The 45 year old man who met my gaze as I walked into the exam room smiled and, at least on first glance, appeared to be relatively healthy. When there is a patient on your schedule listed as "routine health maintenance exam," it's hard to know what to expect. Immediately upon entering, however, you can often gauge about how long your visit is going to take. If it's a 22 year old female who's not obese and looks pretty normal, then you can expect to do a pap smear, some contraceptive counseling - done. If it's an 85 year old man in a power chair who's here with his caregiver and sporting a bulge under his shirt suggestive of a nephrostomy tube, you can expect to be running behind for the rest of the day.

"Hello, Mr. Brazil, I'm Dr. Logan," I offered my hand in greeting. "This is one of our medical students who is working with me today."
"Hi!" Jill smiled brightly and waved.
"Um," Mr. Brazil eyed the attractive 24 year old medical student uneasily, "Would it be ok if I just talked to you today?"
"Sure, no problem at all." I shewed Jill out of the room. "What can I do for you today?"
"Well, I've been noticing over the past several months that my penis has been getting more and more crooked."
"Crooked?"
"Yes."
"How do you mean?" I asked.
At that point, the patient lowered his pants to reveal a circumcised penis that was normal in every way except that it made a nearly 90 degree turn midway through and pointed to the patient's right.

After a bit of research and after talking it over with my supervisor, I went back to see the patient.
"I'm going to give you a referral to urology. There may be some treatment options available but, if none of them are helpful, the definitive management for this condition is surgery to release some of the connective tissue surrounding your penis."
"Surgery?" The patient appeared to turn a light shade of green at the thought of his penis being flayed open and I can't say I blamed him. "Is there anything else I can do in the meantime?"
"Well," I mused, "Are you right or left handed?"
"Right handed."
"I thought so. I would say, in the meantime, try masturbating with your left hand. See if things improve. Either way, I'll go ahead and put in the urology referral."

I must confess, I haven't looked at the literature on this - not even sure if there is any. Would any urologists who may read this care to comment on whether there is an association between Peyronie's disease and which hand a patient masturbates with? Could be a good research project.

Mr Paul Lewis's elbow had been swollen for the past month when he fell backward and landed on it while walking his dog. Multiple joint aspirations hadn't shown any evidence of infection or any crystals to suggest he had gout. What they did show was blood. He had lots of blood in that joint and a subsequent MRI showing what the radiologist called "extensively destructive arthropathy," which means that he had all kinds of badness going on inside that elbow. As part of the work-up, our attending suggested we get a rheumatoid factor.

Seriously? A rheumatoid factor? In a patient with an acute problem in a single joint following a traumatic event? And if the rheumatoid factor is positive, we're going to do what exactly - start him on some NSAID's and possibly methotrexate and hope he gets better?

The doctor in the example above is double boarded in internal medicine and neurology and was covering our inpatient service for the week. He really is quite knowledgeable. He's the guy that you want taking care of you if you have diabetes concurrent with poorly controlled seizure disorder. Bone and joint issues...not so much his thing.

I struggle on a daily basis to delineate those facts that I should absolutely know in order to consider myself a competent family physician from those facts which I absolutely do not need to know - to figure out during which lectures I need to perk up and during which lectures I can plug my ears and yell, "la la la la la." This is quite a bit more difficult than one would think. Nearly everything written in every medical textbook or journal from any specialty is potentially relevant to family medicine. But, even the very best family docs are only familiar with a small portion of this information. In fact, those in our field who have attained the highest levels of prestige and stature (program directors, department chairs, etc) often are the most actively involved in research and therefore have only mastered a relatively smaller portion of medicine as they've had to devote more time to learning fewer topics, albeit in greater detail.

So, is the guy who thinks you need to get a rheumatoid factor on someone with an obvious hemarthrosis competent? Every physician has gaps in his or her knowledge. If I graduate from residency with as much knowledge of psychiatry as our obstetrically trained faculty and as much knowledge OB as our sports medicine faculty and as much knowledge pediatrics as the guy who only does adult inpatient medicine, will I be competent? I certainly hope so, because there isn't a doctor alive who knows as much OB as an OBGYN and as much psych as a psychiatrist and as much peds as a pediatrician and as much about your teeth as a dentist etc. Yet, in family medicen, we're supposed to know about all of these things. The question is, how much? Where can we stop? Since the very start of my medical career I have been searching for this minimum standard for what it means to be competent. Does passing your boards make you competent? Nah, I think there are plenty of incompetent physicians who've managed to pass their boards. The only standard I've found so far is that you are competent until you start doing too many things that embarrass your colleagues. And that's no kind of standard.