The Lancet Student

A Study in White

This blog was submitted by Stephanie on 13th February 2012.
Tagged with diagnosis, observation, Sherlock Holmes

I have to confess that I’ve secretly wanted to be Sherlock Holmes ever since I was ten years old, and my mother handed me a collection of stories featuring the most famous detective of all time as a birthday present. I remember reading with fascination as he casually told people things about themselves that he had discovered seconds after first glancing at them. I loved that ‘super-power’, I admired and wanted it, and at the time, I was sure that such an awesome profession was impossible to aspire for, because it did not exist.

Fast-forward a dozen years or so, and I re-discovered my love for the character through a recent television adaptation. Sherlock was, more or less, the same as ever; but I had moved on from the starry-eyed ten-year old in her shiny fantasy world to a twenty-two year old medical student who is currently very much forced to live in the solid, and slightly bleak reality of her approaching finals.

My ten-year old self dreamed, hopelessly, of being Sherlock. My twenty-two year old self suddenly realised, in a mix of joy, horror, and a pinch of hopelessness, that I am expected to be Sherlock.

I only found out after entering the medical course that the character of Sherlock Holmes was actually based on that of a doctor; Dr. Joseph Bell, who Sir Arthur Conan Doyle (himself a medical man) met in Edinburgh when still a student. Dr. Bell was a famous lecturer and renowned for his abilities of observation – he was also a pioneer in forensic science and sometimes collaborated with the police.

I found it slightly ironic that with my admiration for those very skills, and yet without ever making the connection, I am now in the same profession, and being asked to do practically the same thing that Dr. Bell did to inspire the famous character – i.e. deduct through observation – though  it must be appreciated that in those days, with their lack of suave investigative methods; doctors relied much more heavily on their observational skills (which were refined to a point that is slightly more difficult to hone nowadays).

That consideration aside, a great deal of what I have been taught, especially by very experienced doctors, has fascinating parallels with the philosophy that Sir Arthur Conan Doyle infused in his own works.

For one thing, we are all encouraged to consider investigations as a handy aide, rather than the default method of arriving at a diagnosis. Therefore my medical training has focused greatly on history-taking and examination; as well as the more Holmesian ‘spot diagnosis’. Consultants periodically point to a patient, or to pictures; showing a person in bed or standing up, or even to a part of a person; such as his hands, or legs, and ask the oft-dreaded question ‘Just by observing this patient, what do you think is the diagnosis?’. And then ‘So what do you expect to find in the patient’s history?’, or ‘What do you think the patient may complain of?’.

And it doesn’t just apply to outward appearance; in effect we are asked to apply the same principles of observation when looking at a radiological image, or an ECG, or a set of lab results. We are given one side of a multi-dimensional picture, and are expected to use our minds to project that information into a moving, breathing, 3D image. We are asked to become detectives.

This fact didn’t strike me earlier on in my training, when I was still thick in the process of assimilating data about all sorts of things; but now that I am in my (hopefully) last stretch of studies it has become obvious every time I am asked to go ‘have a look’ at a patient, that what they are expecting is for me to use my background knowledge to observe, infer, deduct and diagnose.

When my lecturers tell us to organise all the information in our minds so it’s easy to go through and access quickly, it’s very similar to Sherlock telling Watson that he arranges data in his mind like ‘furniture in an attic’, and discards useless information (such as the fact that the Earth orbits the sun) so that it doesn’t clutter up the limited space (although personally I will opt to keep my basic knowledge of astronomy, I did make a conscious choice to avoid celebrity gossip, which – let’s face it – is nothing but mind-trash ).

And just like Mr. Holmes often probes the person in front of him, asking questions which might – to the recipient at least – appear unrelated to the presenting complaint – so must we pick and choose from thousands of possible questions, the ones which are most pertinent to the condition and which are likely to lead to a diagnosis. At the same time, we must keep an open mind and be careful not to be ‘prejudiced’ by an initial, hasty impression, and fit the questions and the patient’s answers to the diagnosis we have pre-selected. Even that is fascinatingly reminiscent of the way in which Holmes remarks to Watson, “It is a capital mistake to theorize before one has data. Insensibly one begins to twist facts to suit theories, instead of theories to suit facts’.

The thought that each patient, each case, is a mystery that needs unraveling is an exciting one. And while it would be dangerous to act too much like our favourite pipe-smoking, drug-abusing, unsociable detective, and forget the person lying behind the mystery – their hopes, expectations, and fears – I don’t think I’m alone in finding my future career as a puzzle-cracker something to look forward to.

One of the reasons I embarked on this journey to become a doctor was because I despised the idea of boredom; of a monotonous, never-changing job. Or as Sir Conan Doyle more eloquently puts it in ‘The Sign of Four’: 

"My mind...rebels at stagnation. Give me problems, give me work, give me the most abstruse cryptogram or the most intricate analysis, and I am in my own proper atmosphere. I can dispense then with artificial stimulants. But I abhor the dull routine of existence. I crave for mental exaltation."

Well, Mr. Holmes, if what you meant was a life of never-ending problems, analysis, and mental satisfaction, I do believe I have found it.