The day is early, and the air is crisp. The aroma of freshly baked bread fills the bustling streets of Philadelphia. Footsteps are heard steadily on the cobblestones when the postman arrives in the bank.
Upon entering, the postman feels his heart begin racing. His pupils dilate. A glimmer of sweat begins to form on his brow, beading. His hands go numb. All is silent.
You may be wondering if this man is having a heart attack? A panic attack? Hypertensive crisis or thyroid storm? Is he about to walk into a physical diagnosis practical examination? ... Close, but not quite.
This “postman” is really the notorious William “Willie” Sutton, Jr., bank robber extraordinaire of the 1930s. He is about to commit yet another newsworthy crime.
Sutton was known to be a gentle man, never thieving in the presence of women or children ... a respectable kind of criminal. He was cunning, intelligent, and infamous for his well-thought-out disguises and ploys.
Being the exceptional criminal that he was, he was often asked: “Why rob banks?”
Sutton simply replied, “That's where the money is.”
This statement has taken on a new meaning for me.
Fast forward to modern-day physical diagnosis class, where PA students are taught systematic examination skills. We memorize and recite templates ad nauseam until we perform them as second nature. This painstaking task is then applied to actual patient scenarios, where we must use the tools we have learned to figure out what is ailing the patient in front of us.
Traditionally, students are taught to work in a comprehensive “head-to-toe” fashion, picking up every subtle hint or negative examination finding to aid in the correct diagnosis. This method helps steer the inexperienced student away from the unlikely diagnostic rarities that we spend so much time learning about during the didactic year. Eventually, an inevitable transition must occur: the student reciting line after line must transform into a streamlined professional, examining exactly what is crucial to the diagnosis, while simultaneously foregoing the unnecessary.
This transition from robot to practitioner can sometimes be difficult for students; it requires forgetting the precisely organized and memorized template and instead customizing the examination to the person sitting in front of them. Students must learn to think on their feet, no longer able to fall back on the net of the comprehensive physical examination for forgotten details. Many wonder where they should even start. This is where William Sutton comes in. Instead of starting with a full scalp examination on every patient that comes in complaining of chest pain, Sutton's Law of Medicine dictates that students go directly “where the money is”—that is, in the case of chest pain, go for the cardiac examination!
So, PA students, the next time you are about to begin your physical examination, when your heart starts racing and you feel like you've lost all blood flow to your brain, when you feel you've forgotten everything you were taught in school, simply go “where the money is.” When you do, the rest will fall into place.