The Burden of Knowledge

by Abdul S. Hassan, MS4

Before medical school, I was fascinated by the myriad diagnoses that seemed to live in the brains of doctors and how these doctors were so adept at keeping all of those different diseases in order. As I started medical school, I was invigorated by the notion that I could spend my time learning countless different maladies and become a cornucopia of medical knowledge.

Four years later, I can confidently say I know (some) diseases. Maybe even close to a hundred or so, but nothing that could compare to to the likes of Harrison’s Principles of Internal Medicine (the venerable tome of medicine). The reality is, the name of the game for medicine is pattern recognition. We are trained, and nowhere more rigorously than in our 3rd year and beyond, to recognize the specific ways different diseases present as well as the most common illness we will come across.

Take for example, the following vignettes:

1. 18 year old male with 2 days of umbilical pain that has radiated down and to the right; he endorses nausea, vomiting and no appetite

Appendicitis; confirm with ultrasound if stable or straight to OR if highly suspicious for perforation

2. 74 year old female with 3 months of dark black stools and 15 lbs of unintended weight loss; she endorses feeling weak and increased fatigue throughout the day

Colon cancer; confirm with colonoscopy and biopsy; CT scan for staging; potential surgery and chemotherapy or radiation

3. 29 year old female with intermittent history of eye pain as well as right hand and left thigh numbness; symptoms arise without warning and eventually return to normal

Multiple sclerosis; MRI to assess for plaques; initiation of DMARDS; possible physical and occupational therapy for residual deficits

Ask any medical student worth their weight in stethoscopes about the above scenarios, and they should be able to come up with the exact same diagnoses I have made.

At the time of writing, I am at the beginning of my 4th year of medical school, and I’ve come to see how this type of education has changed me. The pattern recognition algorithm doesn’t just turn on when I’m at the hospital or taking an exam, but it is now a base program that runs in the background constantly analyzing the outside world and all the people within it. This realization hit me in the middle of a much needed post-call run.

Running alongside some construction, I noticed a small patch of sidewalk that had not yet been demolished. And upon that small patch of concrete stood a gentleman with a bright orange hat, white dress shirt, some brown khakis and a cart with a random smattering of goods. I wouldn’t say he looked completely untoward, but he was a bit disheveled. He appeared to be talking to something or someone who was not there – his conversation was unheard against my running playlist. As I passed him by, I noted how his mouth and tongue seemed to writhe and undulate with preternatural conviction. And in that moment, my brain shot out:

Elderly male, disheveled appearance, questionable auditory/visual hallucinations, involuntary and repetitive movements of mouth and tongue

Schizophrenia and tardive dyskinesia likely secondary to antipsychotic medication.

Maybe I am wrong, but if you were to see this presentation on a medical school exam, then again, most medical students would think of the above answer.

A big part of me is taken back by how my brain has changed and how it will further change with more studying and more patients. But another part of me is saddened. Saddened because we in the field of medicine, know what the scariest and most life-threatening presentations of the most common diseases. At this point in my life, a headache, is not just a headache. A simple course of antibiotics for my patient is not just an afterthought. The nagging pain you have had in your back that seems to keep you up at night, has the same effect on me.

I know that there will be many people in my life, for which my inner conscious will be a harbinger of their ultimate end. I will have a close approximation of the diagnosis before they even finish their sentence. The people I love, my friends and family, are not safe from this constantly running program that seeks out disease. It is a gift, but it is also a burden. The burden of knowing too much is engrained in medicine.

And yet, I accept this knowledge with great humility. There is tremendous honor in being the voice that a patient listens too. The voice that has the power to completely alter someone’s life with only a handful of syllables. With that voice in mind, no matter how quickly my algorithm darts to the most malignant of diagnoses, I hope I can continue to call upon my heart and remain steady. May the burden of knowledge be not a weight that slowly drives us into the ground, but a shield we use to know when and how we can protect our patients; the people that have entrusted perhaps not just their lives, but the end of their lives to us.