Internal Medicine. A science or an art?

Every speciality will claim that it is the best. Surgeons will tell you that they are the most skilled. Family physicians will say that they make the most holistic difference to people’s lives. Obstetricians will argue that they are responsible for two lives in one. But there is something special about Internal Medicine. It is medicine in its purest form. If you let it, it will find its way beneath your skin, into the bones of you. For me, when it did, it was a kind of homecoming.

Internal Medicine is the epitome of diagnosis; of problem solving; of critical analysis. It is using what is in front of you as well as that which you cannot see or hear or smell, but suspect may be there, to form a clinical judgement. It’s a weaving together of all your senses to make a whole.

Yes, it’s a science. But it’s so much than that. It’s an intuition.

It’s an art.

It’s a putting together of the puzzle pieces: A little bit of history, an examination finding that confirms your suspicions. A touch of blood in the urine here. A heart murmur there.

There’s a deep satisfaction that comes with building a differential diagnosis using your clinical skills alone. A true physician will tell you what a CT scan or a blood result will show before it’s even done. Often the investigations performed are mere formalities.

It is a delicate dance between what looks obvious and what you might be missing. Between trusting your clinical instinct and keeping an eye out for what might catch you off guard. It is using a history to guide you without leading you astray.

It is also an exploration into the human body; into its resilience and into the fall down that occurs when the end of resilience meets pathology. It’s an enquiry into how the body adapts when its physiology is challenged. It’s that adapted physiology that produces the clues that a physician gathers to make a diagnosis.

But my boss said it the other day; there’s something about Internal Medicine that cannot be taught – the beautiful balance between critical thinking and gut feeling. Textbooks can teach you the patterns.

Exertional angina + low volume pulses + ejection systolic murmur = aortic stenosis

Right hemiplegia + dysphasia + homonymous hemianopia = left anterior circulation stroke

Anyone with an analytical mind and an eye for detail would make a good physician. But it’s the gut feel that makes a great one.

It’s the gut feel that makes internal medicine the art that it is.

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