When easy familiarity blurs the boundaries

When the patient jokingly touched my nose, I knew I had muddied the boundaries between us too much and it was too late to go back.

(Note: Except for the aforementioned sentence, all of the patient’s details and quotations have been fabricated.  Events from the interview and exam have been drawn from a conglomeration of patients and scrambled to illustrate a general theme.)

It didn’t happen until the end of the interview, but it was not an entirely unsurprising turn of events.

“What can I do you for?” he had asked affably as I entered the room.  The nurse had mentioned that he was a talkative man in good spirits.  I needed someone in good spirits.  He was about to become my body to practice my physical exam skills on, and I wasn’t very good at the physical exam.  Done well, it should take 15 minutes.  Done by me, it would probably take several times that amount as I missed reflexes, shined my penlight in the eyes for an uncomfortably long time, and struggled to remember the order of tests and develop a natural rhythm.

Before entering the man’s room, I asked my tutor, a fourth-year medical student, how long she told patients the interview and physical exam would take.  ”There’s no way I can say something that sounds close to an hour,” I told her, remembering the previous week when a patient told me 30 minutes was too long and I had to haggle my way up to 15.

“I just ask if I can ask him a few questions and do a few easy tests on them,” she said.  I laughed, realizing that avoiding the quantitative would probably be my best bet.  Even though this was a teaching hospital, the patients had no good reason to let second-year students near them.  Unlike the upperclassmen, we weren’t a part of their care.  We could be kicked out of the room at any time, if the patient became bored or tired.  Patients would derive no benefit from the exhaustive interview and physical exam other than the vague satisfaction of helping a fledgling physician-in-training become less fledgling.

So, to get the practice I desperately needed, I needed to make my patient want to help me become less fledgling.  In short, I needed to win my unwitting participant over.

My current 60-year-old patient definitely saw me as fledgling.  He grossly underestimated my age.  (I thanked him for the compliment but told him he was off by several years.)  Then I asked him if I could ask him a few questions about why he was in the hospital, and we were off.

It took about 20 minutes to talk about his current illness and the events leading up to it, his past medical history, his social history, and his family history.  I had done this dozens of times first year, so I felt at ease in making transitions and gathering relevant information.

At this point during first year, we would wrap things up and thank the patient for his time.  But I was just beginning.  I reached for my bag, which was heavy with my tools.  It was time to pull out the opthamoloscope and penlight (for eyes), otoscope (for ears, nose, and throat), tuning fork (for ears and nerves), and reflex hammer.

In addition to sticking devices in and near his orifices and banging away at his knees, ankles, and arms to elicit reflexes, I would have to push and pull at all parts of his body, checking his muscle strength, tone and bulk.  I would have to ask him to follow my finger as I traced an “H” in midair to test his visual fields, to tell me if my metal tuning fork felt cool on his extremities to test for peripheral neuropathy, to swallow as I gripped his throat in a chokehold and tried to feel for an enlarged thyroid, and to stay still as I traced along the bottom of his foot to check for motor disease.

I hoped he would still be in good spirits after I was done with him.

Thankfully, he was.  I wanted to make the experience less tedious in any way I could.  I relied on a sense of humor.  I also periodically tried to convey how much I needed him for practice and how grateful I was for his help. Unfortunately, what couldn’t be hidden with words was fledgling, fledgling, fledgling.

He looked at me warily as I approached his nose with my otoscope tip.  ”Don’t worry,” I told him.  ”You’re not the first person I’ve done this to.”  (He was the second, after all.)

He was happy to help, cheerfully telling me about his newest granddaughter as I poked around inside his nose and tried to see past mounds of nose hair.

I worked my way down his body, complimenting his reflexes and muscle tone.  I laughed at his jokes and bantered with him while I tried to remember each of the eleven cranial nerve tests.  I told him he was being the perfect patient.

I felt comfortable and I felt like I was learning.  I was even having a good time.

At the very end of the exam, I tested his cerebellar function.  Touch your nose and then touch my finger, I directed him, as I moved my finger.  I told him he was doing well as he hit his marks.  Then–probably out of boredom–he decided to touch my nose instead of my finger.

It was such a minor gesture, I doubt he even remembers doing it.  But my face flushed as I realized its significance. A literal boundary had finally been crossed.   Somehow, in the hour we had been together, I had let things decline so that this gesture seemed appropriate and natural for the patient.  How had this happened?

At this point, the exam was over.  He was still cheerful (though exhausted) and had genuinely seemed to enjoy the experience, so I took that as a good sign. I had gotten exactly what I wanted–information and practice in a way palatable to the patient–but I had sacrificed seriousness and stature to get there.  As time passed, the patient had grown increasingly at ease, to the point of informality.  Although I had reacted professionally, I wondered how I could better control the room so I wouldn’t have to be the one reacting.

I acknowledged what I couldn’t change: being young and female.  Then I ran over the 60 minutes in my mind.  Should I have smiled less?  Made fewer retorts to his banter?  Fumbled with the tools less (easier said than done)?  Feigned greater confidence?  Toned down the affability?  I saw the affability as compensation for the fumbling.  If I was going to be the incompetent medical student, then I’d rather be the pleasant incompetent one than the dour incompetent one.  But how to remain pleasant while still being taken seriously?  How to be taken seriously when I couldn’t even make out the eardrum?

I concluded that until I stopped fumbling, authority would be difficult to garner.  And to stop fumbling meant repetition of the tedious on patients with patience.  I wondered who else would decide to touch my nose along the way and how I could stave off the advances while I gained proficiency.

When I applied to medical school, I wrote in my personal statement that I had a knack for being able to quickly gauge my audience and relate to it.  No one could argue that I hadn’t been able to relate to this patient.  But it was precisely this easy familiarity that had blurred the boundaries.

In that room, I made a friend.  Friends touch each other’s noses.  But patients don’t.

Shara Yurkiewicz is a medical student who blogs at This May Hurt a Bit.

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