The Doctors-To-Be Are In

By Claire Vail, Senior Web Content Specialist

This story originally ran on March 5, 2007

The patient, a man in his 50s, explains that he's had a bad flu for nearly a month. In the last few days, a strange soreness under his left arm has put him into in a mild panic. After researching his symptoms on the Internet, he fears he may have a lymph node infection or worse -- angina pains.

"The guy who sits behind me at work died of a heart attack," he adds nervously. This evening, his symptoms have brought him to the Tufts-run Sharewood clinic in Malden, Mass.

First year Tufts medical students Miriam Schwarz and K. C. Collins record every detail of the man's case history. Though both are years away from an MD, each moment with a live patient is precious.

A freelance contractor with no health insurance, Schwarz' and Collins' patient is a typical Sharewood visitor. A doctor is out of question, thanks to his budget. The last time he was ill -- with a kidney stone -- he went to the ER, a move he now regrets due to the cost he incurred.

After finishing the case history, the students consult in private with Dr. James Bath, the resident physician.

Bath quizzes them in a friendly, brisk fashion. The patient said he had a fever, but did he use a thermometer? Did his cough sound dry or congested? Does he sound wheezy? Does he smoke? Does he have asthma? Are his symptoms isolated -- just in the throat, for example, or does he ache all over? Bath reminds them to always try to determine how chronic the illness is by asking things like whether they've had these symptoms before.

Bath runs through the list of possible suspects. He advises Schwarz and Collins to ask about lifestyle issues (such as smoking) and established ailments (such as asthma or emphysema) to help determine whether the patient has a bacterial or viral illness. While bacterial infections tend to be isolated in the body, Bath points out, viral problems tend to be more pervasive, with more general symptoms such as aches and pains. Bacterial infections are treatable with antibiotics; viruses typically are not.

"Fatigue, cough, all over aches and pains, it's likely a virus," says Bath.

But their patient is a mystery, say the students. He seems to have everything.

Together, Bath and the students examine the patient. Bath listens to the man's lungs with a stethoscope, explaining to the students what he's hearing in the patient's chest wall. He identifies a crackling sound low down on the patient's right side, between his ribs. Schwarz and Collins each take a turn and listen, nodding, though clearly straining to hear. "The air quality at the base of his lungs has a lower, coarse pitch," he notes. He suspects the patient has what is called an atypical or 'walking' pneumonia.

Bath explains his diagnosis to the student team. "More than likely he has two illnesses, which explains his confusing symptoms. He probably had a virus -- one that affected his upper respiratory tract, and gave him aches and pains. In that weakened state, he contracted a bacterial infection in his lung, which we can treat with an antibiotic."

The patient is concerned about the diagnosis, but Bath, who has found enough erythromycin in the clinic's pharmaceutical cabinet for a full course of treatment, tells him that as long as he finishes out the medication -- which the clinic provides for free -- he should be fine.

And the sore arm? After examining it, Bath smiles and assures him it's nothing to worry about. "Just a pulled muscle. It'll heal in a few days."

Photos by Jodi Hilton for Tufts University