Absolutely Confabulous

The process by which medical knowledge is passed on to the next generation of doctors has always had a certain "hands on" element to it.  Some things can't really be taught from a text book, to reliably establish the "pattern" that must be recognized one has to see it close up.

It is probably a good thing that I am not regularly involved in teaching these days.  Late in your career there is a tendency, even with the best of intentions, to operate in a kind of "shorthand mode".  I generally will take any clinical challenge that hits my ER and very quickly create a mental checklist of three or four things it could be.  Even allowing, as I always do, for the possible diagnosis of "some other weird stuff", it is perhaps a bit too much data compression for kids just starting out as clinicians.

But every now and again one of the clinic docs who has a med student or resident working with them will drop them off for an ER shift with your grizzled correspondent.  I wonder what kind of instructions they get first....

We always have fun.  My standard line is: "Every patient has a reason why they are in the ER at this time and with this problem.  Figure it out."

Maybe their shoulder is dislocated.  Maybe the twinge of discomfort in their chest worries them because their dad just had a heart attack.  Maybe they did not feel like going to work today.  Maybe they have a 105 degree fever.  Maybe somebody thinks they have a bizarre, rare diagnosis.  Once in a while they might even be right.  (Working with a student one day we had a Latvian college student with an EKG diagnostic of acute myocardial infarction.  As it turns out he really had a viral myocarditis but either way I said "study this case closely, it will be a very long time before you see another like it".)

One of the hardest things to sort out is confusion.  It takes a fair amount of effort to figure out, mostly because the patient can't help you much.  One day when working with a medical student we had a classic.

Mid 50's but looked older.  Reported history of alcohol abuse but at the time we saw him neither intoxicated nor in obvious withdrawal.  He was a pleasant, talkative fellow, but much of what he said made no sense.  It lacked context.  I told my young Jedi Padawan to pay attention:

Me: "Hey, have we met before?"
Patient: "Sure, sure we have!"
Me: "Oh yeah, it was that time we went to Las Vegas!"
Patient: "Yeah! Vegas! That was fun."
Me: "And those two waitresses we met, was one of them named Ruby?"
Patient: "Yep, Ruby and Emerald, swell gals!"

At some point you need to stop, because the poor guy was obviously inventing stuff on the fly.  He had a condition called Korsakoff syndrome.  It is caused by chronic alcoholism and nutritional deficiencies.  They live in the moment mostly, they have memories, albeit with many missing elements,  but no way to sort them, no way to tell the difference between real and imaginary.

In the later stages of the condition they tend to be dull, torpid, "burned out".  But in the earlier stages they retain the gregarious personality that likely made them the favorite patron of their local tavern, and add to it the "gift of gab", that uninhibited freedom of thought that all the very best story tellers have in spades.

The process of filling in the gaps in what they know is called confabulation.  Translated from the Latin in means "to tell tales together".  The shared conversation we had was a "fable" that we created together.  I wanted to demonstrate "confabulation" so that my student would spot it next time it came along. The patient was just having a nice chat, assembling his reality as he went along with what ever brightly colored bits he could collect from my verbal cues or out of thin air.
------------
Post script.  After dashing off this post I googled the title I had used.  As it turns out the phrase Absolutely Confabulous pops up in an article about conversation forums held in Washington DC by some very serious minded and frankly sour faced looking young folks.  You would probably have more fun at the local tavern.