Medicine

Why?

Why does this blog even exist? For quite some time I was looking for ways to creatively express myself - fully aware that almost nobody will read these posts. I didn't have an answer to this until now. Now I realise: I feel lonely.
I feel like this realisation has been slumbering within the depths of my subconsciousness for a while. Paradoxically I do have many friends. Maybe that is the culprit of this resistence.

Things that have been keeping me awake

A word (on) Passion

I prefer the German translation "Leidenschaft" — a compound word containing "Leiden" meaning "suffering". Passion describes a type of love for something that implies at least the acceptance of some level of suffering, or even an almost melancholic kind of seeking for it.

Work politics in the health system

TLDR: Junior doctors feel overworked. I once took part in a mentoring course meant to connect scholarship alumni with students at our university. Topic: work-life balance in medicine. Only one alumnus showed up - which already kinda says something. At one point he told the story of how he collapsed after a during a shift. Other Clinicians I talked to echo similar stories. One metaphor in mentioned quite often: being "thrown into cold water." More and more rural hospitals are closing. There are reports and documentaries expose this crisis, yet policymakers remain indifferent.

Clinical Reasoning

There are certain phenomena in the world of health and fitness that have always perplexed me. Some of these toxic phenomena are upheld by so-called "influencers". Unfortunately, even ppl who should know better perpetuate these pseudoscientific beliefs. One of these is the phenomenon of "Einmal alles Durchchecken lassen". The fascination of tracking every little thing: from smart watches and smart rings to explorative full body MRI scans or extensive tumor marker, hormone, and/or vitamin panels.

Nobody taught us how medicine works. We learnt about statistics and basic science (e.g., physiology), but these things felt disseminated like puzzle pieces. I feel like I see how the pieces fit together now (sounds kinda manic ngl), and the puzzle pieces are called "Clinical Reasoning" - the concept that describes how doctors think.

Tearing things apart to put them back together.

Understanding someone

What does it mean to "understand" someone?
A physiology professor at the end of the preclinical med school years mentioned something I will never forget: "Am Ende der Vorklinik sollen wir in der Lage sein, einen Menschen von 0 zu bauen, denn derjenige, der eine Sache gebaut hat, ist der geeignetste, diese zu reparieren, wenn sie kaputt geht." Quite technologically biased metaphor, yet I will never forget these words. I have integrated them deeply into my professional identity.

I think it is part of the core identity of the physician to understand what is going on (or going wrong) inside a person's body. Sometimes this is also verbalized: "Tell me doc, why me? Why do I get cancer? What is wrong with me?" Of course we can't explain everything to a molecular detail to everyone, but I like to imagine patients can feel if you are an expert at this. I think being able to give someone this feeling of closure - this feeling of "you are at the right place, we are the experts and we will take care of you" - is something worth striving for.

Also: Pathophysiology helps us remember things. It represents the "why" that glues other aspects of a disease like symptoms, etiology etc. causally together.

Do no harm

... is honestly an oversimplification. Everything we do (or not do) is associated with harm. One decision can change the trajectory of a person’s life - for better or for worse. This is a responsibility that needs to be taken seriously. Decisions shouldn’t come from a place of authority. Medicine is per definitionem an applied science. Science being not just a commodity but a moral obligation. No one likes to go to the doctor (not even I, paradoxically, even though I am becoming one lol). When someone presents, usually there is some type of suffering involved. We cannot "heal" everyone, but for god’s sake we owe everyone good scientific practice. One of the better-known German physiology textbooks starts with the quote by Bernard Naunyn: "Medizin kann entweder eine Wissenschaft sein, oder sie kann nicht sein."

In stats we learned about test quality criteria, including parameters of criterion validity like sensitivity/specificity, related to this likelihood ratios and related to that pretest/posttest probability, base rate—to only mention a few aspects. However, "statistical tests" are not the only kind of test. In the very second we start perceiving a patient with our senses when they come towards us on the clinic floor, a magical process begins called the "clinical exam". How this person comes: Alone, or brought by someone else? On foot or in a wheelchair? If on foot, how does the gait look? If in wheelchair and brought, are they looking/speaking at you or are they reduced vigilance? When you touch their skin, does it feel warm or cold, rough or smooth, dry or sweaty? And so on. All these things are tests, and their criterion validity is described in the literature. I came up with a (I guess grossly oversimplified) equation that roughly describes the "clinical process": posttest-probability = pretest-probability × LR⁺_N,
while LR⁺_N describes the positive likelihood ratio of N tests we do.

One dimension that I teased in the first paragraph is: Overdiagnosis is harmful. Some tests are quite literally unpleasant, bc they can hurt or have complications potentially leading to death - stories of interventions going very wrong, we have all heard of them. Others have (if not used in the right context) bad statistical properties, possibly leading ppl to believe they have cancer, maybe putting them (or pushing them deeper) into a depressive spiral.

