Mirror mirror on the wall who is the smartest doctor of them all?

Nitin K Sethi, MD

New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, U.S.A.

As a resident in training, I quickly came to the realization that some of my attendings were smarter than others. No matter how vexing the clinical problem these were the few who always knew the answers. I would present the history, examination findings and pertinent labs and voila these master clinicians would be able to put the pieces of the puzzle together. If they did not know the answer right away, they always knew where and how to look for it. What organ system to focus on and what tests to order. They stood out in stark contrast to my other attending, all ‘good’ neurologists but who I frequently found ordering multiple and at times random tests struggling to find answers to what plagued the patient. Eccentric with bedside manners that at times bordered on the theatrical, these master clinicians on the other hand made medicine fun and easy. It was as if they could walk into a patient’s room and smell his disease.
I frequently wondered what set these doctors apart from others. It could not be the medical school or the residency program they graduated from. Few were from Ivy League colleges and a seldom few were known outside the corridors of the institution they served in. On the other hand a good number of the ‘good’ doctors made it to the New York’s best doctors list time and time again. Was it their depth of knowledge? Many of the ‘good’ doctors would quote articles and studies with ease but still came up short at the patient’s bedside. It had to be Factor E (excellence factor) coded by the M (master) gene. Only a chosen few had it.

Now when I am on the other side of the fence teaching residents and fellows in training, I still at times wonder whether master clinicians are born de novo (with copious amounts of Factor E) or whether a chosen few good physicians become master physicians and the rest remain good. A lot has been written about improving residency training. The goal is to produce competent physicians at the end of the training process but can good residents be trained to become master clinicians? Is Factor E teachable and transferable? Does training under the wings of these masters automatically ensure transfer of gene M to the trainee? The field of medicine glitters with examples of master clinicians who taught, mentored and inspired their residents and fellows to become master clinicians themselves. A closer look at these attending teacher-resident trainee relationships is worthy of our attention. The patient’s bedside is your laboratory is the central tenant that master clinicians teach their students encouraging them to spend time at the patient’s bedside hearing their stories with rapt attention for a small detail in the patient’s history may very well be the key which unlocks the whole puzzle. Sherlock Holmes the master sleuth once told his prodigy Dr. Watson “you see but you do not observe”. Blessed with astute powers of observation and an analytical mind master clinicians similarly teach their students that the eyes do not see what the mind does not know. James Parkinson, a master clinician in his own right, in his short monograph titled “The Shaking Palsy” described 6 patients in total, three of whom he simply observed walking on the city streets. Much of the description of the longitudinal course of the illness we now know as Parkinson’s disease was derived from his observations of a single case only. Master clinicians report just not their successes but also their failures. Always remembering and learning from their failures constantly striving to become better they inspire trainees to follow in their footsteps. Knowing all too well that medicine never was nor shall ever be an exact science, they encourage their trainees not to hesitate to think out of the box when confronted with a vexing case. “When you have eliminated the impossible, whatever remains, however improbable, must be the truth” another quote attributed to Sherlock Holmes is well worth remembering. Last but not the least these lone stars of neurology teach their trainees the importance of treating patients with respect and dignity reminding them ever so gently that our patients remain our best teachers.

“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”
(William Osler-Canadian physician 1849-1919)