The Road through Residency:

The Pedagogue

I sit there, intently but warmly watching the intern in front of me. She tells the story of the patient sitting in the room with us, the curtain closed around him, his age-related hearing loss precluding him from hearing our conversation. She describes the details of his case, the story of how someone born early last century has come to find himself in a room that didn't exist when he got married, behind a curtain whose fabric wasn't woven while he fought in a war across the ocean, and whose medical care will be decided by two young physicians who weren't even alive when he became a grandfather. The chief complaint is "forgetfulness." Confusion, altered mental status, transient memory lapse, cognitive vacation… delirium has so many names.

"Over the past week he has had a gradual cognitive decline. He denies chest pain, shortness of breath-" the intern relates to me before I interrupt.

"What does the family say?" I ask.

"They said he's been warm, possibly febrile, has chills, but no complaints about anything."

"They usually don't complain about anything. You have to know who and where you are to be aware of pain. How about the exam?"

"Nothing obvious. Lungs have some slight crackles, heart is distant, some mild abdominal tenderness, non-focal neurologic examination-"

"How about mental status?"

"He's… confused."

We go back to the consultant's room and go over the assessment of altered mental status. It's inspiring to see the glimmer of learning in someone's eyes. That "Ohhh" moment is a two-way gift. Walking this young physician through this difficult and complex work-up, this rough terrain of diagnostics, is a rewarding adventure. It revitalizes my interest in internal medicine, both for being able to help a fellow physician learn and to prove to myself that after several years of living in the hospital, I am beginning to find intellectual ease in my position, in my career.

We spend half an hour, maybe 45 minutes before heading back to the patient's room in the emergency department. Urinary tract infection is the diagnosis. We send him to the floor, comfortable and confident in our diagnosis. In two days the infection wanes, and he becomes more lucid. The intern is beaming with pride. Assessment, diagnosis, treatment, and convalescence-it's almost a storybook ending.

I've always felt that teaching is a requirement of being a physician. Teaching not only your patients, but also those who will one day care for you, is not a charge I ever felt I would take lightly. Too often have I seen other physicians ignore residents and medical students. They would walk by, pretending as if we didn't exist, feeling that our lack of knowledge not only excluded us from patient care, but also was not even worth correcting. Secretly, we reminded ourselves that we would one day take their places, and the relationship of student-to-teacher would become physician-to-patient. I suppose we relished in it, believing we would never mistreat or ignore such vulnerable, budding physicians.

Three weeks later, I had grown tired. The census-the number patients I was called on to treat-increased, and it remained in double digits for the remainder of the month. My time spent in front of the dry erase board began to decrease, till it sat on the wall empty of knowledge, just a white desert where once diagram, algorithm, and differential diagnosis list had been posted, reviewed, revised. Teaching quickly became a luxury rather than a mandate. I changed from a Socratic mentor, answering each question carefully with another question, to a pedantic pedagogue, throwing off fact and order but never guiding the interns along the pathway to them. The blinders were on, and work became just that: work.

At the end of the month, the interns evaluated me and indicated they were satisfied with my performance as a senior resident. They looked and felt fatigued but still retained that glimmer of fascination for medicine, while I simply read my list, irritated that I still had many patients to pass on to the next team of residents and interns. It wasn't until a week later that I looked back in regret. The resident team had run smoothly, but I had become something that disgusted me-a physician who sacrificed teaching for numbers. I had gone from engaging tutor to a micro-managing pedagogue. Throughout the next month I would seek out the interns and medical students, trying my best to make up for lost time, lost opportunity. Soon I will be back in the saddle, guiding another team of interns and medical students. I can only hope I won't make the same mistake again.