A little plot twist that I realised quickly in my clinical years: Real life ain’t like in the textbook.
In med school we learn disease "the wrong way around". Usually a disease is a flashcard consisting of symptoms, etiology, diagnosis, and treatment. However irl ppl present the opposite way around and say: "Doc, I have these issues - what is my disease?" As corny as it sounds: humans are individuals. Every symptom (which are tests in a statistical sense) and every positive test have different statistical features like prevalences and likelihood ratios. Thus the other dimension: Situations with conflicting tests and symptoms & disease not mapping traditionally to one another are very common.

In other words: This equation is a smart way to say the German "Wer viel misst, misst viel Mist" or how I as a born Hessian would say "Scheisse rein, Kacke raus".

Putting the pieces together

The entire point of why medicine is a 6-year-long program (often longer) is bc it is a highly intellectual profession. You are supposed to integrate clinical features and pathophysiological understanding in a statistical machine that is you.
TLDR: We should understand (at least a liiiiiiittle) pathophysiology and statistics to not kill ppl and actually be kinda helpful yknow.

Tearing myself apart, to put me back together.

I realised this section was becoming way too long and also quite personal and therefore probably uninteresting, thus I abbreviate this chapter with 2 aspects I will quickly mention (I need to sleep—it’s way past bedtime UwU):

• I have always had a deep fascination for science even as a very little child.
• Being there, helping and caring for one another is the most fundamental spiritual value that I have.

Motivation

I thought in academia I would finally feel understood since yknow - I assumed at the point where you dedicate multiple yrs of your life to something, you gave a shit maybe? I don’t want to portray my fellow students in a bad fashion since that wouldn’t be statistically correct (it is a small and specific subpopulation I am referring to). However, I was quite shocked when I realised how variable the individual motivations for different ppl to pursue this path can be. Some of the things I heard ppl say: One person mentioned their parents own a doctors office they would like to inherit; another said "I want to become a professor at Harvard or Oxford" (make of that what you will); someone else mentioned that radiologists make "fat bank" (although I had this conversation in pre-med times and don't know if they actually made it with that attitude). Also, I have the feeling the primary force for research by physicians is the fact that it is traditionally coupled to career.

In 2025 there were some things that went wrong. I have had some conversations after which I felt betrayed. Some ppl that I thought were role models to me, were no more. I was disillusioned. I can’t help but wonder what their motivations were?

If this is really what this is about, then I am not sure if this is still what I want - I thought to myself.

But then came the good conversations. E.g.: For anonymity sake (and bc I have a terrible name memory tbh), I will refer to this patient as Paul. Paul, an older fella, has peripheral arterial occlusive disease. He is also plagued by a terrible pruritus all over his body. The chief physician suggests testing for IgE levels in the blood during ward round. Something tells me Paul is sad. During my daily blood draw round in the morning, I start a conversation with him. He mentioned his wife, who died from cancer. I sat on the bed beside him. This was some time ago, but I remember at some point I held his hand. I did nothing clinically-manually demanding, but it was the first time I felt like a doctor.

[!info] A sympathicoadrenergic side-note
Since this is still the "brain and body blog," I want to take a quick moment to at least mention a few other cases that I fortunately met fitting this dualistic theme of "brain and body":One patient, a highly health-focused, athletic young male with diffuse heart symptoms (clinically tachycardic), told me about his disabled daughter - how he travelled across German-speaking Europe to seek out all kinds of doctors and healers, obviously frustrated and easily irritable. I suspect if psychosomatic medicine isn’t involved, this frustration might not resolve soon.Another elderly female patient presents with resistant hypertension. She is obviously very angry that the pharmacy gave out certain active ingredients from a different brand than usual - a pharmacologically irrelevant detail.Of course, this is a narrative I constructed. But I remember at no point did the thought cross the internist’s mind that non-somatic issues might play a role. I can’t help but wonder what their trajectory would have been.
Are we surprised that a chronically sympathicoadrenergically activated person suffers from tachyarrhythmia and hypertension? If we respected physiology, we shouldn’t be.

Overloading myself

I guess at some point I must have forgotten about it.
As med students, we often look at the preclinical years of medical school with quite some distain. When I think about it, those were my best, most productive years. I never had issues with studying, never had to "discipline" myself or "work hard" or whatever the podcast-bros nowadays propose. Actually, the opposite was the case: I had to stop myself. I was so "locked in" that I forgot the reason why in the first place. And when the preclinical state exam was done, I forgot to "switch off" this "mode" and I started working on too many things at the same time.
I engaged in as many extracurricular activities as I could and pursued a scholarship. These were individually often fulfilling endevours, but I did them partly bc I thought "that’s what motivated students/academics do."
I overworked myself.

Closing a Chapter

I always thought a lot when I lay in bed since I was a child. Today something else kept me awake. Those were happy thoughts today. I am writing them down right now in this blog. A new chapter of my life will begin next week, and by some fortunate coincidence, I was able to close another chapter today.
Apparently I am not the typical (motivated) student, bc I am motivated by different things. I don’t care about career, don’t care about money or being validated as a famous scientist. I remember now: I care about Paul.