Years ago as a medical student, I worked as a nurse’s aide in a Chicago area emergency department. One weekend night, a middle-aged woman came in with leg pain after a relatively minor injury. An X-ray confirmed a femur fracture and the young resident physicians, who I admired very much, prepared her for admission to the hospital. They checked her labs, treated her pain and filled out forms. Soon, she was resting comfortably. I transported her to her hospital floor.
A short time later, the attending orthopaedic surgeon strode in from the parking lot and rummaged through her X-rays, which were still in a box in the ED. “Did anyone do a complete physical examination?” he barked. “Go up and do a breast exam!”
I wondered, How can he look at an X-ray of her leg and conclude that she had a problem in her breast? But, sure enough, there it was: a huge, ulcerated and long-neglected breast cancer stuck to the chest wall and growing out through the skin.
How could he have been so sure? His experience had taught him to recognize the bone metastasis and to know the most likely source. Now, years later, I realize that all physicians learn to make associations like this one through experience and training, but I distinctly remember how amazed I was at the time. I wondered, How will I ever be able to remember everything that I need to know as a physician? I’m still wondering.
