I remember learning about otitis media as a third-year medical student. Knowing at the time that I was interested in pediatrics, I was eager to master the diagnosis. It was one of the quintessential diagnoses that the pediatrician encounters daily. Just as "anterior superior iliac spine" was the first medical-sounding term that I learned to recite in the predinical years, I hoped that otitis media would be the first diagnosis that I would learn to make and to treat during the clinical years of medical school. With that enthusiasm, I began my pediatrie clerkship.
We first learned the causative organisms of otitis media: Streptococcus pneumoniae, Haemophilus influenzile, and Moraxella catarrhalis. The word "resistance" was used primarily in my microbiology class. It seemed like a concept with more theoretical than clinical relevance. Second, we learned the proper ways to diagnose otitis media. I stared at beautifully illustrated diagrams of middle ear infections, anxiously anticipating seeing these in a child. Finally, we learned about treatment. Choosing an antibiotic for otitis media seemed much like ordering from a fixed-price menu at an expensive restaurant - I could choose from the "first-line," "second-line," or "penicillin-allergic" menu. In the context of medical school, these factual concepts were straightforward. However, as I began pediatrie residency, the clinical part was not so easy to master.
I hoped these skills would develop quickly during internship. However, I promptly realized that the key to a successful ear examination did not exactly come with my long white coat. First there was the wax. Removal seemed an endless undertaking. I could never quite convince anyone to hold still, either. Children were different from the fellow medical students on whom I had practiced. Then there was nonstop crying from nearly every child whom I examined - and with crying, every child seemed to have a red tympanic membrane. This made the subtle aspects of the diagnosis more vital. Gone were those beautiful illustrations. The diagnosis instead seemed to rely on subtleties and on what seemed like a great deal of clinical experience. It was going to take some time to master this elementary diagnosis.
Eventually, things started to make sense. After a year or two, I could correctly diagnose otitis media on most occasions. Choosing appropriate therapy was easier.
My pediatrie residency learning curve has had an upward slope overall, but in a stepwise fashion. In fact, just as my clinical confidence regarding the diagnosis and treatment of otitis media was improving, I began to get confused again. This confusion started abruptly when I came across a patient who had been treated with both amoxicillin and amoxicillin-clavulanate. Although I first assumed that this was a mistake, I soon learned that this choice had been made intentionally because of concern about antibiotic resistance. Next came the lesson about using high-dose amoxicillin for the patient at risk for resistant pneumococcus. Suddenly, issues such as day care attendance, recent antibiotic use, and even age were guiding therapy. The reality of emerging antibiotic resistance was no longer theoretical, and it was changing clinical practice.
As I progressed through residency, the next logical question was, "What will I do when I am in practice?" I talked with other physicians and read journal articles, position statements, and opinion pieces. The volume of literature dedicated to what I had once naively assumed to be just "bread and butter pediatrics" was amazing.
Now, as I look back on my residency, I can say that I have developed my own approach to the diagnosis of otitis media, but I have also realized something far more important. I had believed that the answers in medicine were black or white, and that any shade of gray was intolerable. I now appreciate that the world of medicine consists of both concrete answers and a myriad of questions whose answers are less well defined. We do not always know what we think we know well, and even the seemingly simple problems must be reexamined periodically. I had hoped that I would know all that I needed to know about pediatrics by the time I finished residency. Instead, my medical training was merely the foundation for lifelong learning, filled with questions and shades of gray
Rebecca Baum, MD
Department of Pediatrics
University of Pittsburgh
School of Medicine