Crozet Annals of Medicine: The Eye Sees What the Mind Knows

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Medical training can make for strange bedfellows, and not just in the on-call rooms. In the distant past, when I trained, many if not most doctors did what was called a transitional internship. The first year out of medical school was divided up into six months of surgery and surgical sub-specialty rotations and six months of medicine and medical subspecialty rotations. Pediatrics and obstetrics were sometimes squeezed in as well. I liked this system; it meant all doctors had some basic clinical foundation in common. Surgeons could recognize heart attacks and internists could recognize appendicitis. Most doctors could deliver babies if forced by emergency to do so.

That was then. Now with the explosion of knowledge and techniques very few specialties can afford to spend this time on the common basics. Interns start training in their specialties right out of medical school and spend little time on other medical services. This is unfortunate in my estimation. Lay people expect all doctors to have certain skills, like first aid, wound care, fracture management and heart attack and stroke treatment, for example. Also I miss the camaraderie of knowing all of the house staff well, by virtue of having had every intern and resident in the hospital rotate for a month with us in the ER.

The lone transitional holdout among specialties is Emergency Medicine. Our interns still do a transitional internship and indeed continue non-EM rotations throughout their three years of training.

There is a cross pollination that occurs when different specialties train together, which can produce some interesting insights.

When I was on my surgery rotation, for example, we had a broad representation of trainees including pediatricians, obstetricians, and even dentists beginning their oral surgery training with us on rounds one morning. We were down in the basement of the hospital, the traditional dark haunt of radiology (and pathology, in the morgue). We were looking at the abdominal X-rays of a woman who had been admitted overnight for some puzzling abdominal pain. We all looked at the X-rays, which seemed unremarkable to us. The dentists, while the most affable of the group, weren’t too engaged on rounds usually and only glanced at the X-rays as we were filing out.

“Hey, that’s a tooth,” one of them said, pointing to the pelvic area of the X-ray where the ovaries were located. 

“Yep,” his buddy said, “a central incisor to be exact.” Now they looked interested.

“Musta swallowed it,” the first one concluded. Teeth he knew, anatomy not so much.

The obstetrician stepped up and peered at the films.

“Nope, that, fellas, is a teratoma” he concluded.

“Turf her to gynecology,” the surgery chief commanded. It was the first time I had seen him smile.

A teratoma, from the Greek word for monster, is a bizarre tumor, which grows from early reproductive cells (germ cells). Because of the potential of these cells to produce any type of adult cells in the body, a teratoma produces all sorts of weird and out of place structures, most commonly teeth and hair but also muscle bone and skin. As you can imagine, this strange cystic tumor containing hair and teeth resembles some kind of primitive monster. They are most common in the ovaries and testicles but can appear almost any place in the body. The majority of teratomas are benign, but need to be surgically removed as they can grow quite large and interfere with organ function. This one was on the ovary, hence the turf (transfer) to gynecology for removal.

Back on rounds the next day, back again in the dark depressing basement while the rest of the world was basking in the sunshine, we were looking at the chest X-ray of a gunshot wound patient admitted overnight. The trauma surgery chief resident had vast experience with gunshot wounds and was of the opinion that the bullet imbedded in the spine was a .38 caliber, while the attending surgeon was sure it was a 9 millimeter slug. He didn’t need to lean on his experience. He could prove it, he said.

With that he swept his long white coat back at the waist like a gunslinger in the movies pushing his duster out of the way of his holster. He reached to the small of his back and came up with a Glock 9 mm automatic pistol. He jacked the slide and caught a round in midair as it was ejected. He placed the bullet on the X-ray next to the projected bullet and sure enough the calibers matched perfectly. Well, that was a neat trick! He then reloaded the bullet and holstered the gun. The whole group exhaled at the same time. Did I mention that I fell in with some strange bedfellows during training?

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