The difficult questions have to be asked in the exam room

As a medical scribe to physicians, I’ve entered over a thousand different exam rooms and listened to a thousand different patients give their unique histories, but the morning of October 28th was quite different.

On this chilly late October morning, I knocked and stepped into the exam room of my very first “patient.”

“Mrs. Laura Williams” was an elderly woman, old enough to be my grandmother, but slightly taller and a lot less lively. Mrs. Williams was a trained standardized patient who was here to be “evaluated” for an ongoing sore throat. Over the last few days, she had also developed a fever and on scene, she was notably tachycardic. She was the first patient with whom I would have the utmost privilege to hone my clinical skills. Or, at least, begin building them.

Perhaps the realization that Mrs. Williams wasn’t a real patient and I wasn’t a real doctor should have eased my nerves, but it didn’t. In fact, I was so nervous that in an effort to let my mind catch up, I indirectly repeated my first few questions multiple times. She must have noticed the repetition, but was far too generous to remind me that I had already asked twice about the duration of her illness.

Instead, she half-smiled politely and told me again that it had been ongoing for three days. As the line of questioning continued, my adrenaline kept surging, and progressively I became more and more aware of the present. And somewhere in the midst of catching up with the moment, I finally noticed the bruise on Mrs. Williams’ upper left chest wall/shoulder area and her kind, but seemingly depressed affect.

In hindsight, vision is always 20/20. This is perhaps when I should have asked my elderly patient about her bruise. But I admit, I didn’t. At the moment, I chalked it up to a discord between her real life events and her role play. Perhaps the bruise wasn’t a part of the standardized patient role; she must have gotten it elsewhere and didn’t wear the appropriate clothing to hide it fully I thought. Or rather, hoped — if I am being honest. However, as the interview progressed, the details kept adding up.

“Mr. Williams” and she had been having financial issues and were fighting a lot, she said.

Still, I didn’t ask about the bruise.

She had an accident, she said. And he had been angry. She had totaled her car, rear-ending a school bus full of children. And her husband “was furious.”

They had “really gotten into it.”

The elephant had finally gotten too big for our small exam room. I asked about the bruise. She gave me one of her characteristic polite half-smiles and stated that it was from the seat belt during the accident. The answer wasn’t fully convincing, but rather than having a very difficult conversation about domestic abuse, home safety, marital strife, and more- admittedly, I accepted her narrative.

I made many mistakes during my first standardized patient experience. I let my nervousness get the best of me in the beginning and repeated myself more than once. I lost track of time and like a MasterChef contestant whose final second has struck, I ended the interview without adding the finishing touches.

But truly, vision is 20/20 in hindsight. Retrospectively, my biggest mistake was my inability to have a rather difficult conversation with my patient, standardized or not.  Knowing that the elderly population is one of the most vulnerable populations to abuse, I should have asked if she was safe at home, as soon as possible, after seeing the bruise. But I didn’t. Instead, we discussed her differential diagnosis and possible treatment.

There is no denying that for many, like myself, who enter the medical profession, it is easier to cut, to splint, to suture, or to treat the apparent physical illnesses than it is to have difficult conversations about the overall well-being of our patients, including, but not limited to emotional, sexual, and/or physical  abuse. Why this is so, I can only guess. It may be because many, if not most, students entering this profession come from supportive and loving homes.

When abuse has never been witnessed or experienced, it is difficult enough to see and understand the signs, much less have an open and honest conversation about it. And even if you could brave the first few questions, there is no guarantee how your patient would react. We hope that they understand that our intentions are in their best interest, but there is the very real possibility that they might not see it that way. What happens then? But perhaps they will understand. And perhaps there was abuse. That is probably the scariest scenario. As future physicians, it is our greatest passion to heal. But how do we truly heal wounds and cuts and trauma that may have no physical remnant?

I don’t have the answers to these questions or the perfect plan for the time I may actually encounter this situation with a real patient. But I did learn one major lesson from my first patient experience — that no matter how difficult, these conversations have to be started.

For now, that will have to be enough. And perhaps with each conversation, we will be one step closer to formulating the right plan. Until then, I am thankful that Mrs. Williams wasn’t a real patient and that her scar was nothing more than blue and purple makeup hues blended so deceptively by skilled hands.

Nazish Malik is a medical student.

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