Chapter 2.3 Fear of the unknown

I have absolutely no idea what I want to specialise in.

Right now I have two major schools of thought playing tug of war with my brain. On one side, those who say “there’s plenty of time to decide what you want to do”, and then on the other, the organised part of my brain that wants to plan, develop portfolios and generally begin to focus on one main goal.

This is something that many medical students face, but it doesn’t make it any easier. Sure, I’ve started to rule things out (which I won’t mention, because this is the Internet and people get brave behind a screen) but still have over ten specialties to consider. It’s a real worry, a headache and a frustration.

But this isn’t the focus of today’s piece. I simply want to illustrate something; when we aren’t sure what’s going to happen, or where our lives are going, it creates a thunderstorm of emotions that crackle and fizz in the background. If I feel this way about my future job (bearing in mind the career path is relatively certain), imagine being a patient facing an unknown health diagnosis.

We sometimes forget in medicine that, even though we feel incompetent, the average person has very little knowledge of Human Biology. Imagine have a symptom where the differential is every single possible disease (if you’re struggling with this, just do the Cambridge pathology exam, which I have coming up this year…)
For a patient, any symptom could be a clue to a serious, insidious disease that may change (or even end) their life. Add in a dash of Dr Google and you have a diagnosis of a Krukenburg tumour in a twenty-something male patient with some bloating.

Having just finished my last GP block of the year, this was something I had a lot of experience with.

Abnormally normal

Two different patients, both presenting with “lumps” that they had noticed a few weeks ago. One younger, one older. If this were a teaching seminar, it would be used to show the different disease incidence based on age.

The concept of ICE (ideas, concerns and expectations) is something we are taught in communication skills training. Initially, it seemed like something added to please the GMC but as I’ve gone through clinical placements, the value of these questions has really shown itself.

For the aforementioned patients, the answers were clear. Ideas: “cancer”. Concerns: “cancer”. Expectations: “please, please, please do some tests and rule out cancer”. One patient was in tears, the other was stoic, but both had this particular beast top of their differential.

Now comes the good news: neither of these patients had cancer. In fact, neither of them had anything wrong with them. After a long history (which revealed no red flag symptoms, and not really any symptoms at all) and careful examination by both me/my colleague and the supervising GP, we could give the news.

One patient had a bit of a lumpy rib, the other had been feeling their xiphoid process. You can feel yours now: it’s the lumpy bit of cartilage at the base of your sternum (breastbone), roughly in line with your nipples. This patient had a slightly asymmetric, prominent xiphoid process, but it was normal cartilage nonetheless.

I can’t imagine the thoughts going through these patient’s heads when they booked their appointments. Would that day be forever etched in their memory? Would they walk out of the GP surgery a different person, with a ticking clock and a growing lump? Would they have to leave their family and friends behind far sooner than expected? Sometimes, the unknown is the worst aspect of a patient’s journey.

My learning points:

  1. Not knowing what the future holds is a sure-fire way to strain a patient’s mood, mind and mentality. I’m therefore going to try to ask every patient I speak to: “have you been told the plan? Have you discussed your treatment with a doctor or nurse?” I know this isn’t always feasible, but sometimes even a small reassurance can completely change a patient’s outlook.
  2. Never assume a patient knows something. Yes, on one hand you shouldn’t patronise, but also you may be skirting around an issue by not clarifying. This is a fine balance and one I’m still working on, but it’s best to at least try.

For now, I’m going to reflect on the many patient encounters I had on GP. It was a wonderful teaching experience and I have full respect for GP teams, down to the reception staff and IT whizzes. They can truly do everything and, in their infinite wisdom, always seem to know the trick with the sticky doors and broken appliances.

Maybe I should ask them what I should specialise in?

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