narrative medicine

Free clinic

I usually teach starry-eyed ninth graders on Saturday, but since the kids are off for the next few weeks, and since I am a masochist who likes waking up at dawn, I signed up for the free clinic this morning.

I volunteered at this clinic a couple of times during third year, but then I had 3 away rotations in a row, and then my sub-i, and then Step 2, and then I started my master’s program and they took away my EMR access *sniffle*.  So this morning was the first time I’ve picked up my stethoscope in … six months? Awesome.

As per clinic policy, I was paired with a junior clinician, in this case a first-year NP student.  Now, she knew a lot about the physical exam already, and I like to let the JC to as much as they feel comfortable with.  Our first patient was an older guy with poorly controlled DM and HTN returning for follow-up.  We went in and introduced ourselves, ascertained that there were no complaints other than a “broken” glucometer (which still had the store’s plastic wrap on it).

My JC asked if she should start the physical, and I told her to go for it.  She did the ENTIRE physical exam.  She rooted through the guy’s hair like she was looking for lice.    Searched for supra- and infra-clavicular lymphadenopathy. (She actually asked me if she should continue with the axilla and arms, and I nearly retorted if she thought the gentleman was s/p radical mastectomy.)  Felt for a spleen.  Suggested we check femoral pulses, though I pointed out that if we got strong peripheral pulses, his femoral artery is definitely patent.

We spent nearly two hours with the guy.  And that was before presenting to the attending.

I remember the feeling of just starting physical diagnosis, of spending several hours doing an unbelievably thorough exam on everyone.  And then somewhere along the line, I learned to be focused at follow-up.  If I were seeing this diabetic, hypertensive gentleman in, say, my primary care clerkship, I’d probably have done a fundoscopic exam, a quick check of cervical nodes, carotid bruits, heart/lungs/abdomen, and a careful foot exam including joint position sense.

Maybe this means missing something.  There’s a fine, fine line between a focused and a shoddy exam, that’s for sure.  I guess the difference is that I’m thinking of red flags based on the history — eyes, feet, and stroke risk are all important for diabetics — rather than the broad-based annual physical exam.

I mentioned speed (as gently as I could) in between patients, and our second patient went much, much quicker.

Timing issues aside, though, I was quite pleased to see that I hadn’t lost all my clinical skills during this year off.  It was incredibly easy — and delightful — to slip back into the doctoring mindset.  Oh, how I’ve missed caring for patients!

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