edu93Charity Hospital in New Orleans was an incredible place for learning clinical medicine in the 1980s, a veritable clinical playground.  As a third year medical student I was required to do difficult blood draws, put in central lines, and other tasks after seeing someone else do one (the phrase is  “see one, do one, teach one”). In addition, I was called upon to write orders for antibiotics and do other “doctor” things which taught me responsibility, with my role increasing as I become more experienced. It was, however, a playground that was largely unsupervised.To say that supervision was limited was, well, charitable. We saw the attendings maybe once a week in the clinical wards. The residents were overwhelmed, leaving much of the work and the decision making to the medical students. As a student I grew up fast but often acted with little clinical seasoning and limited information.

Mostly what I remember is being scared that I would miss something. We had lectures in every clinical specialty but I remember them as being esoteric. at best. The Starling curve, while unquestionably amazing and unfailingly covered once a week, had little to do with what the Lasix dose should be in heart failure (for this particular drug the “Fat Man’s law” was much more useful). When I discovered the lectures were less useful than a work of fiction, I really panicked.

What did I use? For Internal Medicine, there were two great books. Harrison’s was written by a gentleman named Tinsley Harrison who had by that time made his way to UAB. Cecil’s was written by another guy (named Cecil, I believe). They covered the same material and were each over 1000 pages in length. I had classmates that read them both, in case there were discrepancies. The Washington Manual  was written by some residents at Washington University (St Louis). My attendings looked down on it because it was lacking the academic rigor of Harrison’s or Cecil’s. I found it very useful at 0:darkthirty with a sick patient and not much time. If we had time, we went to the library. There was a multi-volume set,  the Index Medicus, where one could look up a factoid using key words and track it to the source.

In addition, we used each other. We would ask each other  “Hey, what do you think about…” and reassure ourselves that whatever course we decided on was the best one. We would then get the opportunity to defend ourselves in the cold light of day, always being asked for our source of information. We never claimed our colleagues as the source.

Which brings us to yesterday. I was the attending (Attendings now round every day) and their was a question about optimum antibiotic selection for a neonate with a fever. No textbooks. No manuals. Cellphones and tablets came out, databases were consulted (along with Up To Date) and within 3 minutes an evidence based answer was obtained (in fact, I won the mad google prize by getting to it in 3 clicks). Patient received optimum treatment less than 3 minutes after the treatment course was decided.

From the literature, it was clear that the Cecil’s/Harrison’s/Index Medicus skills used in residency did not move with the physician to private practice but asking a colleagues (or drug reps) opinion did. I am hopeful that mad googling skills will.