Each month in my ED, we greet a group of fresh, smiling faces from the third-year medical school class.

Especially in the first 3 months of the academic year, these neophytes have a bit of the deer-in-the-headlights look about them the first few days of their rotation. They are visitors to a strange land (on a distant planet), and they are uncertain about what to do, how to do it, or even where to find the bathroom.

Throw in an unfamiliar computer program, and it makes for an uncomfortable transition.

They all eventually catch on and, for them, it becomes a month of wonders. They get first crack at patients who will eventually tell the story of their abdominal pain or ankle fracture multiple times.

By the time these patients make it to their inpatient bed, they want to charge admission for anyone else to hear their story. But for these medical students, they have an eager patient who will tell them everything they want to know.

And that, I suppose, is one of the biggest lessons.

These students must learn to separate the wheat from the chaff. They learn that if you want to see more than one patient per hour, you must get to the point quickly while allowing the patient to tell the pertinent aspects of the story.

Essentially, they learn that if a patient falls over while trying to put on their shoe, the shoe size is unimportant. This is a concept that many of our internal medicine colleagues seem to have missed.

When these students emerge from the room, they then must cull from 2 years of book learning a reasonable differential. It’s interesting to watch the wheels spin while they try to put it all together.

“Schistosomiasis can be a reasonable thought in someone with abdominal pain and a rash—but really is quite unlikely if the patient has traveled no further than Detroit.”

They nod at you and quickly learn that what you need to know to pass the boards and what you need to know to practice medicine in Ohio are not the same.

Next come the tests. If the student has rotated on a medicine or neurology service already, they will rattle off a bunch of expensive tests. After we weed out the serum plutonium level and the like, we talk about the utility of what we are going to order.