Knowledge, and lack of knowledge

We’ve attended at least 25 informal classes or formal lectures on various aspects of HIV/AIDS, treatment and opportunistic infections here, mostly with Yale people but also on the wards and at the Infectious Disease Institute. Even though we’re obviously barely skimming the surface of all the work that has been done on this disease, I’ve been reminded again of the joy in learning one subject well, in thinking about the details of pathophysiology and practice, diving to the depths, marveling at how much we’ve figured out and how far there still is to go. At this early stage in my medical training, it is rare for me to feel confident in my own knowledge, to be able to present a medical opinion or a treatment decision with solid data, and so I’ve loved the feeling of knowing at least a tiny piece of medicine so much better in such a short amount of time. I can feel secure talking to an intern about how tenofovir is actually a nucleotide reverse transciptase inhibitor (even though it sounds like it should be a protease inhibitor), and why it might matter for a particular patient that it is already phosphorylated as a nucleotide and not a nucleoside RTI. I can answer the question about why rifampin is going to be a problem with a particular regimen, posed by the doctor on one of our first days in clinic, not with a vague answer about “drug interactions” but with a detailed understanding of P450, actually seeing the mitochondria in my mind.

Most of the time, though, I feel much more exposed here than I ever do in the states, more frustratingly aware of my relative lack of knowledge. We were at Mulago during the annual examination period for the students and residents, which meant that the residents were busy cramming and the attendings were busy administering bedside practical exams. The interns, therefore, were carrying a larger-than-normal burden of responsibility for patient treatment decisions (one attending told us that patient mortality spikes every year during exam period). It took me a few days to recognize that typically, when interns questioned us during rounds, they weren’t doing it to teach, to test whether we understood various treatment decisions. More often, they were themselves unsure what to do with a particular patient, and were looking for any available opinions. And unfortunately, much of the time we didn’t have a lot to offer.

This became abundantly clear one morning in the first week when Rachel, Lily, and I joined a smart, friendly intern on hematology/dermatology rounds. Hematology and dermatology have never been my strongest academic areas to start with, and my sinking, slightly panicked feeling increased as the morning went on. We’d get to a patient, he’d wonder what we thought, and as the morning went on, it became clear that in most cases, he didn’t really know what to think either. As the three of us plus the intern stood around a patient’s bed, trying to make sense of her low white blood cell count and dropping platelets, we were pawing through Pocket Medicine and scrolling through epocrates with a collective sinking feeling. It was a disturbing feeling, not to know. It is always disturbing not to know, to be called out during rounds in the states, to be unable to answer a question someone thinks you should know. But here, the intern didn’t care at all whether I knew an answer. He just needed an answer, from anyone, for the patient in front of us right now, and none of us could offer one. As Rachel said in disgust, “these are people’s lives, and we’re looking through Pocket Medicine.”