Why It's Called "Practicing" Medicine

I'm in this awkward period in my career right now where I want to work independently most of the time yet I still like having that comfort level knowing I have people to turn to and ask for help when I'm just not quite sure about something. I have good days where I seem to know all of the answers and then I have days where I am confused on what to do and I have to run to my attending and ask for help. This month has been an eye opener in terms of what I don't know. Keep in mind that not only have I graduated from an accredited US medical school, I also have a medical license from the state of Indiana. What I'm trying to say is that this isn't exactly my first day on the job.

As I do dermatology this month, I repeatedly don't know the answers. People come in and point to some random area on their body and ask "What is this?" My attending then asks me the same question, to which I respond "I don't know." He then informs me that it is a case of sebaceous gland hyperplasia, identified by its yellow color, central clearing, and the telangiectasia surrounding the lesion. Of course, how could I not have noticed that? I do have two defense points. First of all, I have never been taught dermatology. I never had a class in medical school and I never had a dermatology rotation until now. My second defense is that dermatology is very low yield on our boards and a lot of what they ask is fairly rare stuff like Stevens-Johnson Syndrome.

I had clinic today and low and behold I had a dermatology complaint with one of my patients. He had a "rash" on his knee. I walked into the room and his entire knee was bright red, warm to the touch, it blanched with pressure, part of it was crusty, part of it had pustules. I looked at the area and tried to use the systematic approach my dermatology attending taught me for rashes and I was coming up with nothing. It had so many characteristics I couldn't fit it into one type of rash. I honestly had no idea what it was, and thus no idea how to treat it. I went to my attending with my tail between my legs, explained the rash to him, and honestly told him that I had no idea what it was. Long story short, my attending somehow determined it was fungus with a secondary cellulitis. Now I've seen people with ring worm before and I'm gonna tell you it looked nothing like this guy's knee. We did a scraping of his knee and a KOH prep and sure enough, we saw branching hyphae of fungus (see below). We treated him with antifungal and antibiotic and he is coming in early next week for a follow up.

Moments like this really put my confidence down in terms of being able to go out on my own. If I were by myself and had no one to turn to (which I might be here in a month or so when I start moonlighting) I honestly don't know what I would have done. I probably would have just done the best I could have until I could have got him into someone smarter. Don't get me wrong, more times than not I have a pretty good idea on what to do, but every once in a while I get stumped like this and it is a humbling experience. I learned quite a while ago that medicine isn't black and white like I thought it was. Most of it falls into this gray area where diagnoses can get mixed up easily, especially to the unexperienced. I guess this is why it's called "practicing" medicine instead of "performing" medicine or some other word.