Monday, March 28, 2011

the algorhythms of my mind

no one loves an algorithm like a doctor.  and no doctor loves an algorithm like an internist.  we have algorithms for EVERYTHING.  give us a symptom, a disease, a lab abnormality, and we've got an algorithm for it -- it's how we think.  (to give you an idea of what they look like, here is a relatively simple algorithm for a sore throat, you start at the top and work your way down... )

i spend my days navigating the algorithms of my mind.  you might have biorhythms, i have algorhythms. you don't see it, but my mind is a whirlwind of activity in that exam room.  i'm like pacman, gobbling up clues, traveling down pathways, retreating in the face of conflicting data and then choosing a new pathway, always moving, making choices at each branch point.  if the nurse notes that you have knee pain, then before i've even seen you my mind is pulling up the knee pain algorithm and lining up the data i must gather to navigate my way to a diagnosis and plan.  before you've even said a word, i've factored in your age, your history, even how you are sitting there in the chair.  then i get to hear your description of your symptoms and fill in any gaps with my own questions and exam - is the pain acute or chronic? is there swelling?  redness?  trauma?  limited range of motion?  has anything made it better?  worse?  the branch points go on and on leading me to my conclusions.  a well designed algorithm serves the purpose of providing a framework for my thoughts to follow.  an elegant, efficient algorithm is a brilliant thing to an internist like me.

there are some problems though. some algorithms are so large and complicated as to make my brain stall for a split second when i first face them.  but like standing at the entrance to a corn maze, the only way to get through is to get started.  dizziness, fatigue, abdominal pain - the possibilities are so vast!  in those cases, the initial branch points are crucial to my success.  Is it right upper quadrant abdominal pain or left lower quadrant?  Are you lightheaded like you might faint or off-balance like you might fall?  and then, some people dare to defy the mighty algorithm - they are both light-headed AND off-balance!  that throws my poor brain, momentarily, into near chaos.  but i recover and move on.  or sometimes, my patients try to trip me up by mentioning that they have also been having a shooting pain in their left leg when i am still in the middle of the headache algorithm.  i tell my patients, wait! we're not done with this first thing!  they understand.

algorithms are also the reason we cringe (hopefully on the inside only) when we have our hand on the door and are ready to leave the exam room and you decide now is the best time to mention the real reason you came in today, which is generally a more significant reason then the one you told the nurse when you called to make your appointment. (patients, please do not make an appointment for a bladder infection and then share with me at the end of your appointment that you've been having these funny chest pains that you really think are nothing but...)  i know you think maybe there is just a quick answer or bit of reassurance we can toss over our shoulders as we continue our exodus, but we are too conscientious for that.  we cannot abandon our training.  so we close the door, sit back down, and begin our journey together down the next algorithm.

1 comment:

  1. Beth, what a great description of the way the mind of a diagnostician works. Thanks for being able to put that into words. You have changed the way I interact with my doctors, for which they shall be eternally grateful.