Have You Completed Your AME (Anecdotal Medical Education) Requirements?

crispydoc Uncategorized 8 Comments

As a reformed academic, I still have moments of unrequited yearning to teach the young (defined as my age minus ten years). While I enjoy sharing interesting x-rays or clinical findings with our techs, nurses, and the docs I work with, my favorite teachable moments fall under the category of Anecdotal Medical Education (AME).

Most of us working in the ED use a shared belief system that includes certain illogical ideas. These beliefs have become accepted wisdom despite the fact that they fly in the face of reason and range from superstitious to absurd.

For example, if you arrive on shift and it’s a quiet night, and then someone on the team acknowledges aloud, “It sure is a quiet night,” this is akin to a brazen display of hubris in a Greek tragedy. Despite rigorous scientific training, 99% of people working in the ED are convinced that Zeus overheard that comment from his perch on Olympus, and is preparing an immediate response in the form of a clinical thunderbolt (a busload of acutely psychotic patients arriving exactly as we receive multiple ambulance runs with cardiopulmonary arrests). Keep in mind that if a patient were to confide to me that deities are listening to his conversations and punishing him, he’d usually get a psychiatric evaluation.

Another favorite is the Throckmorton sign, which I learned of from a beloved emergency radiologist: If a male patient presents to the ED with a hip fracture, the soft tissue shadow created by the genitalia is said to point to the side of the pathology. AME is even developing it’s own literature: an article from The Medical Journal of Australia  sought to validate Throckmorton’s sign, known in those nether parts down under as the John Thomas sign.

Over the years, I’ve had the pleasure of either developing or helping to evangelize others’ theories that expand upon this underappreciated fund of AME knowledge.

Medical students are taught of Occam’s Razor, which in lay terms means the simplest explanation is bound to be the most likely. This was drilled into us with the teaching, “If you hear hoof beats, think horses (common diagnoses), not zebras (rare diagnoses).”

My personal contribution to the AME canon is the contrarian concept of Occam’s Blender: the most likely explanation is that the patient has multiple unrelated complex processes occurring at the same time. Yes, the patient arrived at 3am on my overnight shift high on meth complaining of leg pain for three years, but her x-ray demonstrates an osteosarcoma (rare bone cancer) and her heart rate is fast not only from the meth but because she is anemic from an actively bleeding ulcer. Also, her urine pregnancy test is positive and she doesn’t know it.

Another favorite: Max Planck is credited for discovering that minimum units of energy and radiation exist in discrete packages he termed quanta, which counter-intuitively  exist in multiples rather than as solitary units. A popular corollary builds on his idea to posit the quantal theory of disease. If I diagnose a case of appendicitis early on a shift, I stand like Zoltar and gravely pronounce to my team that there will be two more cases of appendicitis before my shift is through.

Fast forward ten hours, and the nurses and techs jockey for position around me like I’m a balloon clown at a child’s birthday party to eavesdrop on my phone exchange with the incredulous surgeon on call.
“You realize this is my third frigging appy tonight?” she pleads, to no avail.
Operate you must, young Skywalker.”

A final crowd pleaser comes courtesy of a colleague whose observations derived the wholly original T’s Triad: Let’s say you encounter a young adult patient who arrives in your ED wearing 1) sunglasses indoors and 2) Ugg boots while 3) lying on a gurney in the prone position. T’s triad predicts that if all three signs are present, there is a high likelihood the patient is here as one of twenty annual ED visits for migraine headache exacerbations that only respond to IV narcotics (“I’m allergic to all other pain medications.”). Should the patient be clutching a stuffed animal, the predictive value rises to nearly 100%. Non-medical readers will think this oddly specific and weird, while those working in the ED will nod with recognition.

Leave a comment including your favorite unsubstantiated bit of wisdom and I’ll gladly attest that you have received 3 units of AME credit for reading this post.

You’ll get an extra credit if you are old enough to have seen a balloon clown.

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Comments 8

  1. Very enjoyable read. One possible concern or correction re: The Throckmorton sign study in Australia. If the sign is proven to be valid (penis points to pathology), it will be inferred that the opposite is true on this side of the equator. 😉

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  2. This made my day!

    I am an intensivist and we have a related pantheon of Gods. We have a few well validated prognostic factors that we consider in addition to APACHE III.

    “A tooth:tatoo ratio of <1 predicts survival of otherwise fatal injuries.”

    “The word “found” in the first line of any consult note is a poor prognostic sign.”

    It is not a prognosticator, but a good ICU management principle: “If the dose of [blank] doesn’t work… double it.”

    The best is to deliver these facts to the younger trainees with a completely flat affect.

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      As a reader I enjoy your finely honed sense of the absurd, so I’m happy to provide more fodder. I’d heard the tooth:tattoo ratio popularized by Billy Mallon, a brash and colorful faculty member who was LA County-USC’s residency director for many years before he departed for New York.

      Your others are novel and much appreciated.

      I think the old school source of anecdotal medical advice comes from Samuel Shem’s book “House of God,” which while very much a product of the 1970s still has something that rings true these many years later. Gave us gems like:
      If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion there.
      and also

      The delivery of good medical care is to do as much nothing as possible.

      Look forward to learning more from you!

      CD

  3. My fave from OB/GYN is the explanation for unexpected blood loss is She Is A Redhead. Is a clotting factor located on the gene that determines hair color?

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  4. Agree with Hatton 1….I used to cringe when having to operate on a redhead….things never went as well.

    Also…”the likelihood of a complication rises with the medical education of the patient”….i.e., if you are caring for a nurse, the complication rate is higher than that of a non-medical person…but if caring for an attending…watch out! High likelihood that something will go wrong in their hospital stay…

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