Guessing and Pride

Vocabulary: Pimp (v.): to ask questions, often in front of other trainees or professionals, to assess a student's or resident's preparedness, medical knowledge, or professionalism

Third year medical students get used to getting pimped. We're advised (by survival guide books, by older students and residents, by faculty) to guess if we don't know an answer. This advice is logical. A third year knew even the smallest biochemical details of the pharmacology he's being asked about a mere six months ago, but after STEP 1 and two or three other rotations, he's refocused so many times that he can't exactly recall the correct answer. A third year sort of knows what to study for clerkships, and definitely never knows what to study for particular attendings. In general, a third year has just enough knowledge to know what's being asked, what the answer choices mean, and what he's missing to know the correct answer. (It's a very frustrating experience.)

We're advised to guess because we have enough knowledge to say something vaguely correct. I followed this advice, and had good and bad results.

I should have played the lottery during my pediatrics rotation. That's how lucky my guesses were. One outpatient physician with particularly pronounced ADHD forgot that he told me the most common cause of URI was "viral." When he asked me the question and I informed him that it was "viral," he was very pleased. I answered a few more softballs correctly, then he hit me with a hard one. "Why no fluoroquinolones for this patient?" he asked.

Fluoroquinolones! My M1 box of memories contained something about teeth...or was it cartilage? Tendons? Shoot! I had to pick between them. Because I remembered "cartilage" and "tendons," I eliminated "teeth," and then flipped a mental coin. "Cartilage malformations," I said. The whole internal answer-picking had taken only a fraction of a second.

"Correct!" the attending said. I got a fabulous evaluation.

Inpatient looked like it was going to be a different story. Our attending was demanding and taught in a more classical fashion: we presented patients in front of everyone on rounds, wrote detailed notes, and did long mock case workups. While I was in front of the room at the board (pen in hand) pretending to work up a child with renal failure, he told me a stool culture came back positive for Shigella.

"So," he said. "You wanna give him antibiotics?"

His CBC was terrible, he was febrile, he already had an IV in, and I very much wanted to give antibiotics. I remembered that Salmonella and Shigella had funny reactions to antibiotics...something about the child would feel better but there would still be bacteria in the stool...for even longer? But that was only for one of the two species (darn the person who named these two things so similarly!!)... Do I hazard a guess, or do I just give the antibiotic? I gambled.

"We could," I said, "but doesn't it prolong clearance in the stool...?" I trailed off gingerly, just in case I was wrong.

The attending raised his eyebrows.

"It does," he said, surprised. Apparently I'd skirted the trap he usually set for students. He then told a few case histories of patient's he'd treated. "So," he concluded, "if it's just going to be fluids, what do you want to use?"

"D5 half-normal," I replied. That wasn't a guess; that's what everyone in the unit was on. He gave me a mischievous look and pressed further.

"There is one case in which you would consider using quarter. Do you know who?"

Time for another guess. Babies are all water balloons at birth, so my brain spat out:

"The neonate?"

The attending clapped and grinned. "That's hot!" he said (which must have meant something different when he was a teenager). "Strong work." And I got another fabulous evaluation based on guessing.

But this has terrible effects, especially when we're asked to guess in front of other people. Those of us with the vice of pride (which is many doctors and student-doctors, and (so I'm told) a few other humans) do terribly in this environment. We have one of several reactions. It's a little complicated, so I made a flowchart.

I was typing this post while my attending was at a meeting; he came back and we had a mini lecture/pimping session on hydrocephalus. And I guessed some more. It will never end.