Each one. Teach one.

*Details changed significantly to protect anonymity.

Grady Resident's Clinic, July 2011


"Hi, ma'am. I'm Dr. Manning and I'm the senior doctor working with your doctor today."

"Good morning."

"Good morning to you, too. I heard that you had a rash giving you trouble today, right?" She nodded emphatically and rolled her eyes upward. Without me asking, she opened up her gown to show the angry eruption on her chest wall. I slid on a pair of gloves and asked, "Does this hurt?"

"Like hell," the patient quickly replied. "No, like hell-fire."

With the newly minted intern right beside me, I carefully inspected the flaming crop of dewdrop-appearing bumps spread like a linear stripe just below her right collar bone. "Tell me. . . how did this start?" I looked over at the intern whose brow was furrowed and inquisitive. Then I added, "I know you told your doctor all of this already, but I just wanted to hear a little more for myself if that's okay." I turned my head to make eye contact with both the intern and the patient; this was my unspoken way of getting permission to be redundant.

"First . . . .it felt like. . . .like something burned me. Crazy sounding I know. . . but that's how it felt."

"Ummm hmmmm." I folded my arms and kept listening.

"Then yesterday night I looked and this was what was there. Still burning like the dickens, but now with this ugly rash."

I raised my eyebrows and nodded slowly. "You know what, Ms. Fulsome? You do a great job describing what's going on with you. That was really helpful, thanks. If it's okay with you, we're going to just shop-talk for a few seconds, and we promise to explain everything we're talking about. Feel free to interrupt, okay?" She smiled in acknowledgment and helped us as we closed her gown. Next I faced the intern. "Thoughts?"

The intern licked her lips and pressed them tightly together before speaking. Although we'd met in passing a few times when she was a student, this was our first time working together in a clinical setting. Her brand new lab coat issued during intern orientation was blindingly white; her lack of experience had not yet caused it to be otherwise. Her earnest eyes were unspoiled, just like her white coat. . . . but she seemed nervous.

"No pressure, okay?" I offered. "Look. . . I really just want to hear what's on your mind. When we were outside you mentioned a few thoughts, and I was wondering if any other things had come to mind since we came in here together."

"I guess my first thought was pretty off then." She laughed nervously and then continued. "I was thinking that maybe. . . maybe she came in contact with something? Maybe poison oak or poison ivy? Especially since it is so linear?"

"Good point. Contact dermatitis from poison ivy can definitely give you blisters and you're right, it's one of the only things that gives you straight lines." I gently re-exposed the rash while being careful to keep Ms. Fulsome's breast from being exposed with the other. "This looks less like straight lines per se. . . and more like . . . . blisters on a red base. . . . but limited to one area. Kind of sparing other areas, you know?"

"I see what you're saying."

"What else could this be other than contact dermatitis?"

She sighed and licked her lips again. I could tell that the answer was right there but that, for whatever reason, she was afraid to be wrong. The silence was growing uncomfortable. Now she was biting her cheek, obviously deciding whether or not to say something.

I kept telling myself that this was only the third week of internship for them, and that I needed to be mindful of that. I didn't want to apply too much pressure.

Then, this happened.

Ms. Fulsome finally chimed in. "Doctor? What about the other thing we talked about? Remember when you asked me what I thought this was? And then you started teaching me about that?"

"Oh. . . you mean. . . . shingles?"

"Yeah, the shingles. Dr. Manning, she asked me what I thought and I said, 'I wonder if it's shingles?' and she said, 'You know, it could be shingles, it really could. . . but your immune system isn't weak.' Then she taught me a whole bunch about it. But I still was thinking the shingles."

Wow. Ms. Fulsome for the win.

The intern looked at me and discounted their great idea. "She isn't diabetic and she's had several negative HIV tests. My first thought as soon as I saw it was that it could be Herpes Zoster (shingles) but since she isn't immunocompromised I thought against it."

I smiled wide. "Your first thought was right. Both of you."


"Really?" the intern asked incredulously. Ms. Fulsome made a hand gesture that said, "BOOM!" (which I totally and completely loved.)

"Yes, really. This is classic. Ms. Fulsome gives a perfect history, and lots of people with strong immune systems get Zoster or shingles. Have you been under any stress, Ms. Fulsome?"

"Stress? Well, I got three grown people living up in my house that should be living in they're own houses. Them and their kids. They my grandkids, I know, and I love them like crazy. . . .but I'd say having all those mouths at your table and hands pulling on your refrigerator can definitely give you stress." She released a hearty chuckle. "And two of them grands is teenage boys. You know how they eat!"

"I heard that!" I laughed, imagining two Paul Bunyan-sized teens scarfing down food at her table.
Next I pulled off my gloves and tossed them like a ball into the waste basket. "Whelp, it looks like you both were right the first time. This is sho' nuff shingles."

After that, we chatted with Ms. F about the anti-viral medication that she'd need to take and gave her some information about reactivation of the chicken pox virus--aka Herpes Zoster. Once things were wrapped up, we stepped out of the room, pulled the white "discharge" flag and waved good bye to our patient.

The minute we left the room, the intern hung her head. Her morose facial expression completely caught me off guard.

"Oh my gosh! What's wrong?" I queried. She almost looked tearful; her face was a solid mask of defeat and her shoulders rounded and dejected.

"Zoster! Of course. Of course it was zoster. Pain first. Then the rash. In a dermatome distribution." She smacked her hand to her forehead. "I should have known that." Then she whispered with a sigh in a very tiny voice:

"I'm sorry."

dermatomes

Sorry? Oh, hell naw!

Like the touchy-feely mama that I am, I put my arm around her shoulder. "Sorry? Come on, now. That's why we all work together. That's why we are here with you. How do you think I learned? How do you think I still learn?" She shrugged and kept staring down as we walked back to the physician's room like teammates who just lost the big game.

Finally, I halted in front of her and placed both of my hands squarely on her shoulders. "Listen to me, and hear what I'm saying," I firmly spoke while staring into her glassy eyes. "You will never, ever know everything. Never, ever, do you hear me? You did something really great. You asked Ms. Fulsome what SHE thought it was. And you know what? She was right. You respected her enough to ask." Now, she was gazing back at me, riveted and almost scared by the tone of my voice. I went on. "Look. The more patients you see and the more you listen, the more you'll know, period. With experience you'll see things like this and know in a snap exactly what it is." I snapped my fingers for emphasis. "But some days? You won't. You'll be clueless, you will. So you admit it. You look things up. You get another opinion. You ask for help. You ask the patient more questions and get their input. And you learn."

"Yes, ma'am," she whispered.

"I say, 'I don't know for sure' about something every single day. But I just try hard to be curious enough to be bothered by not knowing. That way I'll look it up."

For the first time, she looked a little reassured. Suddenly, an easy smile broke out over her face; her eyes more confident and with a new determination. "You know what, Dr. Manning? I bet I will never miss Zoster now. Not ever."

You know what? I'd bet she's right.

Sigh. I love this job.
***
Happy Tuesday.