Blog | Monday, October 22, 2012

The internist as a puzzle solver: my (a)vocation


I've been getting GAMES magazine for years. Decades, actually, on and off. I remember doing logic games way back in elementary school, and I still do them first in my GAMES magazines. When I was a kid, my grandmother and I would do jigsaw puzzles together, and I now find myself doing them with my own children.

During a lunchtime panel of the Internal Medicine (IM) Interest Group at UNC today, I was drawn to something that one of my colleagues on the panel said. He noted that if you separate the "medical" specialists (internists, pediatricians, etc.) from the "surgical" specialists (orthopedic surgery, urology, etc.), there is often a difference in the type of intellectual arguments the two groups have. Paraphrasing, he said: "Medical specialists argue more about what diagnosis the patient has over what the treatment of the diagnosis is. Surgical specialists argue more about what the treatment should be, often whether or not to operate, over what the diagnosis is."

Of course, this is an overly broad generalization. He did not mean to say that internists don't argue over treatment plans or that surgeons don't argue over diagnosis. Clearly both do. He pointed out that some medical specialists, like oncologists, tend to keep their discussions more focused on the latter type (e.g. "Should this patient with breast cancer receive chemotherapy?"), and surgeons similarly have to make sure the diagnosis is correct before they operate.

Nonetheless at general internal medicine "morning report", residents often focus on creating a broad differential diagnosis and then figuring out what data they'd need to get the right answer. In other words, using their logic to solve the puzzle the patient is presenting to them.

Thinking back now, I find it interesting that I made a conscious decision in the latter half of medical school to change my career path from surgery to medicine. Puzzle solving has occupied a good portion of my recreational time since childhood. Maybe my choice during medical school to go into IM was my subconscious way of making sure I would enjoy my career. I'm certainly glad I made that choice!

Ryan Madanick, MD, is an ACP Member, a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain. This post originally appeared at his blog, Gut Check.