Another medical student bumped into me - she's from Hong Kong. She stopped paying attention to me when I told her I was a medical student as well. My shirt and tie must have convinced her that I was a registrar or something and I hate how being well presented is synonymous with higher rank. People think there is glory in medicine, in surgery... truth be told, there is glory only in your ego if this is how you feel. There is a satisfaction from helping another human being and that is the result of good knowledge, plenty of experience and inflicting pain on hundreds of people in the form of mistakes. There is no glory in this journey - only the fact that we will be covered in blood, urine, shit, pus, or any other bodily fluid one could imagine and if we're really lucky - maybe we'll be covered with all of those fluids at the same time.
So the student and I were discussing a spinal CT scan of a patient who presented with sudden back pain after a fall to the ground associated also with motor deficit of both lower limbs. The axial images were of the thoraco-lumbar region and one could see anterior to the spine, the abdominal viscera. This student from Hong Kong in her final year thought that some calcification within the liver were in fact gallstones in the gallbladder, even though the anatomical locality was completely inconsistent. So I told her I thought it could be calcification of the intrahepatic ducts, or perhaps calcified vessels, which could not be tracked on a non-contrast CT scan. She didn't respond. I decided not to tell her my background in medical imaging and the associated knowledge in cross-sectional anatomy.
Well I finished my finals, so I should know anatomy by now. I paused and thought I'd brush her up with some questions. She got some basics right and I thought it might be patronising to ask about the gross anatomy. Then I asked her about the muscle attachments of the diaphragm to the abdominal wall and the spinal insertions. She knew the muscle names - the right and left crus.
Yes, the crura are important for the insertion of the diaphragm to the posterior abdominal wall. At some point, the crura are divided and structures pass through the chest into the abdomen. What passes between them?
She thought that this was a no-brainer and decided that all the arteries, nerves, veins, vessels and anything coming from the chest would be going through this opening. I smiled and told her that there were three openings, all corresponding to different topographical locations in the mid-sagittal plane as well as different spinal levels, depending on their function and relationship to the peritoneum. She looked at me funny.
I explained the names, levels and the structures passing through the openings - she looked at me blankly and said: You really know your anatomy. The issue that I had with that comment was that this medical student, not 5 minutes before me asking her anatomy questions, was telling me how she opted to do head and neck surgery.
Now if anyone has ever been exposed to any form of head and neck surgery, they can easily tell you the complexity of the anatomy and that an approach to formal dissection of any structure in the head and neck, requires sound anatomical and physiological knowledge as well as the associated embryology with each structure.
Interestingly, head and neck surgery is a subspecialty in general surgery, which is a specialty in its own right. How is the genius medical student who has finished all of her exams really going to consider applying for any general surgical position before knowing any form of anatomy of the abdominal cavity?
This leads me to really say that medical students are in fact, book smart. They are brilliant with their notes, books and summaries - excellent in study groups, on their own in the library and discussing any topic over coffee. What we're not good at is sitting down with patients and really understanding their view, how they feel, what their symptoms are and how to examine them.
The neurosurgical resident and I were discussing surgery and he told me a short story about a Vascular surgeon that he was assigned to during his student years.
"The essential knowledge is not technical expertise or retraction, but it is in fact the ability for you to manage the patients pre-operatively and post-operatively. I can take a fucking monkey with me to theatre so they can adjust the light, retract the tissue and suck blood out of a wound. Surgical expertise is gained through practice, which comes with time. Human anatomy never changes; human physiology never changes. Pathology does not change. We need to understand these important fundamental topics before we learn the technical expertise of surgery and its implementation. We need to manage the patients after their operations - that is the ultimate challenge."
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