The patient is a….

Last Thursday was my first time examining patients since early November.  After exchanging the usual pleasantries with our preceptor, the four of us trailed her upstairs, where we were split into pairs and assigned to two different rooms.  “Get a history and do a complete physical,” our preceptor said.  “I’ll be back to collect you in an hour and a half.”

My partner and I looked at each other, looked at the patient lying in bed with his nebulizer, pulled up a couple of chairs, and started asking questions.  Our patient was remarkably talkative — in general we have had nice patients — and he had an extensive medical and surgical history, so there was plenty to talk about.   About fifty minutes later, we realized that hey! we had to do a complete physical.  So I pulled out my handy-dandy Snellen chart and we got started.

Getting through the physical was more complicated than I had really envisioned.  We did all the major things and focused on the area of the patient’s chief complaint, but we had to leave out a lot.  The only thing that I was concerned about that we didn’t test was mental status. My psych preceptor used to just throw it out there, which always felt a little abrupt, but then again, he was psych.  Mental status is their raison d’être.  It’s a little less expected on a surgical floor that your medical student would say, “So Mr. Jones, now that I’ve listened to your heart, I’m going to say three words that I want you to remember.”  I just couldn’t think of a good way to segue into it without being too obvious, and so it got left.

Our preceptor popped her head in from time to time to give us tips, but the time flew past.  Although not having her there meant we were on our own, I think it was better this way.  At the very least, there was no awkward moment of delivering bad news randomly.  In due time, she collected us, we rejoined the other half of our group out in the hall, and we all trooped back to her office to do the oral case presentations.

Now, this was the hardest part of all.  I’d never done a case presentation before — none of us had, I think — and even though I knew the formula, I got all tangled up in the actual talking of it.   When your patient is a war veteran, sole caretaker of an ill wife, former smoker, artist — and all of those have a bearing on his illness — how exactly do you introduce this guy in a single, non-run-on sentence? (Ok, the run-on part is my latent literature major coming out.)  I know I’ll get better at it over time, just as I got better at taking a history and taking a blood pressure and percussing a lung.  And so I’m glad we’re starting with this now, in our four-person low-key preceptor groups, instead of next year on the wards, when it will actually matter.

I’m finding that medicine, maybe more than most things I’ve done so far, is really about repetition.  You sit in the library and go over your lecture notes over and over until the material becomes so familiar, you forget it’s not common knowledge. You keep talking to patients until the particular type of conversation that is history-taking becomes the most natural thing in the world.  And so it goes with the oral case presentation.  The more you do, the better you get.


Bad news

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.