Pimping the patient: Please make it stop

It’s two months into my second year of medical school, and I’m at the clinic, preparing to shadow Dr. Neiland, a primary care physician.

I didn’t want to come here this morning.

Yesterday, one of my preceptors decided that it was my turn to be “pimped.” Pimping, in medical education, is when the preceptor asks you questions until you get one wrong. Then he asks more questions, highlighting your ignorance. Theoretically, this ensures that once he tells you the correct answer, you’ll never forget it. This works for some students, but not for me. I get defensive, and the right answer, whatever it is, goes in one ear and out the other.

I’m still on edge. I considered calling in sick, because I was scared that my jangled nerves might interfere with my ability to function. But here I am.

“This next patient is puzzling,” Dr. Neiland tells me. “She has a high school education, and she’s coherent, but she just can’t stay on top of her medications. We tested her for Alzheimer’s, but that isn’t it. We think she might have a learning disability. We went over her medications with her at the last visit, and that helped, because her labs look good. So today we’ll just check in with her.”

We knock on the exam-room door and enter. Mrs. Slate, who’s in her late seventies, has gray hair, soft eyes, and an easy smile. Her chart mentions high blood pressure and asthma.

“Hi, Mrs. Slate,” Dr. Neiland says, speaking slowly and distinctly. “We’re really proud of you — your blood pressure is right on target! You must be taking your medications. Are you feeling better?”

Mrs. Slate smiles proudly, then looks down shyly. “Yes,” she answers. “I’ve been feeling good.”

“OK, great.” Dr. Neiland takes a seat; I stand off to the side. “I see you brought your medications. Can we go over those again?”

Mrs. Slate hands him a paper bag.

“OK, great.” Dr. Neiland places its contents on the exam table: two inhalers, six small prescription bottles, two wide-brim prescription bottles and a slip of paper.

“What’s this?” he asks, pointing at the paper.

“Oh, that’s my reminder for the appointment today.” Mrs. Slate reaches for the typewritten note, reads it and nods. “Yes, this is my reminder.”

Dr. Neiland nods.

“OK, let’s start with this.” He holds up an inhaler. “How many times do you take this when you use it?”

Mrs. Slate squints at the label.

“I take that …” She pauses to think, then says confidently, “Three times.” She smiles at us.

“Why three times?”

“Because” — she nods — “that’s what I was supposed to do.”

“OK, you’re supposed to prime once, meaning you spray it into the air to get the medication flowing, and then you take it for two breaths. OK? And you do that every day, OK?”

“Oh,” Mrs. Slate responds slowly. “Yes, OK.”

“What about this one?” He holds up a large bottle.

“Oh, that. I take two pills, two times a day.” Her right foot begins to tap the linoleum floor.

“Every day?”

“Yes, every day.”

“Why every day?”

“Oh, because” — Mrs. Slate rolls her eyes — “I thought that was what you told me!” She tisks, then lets out an embarrassed laugh, looking down.

“Well, this one is for pain. You shouldn’t be taking it daily. You only take it when you need it. What about this one?” Dr. Neiland holds up a small bottle.

Mrs. Slate reaches for it, her hand shaking slightly. She opens the bottle, spills a few pills into her palm.

“These” — she nods again — “I take one twice a day.”

“What about this?” As the quiz continues, Mrs. Slate begins to wring her hands. She directs her answers to the floor. Time and again, she gets the details wrong. As Dr. Neiland writes notes on the chart and reminders on the pill bottles, Mrs. Slate smiles weakly, and her foot keeps bouncing against the floor.

I feel like shouting, “She doesn’t have a learning disability! She’s trying! And you’re not teaching her — you’re just making her feel even worse!”

I want to storm out, to make a scene. I want to tell Dr. Neiland just what’s wrong with this approach to patient education. I want to spend an hour with Mrs. Slate, drawing pictures of the pills and spelling out exactly what she needs to take, when and how.

Her eyes meet mine. I give a half-smile, trying to convey my sympathy.

The quiz is over. Mrs. Slate didn’t pass. Packing up the bottles, Dr. Neiland asks, “How have your lungs been?”

“Oh, my lungs.” She shakes her head. “Not good.”

“Didn’t we give you oxygen at home?” Dr. Neiland types something on the computer.

“Yes.” She takes a breath, then continues, “I have oxygen, and I use it when I sleep.”

“How long have you had the tank? Have you ever had a refill?”

“Oh,” Mrs. Slate chuckles, seeming more relaxed. “I’ve had it forever. Maybe a year or two? I haven’t had it refilled, because it’s electric — you just plug it in.”

Dr. Neiland adjusts his stool. I saw my preceptor do this yesterday after one of my responses. I brace myself.

“OK, the oxygen tanks don’t refill themselves. You need to get them replaced. Have you been using it correctly?” He already knows the answer.

Mrs. Slate looks at the ceiling, wringing her hands, then back at the floor.

“Yes,” she says uncertainly. “My daughter and I plug it in, and we turn it up all the way” — she mimes turning up a dial — “and it makes a lot of noise.” Her foot taps faster.

“OK.”

Dr. Neiland looks directly at her.

“I’m going to get someone to come to your house,” he says, speaking quickly. “You aren’t using it correctly, and we need you to use it correctly. Before that, though, I’ll do a quick oxygen check. Wait for the nurse to come back, and we’ll get an O2 sat of you standing, sitting and walking with and without oxygen. This is to see how much oxygen is being delivered to your body. OK?”

“Yes,” Mrs. Slate says, looking confused. “OK.”

This is the same answer I gave to my preceptor. I know what it means: Just make the questions stop.

“Great, wait for the nurse. Thank you, Mrs. Slate, it was nice to see you. Keep up with those medications.”

I follow Dr. Neiland out. We leave Mrs. Slate sitting there holding her medications and turning her reminder sheet over in her hand, her foot still tapping the floor.

I want to go back and hug her, tell her that it will be all right, that I’m on her side — that I appreciate the effort she’s putting into learning her medications and understanding her oxygen tank.

And all the while, I’m asking my own set of questions: Can’t we stop pimping Mrs. Slate? She’s like me — a student struggling to learn the material. There must be a better way to take care of her. What help does she need? Can we make sure that she gets it?

Annie Whetzel is a medical student. This article was originally published in Pulse — voices from the heart of medicine, and is reprinted with permission.

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