Pride and Joy

Inside the sanctum of our workroom I ask my intern to tell me what he’s able to pick up from my exam of the patient, hoping he noted the details I intentionally omitted from you.

He tells me, importantly, that: she reeks of alcohol; she’s hypervigilant but not tremulous; her speech is not dysarthric; she moves all four extremities against her restraints with appropriate and equal force.

‘Before seeing her lab results what does that make you suspect?’ I ask.

‘She’s drunk off her ass with some stimulant onboard, likely cocaine.’

I scrunch my nose and give a tight nod.

‘Most likely,’ I say.


The ED resident comes in and tells us her drug screen just came back positive for cocaine and benzodiazepines and her blood alcohol level came back at 262 mg/dl—about half the level needed to kill most people.

‘That’s it?’ my intern says, ‘we had a guy two days ago with one above 350.’

I look at my intern, consider telling him not to show off about things no one cares about, but instead reprimand him the way we do in medical culture: I start testing his knowledge.

‘What are her blood chemistries going to show us?’

This was a low-ball question and he’s smart enough to tell me an osmolar gap.

‘Will she be acidotic?’

‘No,’ he answers, correctly.

‘And if she were?’

He reviews the possible agents that could cause a osmolar gap with an acidosis and tells us what studies he would order to make his diagnosis.

I grin at him and turn back to the ED resident, who knew the answers to the questions as well as I did, if not better, but still—that’s what you show off. Not what you’ve seen, but what you understand.

This is mere pageantry. It’s not the panache of noting a physical finding that gives the diagnosis or ordering a test that was missed, but it’s important to play these games. Next year he’ll be the senior resident. He has to have thought out patients he hasn’t yet seen. But maybe the difference between pageantry and panache is a matter of degree and opinion.

I thank the ED resident, go to the computer and start flipping through the chart while waiting for her labs to come up on the screen.

‘What am I going to be looking for and order if I don’t see?’ I ask my intern.

He rattles off the labs and studies.

‘Do we need to tap this woman?’ I ask.

‘No. We’ve got a clinical scenario that can be explained by toxic ingestion and confirmed the ingestion with lab results. She’s afebrile, with no elevation in her white count and no nuchal rigidity.’

I give him another tight nod.

‘You’re doing a good job,’ I tell him. ‘You’ve got a good knowledge base and—more importantly—you’re applying that knowledge appropriately. Not just to expand the differential, but to narrow it also.’

I guess that’s the important part of panache. It’s not knowing what tests to order and procedures to perform, but knowing what doesn’t need to be done as well.

That’s the real trick—not just in medicine, but in life. Doing and saying just the right amount. Communicating competence without appearing a braggart. Demonstrating interest without appearing desperate. It is a trick, isn’t it?