"So tell me about your 18 month well child checkup," the attending told me.
I paused a moment and then said in my best Texas accent, "You'll see why in a minute, but something ain't right with this kid."
The attending laughed and interrupted me saying that's actually quite an important observation. To have seen enough of the usual suspects to know when something much more dangerous crosses your path is very important. And to see it within the first few seconds of walking through the door is critical. It's horse sense, really. Yes, we have to know libraries of information, but the application of it is really quite simple. Use your powers of observation and then feed that into a Sherlockian mode of deduction. I still remember my brother's oncologist saying, "you'll find that the majority of medicine is just common sense." And he was right. My common sense told me something wasn't right. I then began to rattle all the minor things I noticed that if they were by themselves, wouldn't amount to much. But when you see the big picture and put them altogether, warning bells should start sounding. And loudly. This is when I knew I had earned the attending's trust and was going to get a good evaluation. While I'm still presenting, he starts ordering tests based solely on my presentation as he hadn't even seen the kid yet. This kid should've had these tests 6-8 months ago but had somehow managed to pass a couple of physicians who missed the boat royally. We took a shotgun approach since it had been going on so long - genetic screening, early intervention, surgical consult for testes that had not descended (they are supposed to descend by 12 months and the poor kid had physicals which said they were descended at 9 and 12 months, which they most certainly were not), autism screening, cystic fibrosis confirmatory testing, etc. On the one hand, I felt very proud of myself. On the other, I felt very sorry for the family. They were in shock, and deservedly so as no one had told them this before. And it was only the beginning for them. Their life was not going to get easier, only harder. Such is the way of our training. We learn on the "interesting" patients. But you never, ever want to be interesting to a doctor.