Notes from a Medical Student:

Tell Me What You See

I held the photo in my hands and squinted. Like an X-ray, it was black and white.

But instead of analyzing lung fields or the cardiac silhouette, I found myself looking at a photo of a young man at a rodeo, riding a bucking horse and appearing to thoroughly enjoy the attention from a capacity crowd.

Depicting a scene that was part sport, part theater, the photo itself seemed to be at least a half-century old.

"You're probably wondering why I handed you this picture," said Dr. M., the physician at the Veterans Affairs (VA) Medical Center who meets with medical students such as myself every morning.

"Tell me what you see."

Feeling uncomfortable, I looked at the photo closely, searching desperately for clues, signs of illness that the man (or the horse) might have. Perhaps, I began to wonder, I was missing something obvious.

So, logically, I counted the man's arms and legs. Start with the basics.

Both legs were present, as were his arms and hands-one used to grasp the horse's reins, and the other raised in the air, either to maintain his balance or to tip his cowboy hat to acknowledge the adoring crowd.

Really, I thought, he seemed to be having a grand old time...

On more traditional mornings, Dr. M. shows my classmates and me radiology images of patients, challenging us to find something abnormal-a small fracture on an X-ray, perhaps, or a hidden tumor on a CT scan.

It's all part of what is informally known in medical education as "pimping"-a version of the Socratic method of teaching-designed to put residents and medical students on the spot, always in front of our peers and sometimes even in front of our own patients.

Its purpose is less to make the medical students feel inadequate and more to make us learn and remember something useful.

More importantly, it's to demand that we always strive to know everything about our patients, from their liver enzyme levels to their current living situation, from their vital signs to their personal histories.

At the VA Medical Center, the personal histories come from patients who include former soldiers, Air Force pilots, Naval officers and the like. Some fought decades ago in World War II, while others more recently, in Vietnam or Afghanistan.

My first patient at the VA, a former soldier, was suffering from Hepatitis C. After seeing him every morning for several days, he was ready to be discharged from the hospital.

"My family is coming to see me later today," he said during our morning chat. "I would like it if you could stop by and tell them about my condition."

Indeed, that afternoon I met the patient's family, including his parents, and was grateful to get a glimpse into the patient's life beyond the hospital walls, an impression of what his life might have been like years ago, growing up in Dayton and hoping to nobly serve the country.

He had a kind and caring family, and though he was sick now, it was clear that the past was filled with better days...

I continued to gaze at the ragged photo in my hand, unable to find anything wrong with the mysterious man on the horse.

"He looks healthy, doesn't he?" asked Dr. M. at last.

I nodded. And mercifully, the answer was revealed.

"This is a gentleman who was here in the hospital recently and was very ill," said Dr. M. "I wanted to show this to you as a reminder that these patients at the VA weren't always old and sick."

I looked up, as did the other medical students-realizing that, although we had been duped to some degree, we had become so trained to look for disease that we had missed recognizing something far more important: good health.

Indeed, by the time we see patients, they usually are sick. Many times, they're elderly as well. But knowing everything about them means seeing more than a snapshot-knowing where they have come from, what their lives were like before meeting us in the hospital.

Hopefully, if we do that, we can take better care of them-and perhaps more importantly, help them feel young again, too.