I do my clinical training at the VA. It is an interesting population because the people are all pretty similar (this will likely change as the army changes, but for now, its just a lot of old guys, and a lot of heart problems).
In our last few weeks, we finally switched to doing histories and physicals on patients (this really just means that we stopped alternating doing physical exams on each other). Performing an exam on someone you don’t know, and someone older who is in the hospital, is much different to say the least.
The first day that we switched to patients, I did the history and my friend did the physical. Beyond some occasional pauses to ponder whether or not it was appropriate to have the patient do certain tasks (like without really understanding diseases right now could we say with certainty that this patient could sit up without doing more harm than good), my friend made it look easy. Watching her I ran through a mental checklist of what to do and watched happily as she eased from step-to-step and switched from tool-to-tool. My only awkward situation of her day was that I had chosen to sit in a chair near the foot of the bed (we sit with them so it looks like we aren’t in a rush to do the history and makes them more comfortable) and I accidentally caught a view of the man’s “privates” when she lifted up his sheets to check his abdomen. Being first years, we have yet to learn any of the genitalia exams and so to say I was caught off guard is an understatement. I turned red and tried to casually shift my chair more towards his side … all the while thinking “wooooopsie.”
The next week it was my turn. I started by taking his pulse (which he had mentioned was slow) and quickly realized that I get a little nervous and make stupid mistakes under pressure. I counted for 15 seconds and got 12, but then when my tutor (what we call our physician clinical teachers) asked me what his pulse was it was like I was in second grade and couldn’t remember my times tables. I blanked and then I said the completely wrong number. I think it went something like: “What was his pulse,” “umm … around 50 something,” “What number did you count,” “12,” “What is 12 times 4” … (insert grunts in my head for the next few seconds of anger and embarrassment). Unfortunately, math was never my strong suit. I can only hope I do not need to get a mental math tutor to prevent these instances from occurring in the future.
The next thing that I noticed was that for older patients who have difficulty sitting to begin with (if at all), it becomes really important to do all the laying down stuff first and then all the sitting up stuff, as to not have them stand up sit down (fight fight fight). The problem with that, however, is that we learned the exam in body systems for the flow of it, not in sitting/standing/lying down. After my patient had relaxed back down I noticed (once I got to them in the systems check list) that I had forgotten to do reflexes, muscle testing, and many other neurological exam tests that required him to be sitting.
Oops. I also realized, later as feedback from my tutor, that I did a lot of “if that is ok with you” or “if that isn’t bothering you,” instead of just saying sit up and I will listen to your lungs. I blamed this on not having a lot of interactions with elderly men, and not really understanding disease limitations, but really, I think it was just a lot of nerves and awkwardness instead. Another new difficulty with patients that aren’t our classmates, is that we need to be conscious of the gown and the socks and the draping. When we practiced on each other we would come in sports bras and basically just hung out waiting for the other person to listen to our lungs. Yet, for these patients, draping was important, as was de-robing cautiously. We wouldn’t want another accidental peek now would we?
Beyond being bad at math, I often doubt my intellectual capacity as I tend to fail some of the neurological testing myself. When I acted as the patient for my friend I would tend to forget a word or two in the mini mental status exam (I am going to give you three words to remember and ask you to repeat them in 3 minutes), but I thought that was just because I would zone out or something. That was until I asked this patient to remember three words and then, once again in front of my tutor, the patient said “I only remember two,” to which I responded ” it is ok, the other one was …” and then nothing came out. Blank. I was absolutely blank.
In the midst of his laughter and my silly responses in the form of assurance that he must have great mental status if I couldn’t even remember more than him, my friend did the “cough. it was cup. cough.” and I tried to recover the best that I could. However, I felt that I could really just not catch a break. It did not even stop there as if I phrased a question “Can you tell me where we are right now?”, he would respond “yes” … and I felt like I was back in the “May I go to the restroom” versus “Can I” phase of my life. True, when I would change may to can he would actually answer my questions, but I had to strongly fight the urge to respond in some way that would have gotten me thrown out of class when I was in elementary school.
Can I be done with this exam now and go hide my head somewhere?
Jessica Gold is a medical student.
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