Differentiation by Dahl

Rachel WoodAs a kid, and occasionally as an adult, Roald Dahl’s books have been a staple of my literary diet.  Matilda, The Witches, James and the Giant Peach, Charlie and the Chocolate Factory…the list is long and fantastic.  As I was considering my topic for this month’s post, several of Dahl’s illustrations popped into my head, and I subsequently had way too much fun pulling these books out and flipping through my favorite sections.

The first reason I bring Dahl into this is that with second year now well under way, I am a little embarrassed to admit that my room is starting to resemble Matilda’s.  The first day hit us like a tornado, blowing our sweet summer free time out the window and replacing it with a lengthy to-learn/to-do list full of cardiovascular disease, EKGs, complex kidney functions, and new preceptor assignments.  It also brought a new theme, one that seems to be emerging more prominently this year both within the curriculum as well amongst my classmates and I.

The theme is differentiation, which is defined by the Oxford English dictionary in the following way(s):

1. verb trans. Obtain the derivative or differential of.

2. verb trans. Constitute a difference in, of, or between: serve to make different from [sic].

3. verb trans. Make different in the process of growth or development.

4. verb intrans. Become differentiated or specialized.

Several weeks ago during PCM (Principles of Clinical Medicine, the class where we learn clinical maneuvers and other wisdoms) our class received a lecture entitled “The Undifferentiated Patient.”  During this hour we were taught the nuts and bolts of formulating a differential diagnosis for patients complaining of anything that could be caused by (almost) anything, such as back pain, headaches, fatigue, etc. We were given the following, four-step algorithm to help us along.

1. Consider the organ systems involved.

2. Consider the processes involved.  For this we were given the handy acronym VIIINDICATE (Vascular, Infection, Inflammation, Intoxication, Neoplasm (abnormal growth), Deficiency, Iatrogenic (doctor-caused), Congenital (born with it), Autoimmune, Trauma (surgery counts), Endocrine (hormones).  This acronym qualifies as Dahl-like because the extra “I’s” make it sound like the Grand High Witch’s accent from The Witches (“Qviet!”).  This will also help me with retention because if she was lecturing you bet I’d be paying attention – her eyes have been known to shoot sparks and fry the occasional audience member.

3. Consider possible diagnoses for each process subcategory.

4. Rank the potential diagnoses in order of likelihood and/or severity.

This session was invaluable for me, as I have been struggling to find a way to more easily apply the tangle of information in my brain to the understanding of the patients I see with my preceptor each week.  Although  “headache” might sound easy enough, you’d be amazed at how difficult it feels to compile a list of all the possible causes, let alone what to do about them.  I feel like VIIINDICATE might just provide the silk threads (framework) I’ve needed to lasso the seagulls (info) to keep this damn peach (brain) aloft.  Or something…use your imagination won’t you?

Another kind of differentiation I’ve noticed is amongst us med students.  For the most part, we all start undifferentiated on day one save the lucky few who picked out their field in preschool.  The rest of us are in the process of sampling, trying on, and honing in on one or five top choices.  And though we have not yet even reached the true “audition” stage of our clinical years, it seems like more of us every day are leaning more decisively in one direction, whether that means heading up an interest group, skipping the occasional lecture to attend a specialty conference, or sacrificing sleep in order to scrub in on a particularly compelling procedure.  One could ask if this is the appropriate use of preclinical time, but I’m not sure there is a right answer to that question.  You could also ask if we should even worry about knowing already, or if we should just relax and let the process occur a little more passively?  That answer might seem more obvious, but it certainly isn’t simple.

Personally, I still feel very undifferentiated.  My answer to The question (“what kind of doctor are you going to be?”) goes something like “well, Anesthesiology is fascinating and I really enjoyed my time shadowing before med school but I also think surgery is pretty darn cool and wonderfully hands-on and then there was that pediatric radiologist during GIE last year with those “baby gram” images (who knew that was even a thing?!) which I just loved and then…yeah.  You get the idea.

A squirrel in the nut room, differentiating the good nuts from the bad.