A motivational drama for students beginning their medical school education.
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Hello. My name is Joe Patient. I'm not feeling well. I've got a runny nose
and I have a cough.
I'm almost certain it's just a cold. My managed care plan says I can go see Doctor Goodvibes. I have
great confidence in Doctor Goodvibes. After all, he is so highly educated. He knows the body inside-out at every level. If
there's
something wrong with me, I know he'll find it and know exactly what to do about it.
Hello, Joe. I was just getting my CME credits watching medical TV.
Hello, Doctor Goodvibes. Gosh, I'm glad you're keeping up with everything in medicine. I have great confidence in
you.
Yeah, medical TV is great. It keeps me fully updated. Except I leave the room whenever they show stuff under the microscope. I
hate histology. I say doctors shouldn't focus that much on science, it makes you less loving and caring. When I was in medical
school, and we had a test in histology, I just crammed the night before. I never saw the use of
learning histology. Nowadays
even the pharmaceutical ads in the journals have pictures of stuff from histology. Same blue and pink as in a hematoxylin and eosin
stain. So I don't look at them, or I pretend they're modern abstract art. I even hate the pictures of hair follicles in the hair
replacement ads in People magazine. It reminds me of how much I hated histology in medical school. Also, I ignore research articles
on stuff like what causes atherosclerosis. They are all full of talk about the different layers of arteries, and what happens in them.
Since I never learned histology, it doesn't make any sense to me. As far as I'm concerned, arteries are just tubes, and I don't see
why to bother knowing the difference between events in the intima and the media and the adventitia. For me, the fundamental
mechanisms of health and disease at the tissue level are just words on a page, stuff that I
memorized out of the class notes. I've
been doing medicine by rote memory for so long that it's second nature. A good doctor is compassionate and caring and blows off
basic science, especially histology.
Doctor Goodvibes, I think I just have a cold, but would you check me out?
Certainly Joe. I make the big bucks because people believe I have an overview of the human body at every level, so that they trust me to deal with every new situation that comes up.
I'll just listen to your lungs.
Deep breaths in and out.
What are you listening for, Doctor Goodvibes?
Oh, fluid in your lungs.
What kind of fluid?
I have no idea. It was something from that stupid histology course, and I never believed it was important to know what the stuff
I'm hearing really is. All I know is that if I hear crackles in your lungs, it's some kind of fluid in your little air thing-a-ma-jigs, I
forget what they are called, and I have to put you on whatever antibiotic the pharmaceutical rep told me about. I don't think a
doctor needs to know the lung's cells and its fine structure actually look like. I act abrupt and superior to conceal my lack of
knowledge.
Well, how do my lungs sound, Doctor?
I hear a lot of crackles. I had better send you for an x-ray.
Hello. You must be the radiologist. You must be very learned, too, a specialist able to figure out what something is.
Yeah. My histology class was such a bore. I hated it. I decided for sure I'd do something that didn't ever require using a
microscope.
What do you see on my chest x-ray?
Gee, Joe, you have a spot on your lung.
What could it be?
The differential diagnosis is in my radiology book. It's all words. I haven't seen a real lung since my surgery clerkship. I
ditched histology class, and my pathology course was all based on lecture handouts with no pictures. I don't have a clue what the
stuff actually looks like, or why different things make white fuzzies on x-rays.
Gosh, what could that lung mass be?
Well, it has a tiny fleck of calcium in it, which means it's probably a caseating granuloma. In Kansas City, that probably
means starling poop fungus. I don't have a clue why, I just memorized it. But you'd better do a bronchoscopy.
What did you see, Doctor Goodvibes?
Well, the slippery surface part thing -- I can't remember its name or what it's for -- on the bronchi has this little bump thingy on
it, and I biopsied it. I'm going to take it over to Doctor Friedlander the pathologist. he'll tell me what it is, then I'll look up in my
Merck Manual find out what I'm expected to do.
Moo!
Hello, Doctor Friedlander. Will you look at this lung biopsy under the microscope and tell me what's wrong with my patient?
Sure, Doctor Goodvibes. Pull up a chair and we'll look together.
Aw, I hated histology. I never learned that stuff. I just count on you to tell me what the diagnosis is. Anyway I hate even
coming to see you because I know so little.
