the wisdom available to us and our past experiences) to apply what seems to be the best “practice” in each situation that confronts us. If I understand that, maybe then I will be less stressed by change and more accepting of the challenge of developing new practices? Maybe I can understand that each new challenge brings the opportunity to grow, learn and develop new practices?
My uniform was still crisp and new looking. I had only one ribbon. I looked really young. I had just graduated from my one-year internship. I had a lot to learn. But those 6 months at the Boone Clinic were an amazing and valuable time for me. It was there that I gained independence and grew to learn how to practice medicine.
And so yes – I am still practicing medicine. That is a good thing.
