I get a lot out of the bedside teaching sessions we’re doing this year — I’ll never forget Cheyne-Stokes breathing after hearing a man gasping for air and then falling silent — but I still find it awkward to discuss findings in front of the patients.
For instance, yesterday my group practiced the neuro exam on a middle-aged man who had been immobilized for six months, transferred from one institution to another by stretcher. When we walked in, he was on the phone with a family member and doing a word-search puzzle. He was very excited to see us, and went on and on (and on) about his medical and personal history. There was a funny moment when one of my group members asked him to subtract 7 from 100 (a standard part of the cognitive exam), and the patient retorted, “Serial 7s, huh? Tell me when to stop!” I had to bite my lip to keep from smiling. In spite of significant neuropsych and medical problems, Mr. S. was clearly an intelligent and upbeat man, thoroughly “with it.” So far, so good.
Then we moved on to the physical neurologic exam, testing cranial nerves and sensory/motor function. Our preceptor pointed out that one of his feet was in the “foot drop” position (toes pointed) and even passive dorsiflexion was painful. “Why?” she asked us.
“Um… nerve lesion,” one of my group members suggested. It would make sense, given that it was neuro week. But our preceptor shook her head.
“It’s because his Achilles’ tendon has shortened from disuse,” she told us. “He’ll never walk.”
The patient, who had been rambling a bit about grad school, jerked his head around to face her. “I’m not going to be able to walk? What do you mean?”
Our preceptor explained the biomechanics of foot drop and walking, mostly for us med students but at a level that the patient clearly understood. He was in a lot of distress, insisting that a wheelchair-bound life was absolutely unacceptable to him. I felt very uncomfortable, wanted to reassure him, hoped my preceptor would address his concerns. The only thing she said to him was that if he wanted to walk, even with a walker, he was going to have to work very hard at it. She recommended that he talk with his primary medical doctor about it. And then she turned to us and said, “Time’s running out; on to the next patient.”
So we thanked Mr. S. awkwardly and followed our preceptor into the hall like white-coated ducklings.
The truth is, none of us knew what to say. I felt awful about it, but at the same time, I realize that everything my preceptor said was perfectly true. You can’t argue with physics. You can’t argue with the senior attending, either, especially when you are a second-year med student who doesn’t know anything. Even after talking it over with one of my group members later that evening, I am not sure what we should have done.
I suppose the real lesson is not so much how to go through the motions of the neurologic exam but rather that patients really, really pay attention to what you say in front of them. Isn’t that a nice little homily, kids? Aesop would be proud.