Don't have a cow, Doctor Goodvibes. It's a lot of little blue cells. It must be small cell undifferentiated bronchogenic carcinoma.
Here's my report.
Thanks, Doctor Friedlander.
Moo-ooo-ooo!
Joe, you have small cell undifferentiated bronchogenic carcinoma.
Doctor Goodvibes, you're the one doctor I know personally and who I trust. Did you look at the biopsy yourself?
Of course not. I can't tell lung from liver under the microscope. People call me doctor because I am supposed to have the
overview of the human body at every level. Also I am very compassionate and a good listener. I've called the oncologist. He is
going to do a bone marrow exam and give you chemotherapy.
Hello. I'm your oncologist. I'm glad my days in basic science are over. I'm going to get bone marrow so we can assess your
suitability for chemotherapy.
Gosh. It is good to know that I am being cared for by people who are so knowledgeable. Are you going to look at the marrow
yourself?
Of course not. I'm too busy making wads of money and I don't even remember what the cells in marrow look like. I pay a
technician to do all that. So now when I wipe out marrow, for me it's all just a bunch of numbers like an accountant.
Arrggh!
I felt fine when all this started, and now I think I'm going to die.
I am the new pathologist. I don't know about you, but I worked really hard in histology. For me, it was more than learning the labels on pictures. I saw the body working as a whole, at an entirely new level. I learned things I had always wondered about. Everything made sense if I thought about it. And then, because I knew histology, I had a great time in pathology while everybody else was whining and moaning about how hard it was. Everything made sense because I could correlate the microscopic picture with what the patient actually experienced and what the clinician saw. I love what I do. Now that I've autopsied Doctor Friedlander and looked at the histology on his tissues, it turns out that he died of Mad Cow disease. His brain was affected very badly. That must be why his diagnoses were so far off at the end of his life. Now let's see who is to be autopsied today.
This is Joe. He was a chemotherapy patient. Let's see what's inside of him.
Look! A fungus infection! It must be an opportunistic infection from the chemotherapy. Oh! Here's that little caseating granuloma from the x-ray. The chemotherapy and resulting immunosuppression allowed the fungus to escape confinement and spread and kill Joe Patient. I'm sure glad I understand the why's. While I'm waiting for the autopsy glass slides to come out, I think I'll look at his old biopsy that Doctor Friedlander signed out on this poor guy.
Hmm! Doctor Friedlander called this small cell carcinoma. He was unable to make an accurate diagnosis, or realize his
problem, because he had Mad Cow disease of his brain. This is just a cluster of normal lymphocytes. They do look kind of like
small cell undifferentiated lung cancer. Doctor Goodvibes probably saw a tiny lymphoid aggregate on bronchoscopy. He didn't
remember from histology that these little bumps are normal. He biopsied it and thus the error was made. What a pity. Joe never
had cancer.
I'm sorry the oncologist killed Joe with the chemotherapy. It's a shame that Doctor Friedlander had Mad Cow disease and made the
wrong diagnosis. I hear the oncologist has taken a one-way plane flight to Brazil. It's a shame I don't know how to recognize
lymphocytes.
Hello Doctor Goodvibes. This is a subpoena. You may never have learned histology, but you know medical terminology. Sub
means under. Poena is your penis. I've got you by the balls.
Your honor, it certainly is a shame that Doctor Friedlander is dead. Now Joe Patient's family can't get a huge malpractice award.
Come now, Doctor Goodvibes. It has always been a duty for a physician to explain clearly to patients what is wrong with them.
Your lack of basic understanding of histology prevented you from doing so. Your ignorance deprived Joe of his right to make
informed decisions involving his own health. And in the managed care era, a primary care physician is now expected to possess a far
greater range of skills and breadth of understanding than in the past. To begin with, the system expects you to be able to interact
in a collegial way with the pathologist, and this includes looking at your own life-and-death biopsies. Under the law of deep
pockets, you share the pathologist's liability, and since he is dead, you are now fully responsible to pay Joe's grieving widow.
I am going to tell the Year I's to pay attention and get actively involved in learning histology!
Loyola Histology
Duke
U. of Illinois
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