My preceptor shares the same name as the right hand man of a fictional, yet very famous detective. So it was inevitable that a patient would sooner or later make the connection and so dub me: Sherlock Holmes. I find it rather fitting considering the art of medicine is but a puzzle to be solved with pieces of evidence, some physically clear and some not so obvious, leading to a diagnosis.
“It is a capital mistake to theorize before you have all the evidence. It biases the judgment.” -Sherlock Holmes
I am often asked to provide a differential diagnosis based on a chief complaint, a single sentence. Sometimes I can spurt out various diseases and illnesses. I eagerly name the first ideas that come to mind, a laundry list of medical jargon, eponyms, and Latin terms. Some diagnoses are likely and some are far-fetched, but equally important. Then step-by-step, question-by-question I gain more information. I work through my History of Present Illness as I have been taught over and over again. Those seven dimensions of an illness are engraved into my memory and can be quickly turned into questions to help reveal the mystery behind the illness. Then I leave the room and with every step to the small office behind the nurse’s station I narrow down my differential. I read the notes from my mini notebook, attempt to pinpoint the major findings of the physical exam and quickly come to a conclusion… sometimes I am certain of the diagnoses and sometimes I find myself in bewilderment.
“In solving a problem of this sort, the grand thing is to be able to reason backward.” –Sherlock Holmes
Throughout the busy days of week 6, I began to realize how much I have learned, how nicely my problem solving skills have developed, but how far they are from being polished. Of equal importance, I feel a sense of confidence and comfort when walking into a patient’s room solo with only one year’s worth of medical school education. I often surprise myself. And then there are those times when I take a handful of lab reports with abnormal values highlighted in nearly every row. I stare and try to piece things together like the mystery that they are. I try to think methodically to understand how one problem can lead to another like a domino effect… and then the numbers begin to blur and I have no idea what could be wrong.
“His ignorance was as remarkable as his knowledge.” –Sherlock Holmes
After six weeks, it is nice seeing patients for the second or third time. Relationships grow, I meet family members I’ve never met and I hear more stories. One man stands out in my memory. He was a self-proclaimed politician, an elderly man wearing his cowboy boots proudly. He told me about his work in the mines as a young man only to be disabled with a bad back injury that he would later attribute to saving his life after having watched his brother die of lung disease because of years of mining. He told me how nice it felt after four years of recovery to mount his horse and ride off into the mountains. Then as a middle-aged man, he came into the clinic after sustaining a knee injury during a long horse ride. He explained how he had to correct the nurse after she asked, “What happened when you fell off the horse?” Slightly angered, he was quick to respond, “Cowboys don’t fall off horses! They are bucked off!” I smiled at his story and his enthusiasm. It warmed my heart and I thought of my very own experience with horse riding injuries. I cavalierly looked down at my bare knee and the scar that told my story. He talked for a long while and then changed the direction of the questions. He asked me about my journey, my life, and my family. Quickly connections were made and he began to tell me of my grandfather- the grandfather I lost as a child, whose memories are scarce, but precious. While he didn’t have many stories to share, he spoke of my grandpa’s character, how he had supported him through multiple elections. I was proud of Grandpa Perea and endlessly thankful for such an opportunity. I walked out of the room reminiscing of the past, embracing the moment, and hoping for more.
“I had no idea that such individuals exist outside of stories.” -Dr. Watson about Holmes
The days passed and each day I gained more knowledge. Friday morning, I read the schedule as I usually did when time permitted. It was a lot of the same stuff- Diabetes, ear ache, hurt knee… And then I saw something slightly interesting, a little procedure seemingly insignificant in the eyes of a real doctors, but an exciting way for me to end the day. My preceptor would be removing a toe nail.
"My mind," he said, "rebels at stagnation. Give me problems, give me work, give me the most abstruse cryptogram or the most intricate analysis, and I am in my own proper atmosphere. I can dispense then with artificial stimulants. But I abhor the dull routine of existence. I crave for mental exaltation. That is why I have chosen my own particular profession, or rather created it, for I am the only one in the world" –Sherlock Holmes
The hours passed and before I knew it, we were prepping a sterile field, gathering the necessary tools and getting consent forms signed. The patient was in his 50s with years of stress etched into every crevice of his face. He had a dark face from years of unprotected sun exposure like many men of Northern New Mexico, and large scruffy hair beneath a Semper Fi hat. He had strong energy and spoke quickly. He had a story for every comment and a joke to finish. It wasn’t long before we identified our relation (I’m honestly related to half the patients I see) and he told me how much I resembled my mother. It was a statement I heard often. He then said he was glad he could help his prima learn and told the doc he should let me do the procedure.. he agreed. After the toe was numb, he took a couple of minutes to explain what I should do, walked through the steps and demonstrated the technique.
“You know my methods. Apply them.” -Sherlock Holmes
In the beginning, I handled the toe gingerly. Then I was nudged by my preceptor and the patient to apply more force… so I did and I'll spare you the bloody details. It took only a dozen minutes or so and the man was free of a thick and mangled toe nail. And I was one procedure smarter.
“I consider that a man's brain originally is like a little empty attic, and you have to stock it with such furniture as you choose. A fool takes in all the lumber of every sort that he comes across, so that the knowledge which might be useful to him gets crowded out, or at best is jumbled up with a lot of other things, so that he has a difficulty in laying his hands upon it.”
Furthermore the days pass quickly and I am reminded how intricate medicine can be. Each patient comes with their own unique set of evidence and it is our duty to make sense of it, to ask the right questions and to bring comfort. I don't find myself capable of much, but I am confident that with each passing day I am closer to being the detective that will one day solve mysteries. I wear my white coat like Sherlock wore his famous cloak, but unlike his, mine is still naive with only a short story to tell, but a story to tell nonetheless.
“When you have eliminated the impossible, whatever remains, however improbable, must be the truth.” – Sherlock Holmes
