I Like My Patients (and my patients trust me)

Some of my classmates take exquisite pleasure in their ability to diagnose an unusual disease etiology on their Tuesday clinical rounds.  "I diagnosed Chlamydia psittici because I thought to ask about her pets."  Others can't wait to brag about the unusual (and often disturbing) medical sights they saw.  "We saw a guy with a necrotic...gangrenous...penis."

I'm a medical student.  Of course this stuff interests me.  Of course I would be excited if I was able to be the one who recognized the one clue that led you to an alternate (correct) diagnosis, of if I was able to see a really rare, gruesome, interesting disease process.  I admit that.  However, I think I'm different from many of my (more vocal) classmates.  For me, the most interesting and rewarding parts of my Tuesday physical exam hospital rounds are my interactions with the patients.

One of medicine's really big pulls, for me, is the patient interaction.  Science is great, but it's even better when it's science and a unique person with a unique personality and a unique history.  It's not just the disease process, it's how the disease affects the individual's life.  An ulcer is an ulcer, but how does the patient experience it?  Deal with it?  Require help for it?  I've always known that patient interaction was a crucial part of the doctoring process, but I was never really sure how good I'd be at it.  I don't want to make any premature judgments, and I certainly don't want to brag, but I think I've found out the answer:

I like my patients, and my patients trust me.  This has been evident multiple times over the course of our physical exam course, when my patients tend to look to me for a smile or understanding even when my partner is doing the interview or exam, but it's been especially evident over the last two weeks.  Two weeks ago, our patient was a young woman with cellulitis complicated by a deep vein thrombosis.  She was in good spirits despite being in the hospital with an immovably swollen, painful, itchy leg.  We performed a full physical exam, as always, to get practice at it.  She asked a few questions along the way, curious about what we were doing.  "We're listening for the size of your liver," I explained, or, "We're comparing the circulation in your legs."  She reminded me of myself, simply curious and interested in the process.

Last week, our patient was a middle-aged woman with every chronic disease in the book -- what we like to call a "typical Bronx patient."  Asthma, diabetes, emphysema, and some sort of upper respiratory infection that had landed her in the hospital for a few days, but she was friendly and cooperative.  In taking a thorough history, my partner asked about her social history, which included drinking habits.  "Ohhh...I drink a lot, we'll just say that."  How much, my partner wanted to know.  "We'll just leave it at that," she chuckled.

But this is a crucial part of the medical history, so I stepped in.  I knew that patients often feel uncomfortable talking about how much they drink or smoke.  I also knew that it can be hard to quantify sometimes, even if the patient isn't uncomfortable.  I tried to help out.  "How many days do you think you drink?  Almost every day?  A few days a week?"  That was all it took.

She looked at me with a smile in her eyes.  "Oh, pretty much most days, almost every day."

"What do you drink?"  Sometimes it's easier to quantify when directly asked about the type of drinks.

"I love my Coors Light.  I get me those big cans -- not the little ones, but the big 24-ounce ones."  She gestured to show me the size of the can.  "Yeah, the big ones.  I like to have 'em nice and cold."

"How many do you usually drink?" I pressed.

"Oh, maybe 3.  Sometimes 2, sometimes 4.  Depends how I'm feelin'."

Usually when you ask about lifestyle habits, like smoking or drinking, you get a vague answer.  Usually patients don't like to go into detail.  They don't lie, but they don't really want to get into the whole story.  I don't think it's because patients aren't trustworthy, or because they're unwilling to tell the truth.  I think it's because we sometimes simply don't ask the right questions.  All it took was a little understanding and creativity to get an answer that was much more full of details and trust than I needed or expected.

I like that.  I like being able to connect with my patients, knowing that I'm able to excel at the part of medicine that pulled me into it in the first place.  When we were done with the interview and exam, and we were about to leave the room, our patient asked us about our status in school.  She was wondering how far along we were, and how much longer we had.  I explained that we were in our second year, and that the first two years were mostly classroom learning whereas the third and fourth years will be spent in the hospital doing rotations, and that patients like her are our teachers.  She loved that.  She laughed and smiled, and thanked us.  Thanked us?  For poking and prodding her when she was already sick in the hospital?  Yes, thanked us.  Need more proof that we connected?  She remembered my name.  "Take it easy, Michelle!"  I did.  The rest of the day, I was elated.

Skit Night

I know I kind of fell off the face of the planet in the past few weeks.  Sorry about that.  In the meantime, classes have gotten tougher, sleep has diminished, and we've had this little thing that we call Skit Night here at Einstein.  I can almost guarantee that every med school has its own version of Skit Night, a night where students show funny videos, dances, songs, etc. that they've created to parody our lives as medical students.  This year, I was featured in three short "commercials" between some of the longer skits.  Here they are.

Patient Interaction

The first time, I was nervous.  I desperately hoped that my partner, whom I had happened not to have met during our entire first year and a half at medical school, would be excited and ready to do the physical exam, because I sure wasn’t – I was nervous.  We found our patient.  After introducing ourselves to her, I looked at my partner and suggested, somewhat proud of myself for thinking to do it this way, “Should I start with the history, then?”  I would obtain the medical history, and then he would perform the physical exam.  My plan was perfect.

Unfortunately, my plan was not perfect, and he was just as nervous as I was.  “Well, I could do the history, and then maybe you could do the exam…?”  He asked it as a question, but I already knew my plan had failed miserably.

Come on, Michelle, I thought.  You’re in the Air Force.  You can’t wimp out with something as small as this.  You’ve just got to get through it; it will be fine.  I didn’t want to be difficult, and I didn’t want leave my partner hanging on our very first day together.  I acquiesced.  It felt strange to be examining another human being who probably had no idea how little experience we’d had, but I had expected that.  I was nervous, but I got through it.

The second time, I was less nervous.  I was the one obtaining the medical history that time.  I felt completely comfortable talking to my patient, finding out so many details about something so personal as her own body while also establishing a trustful relationship, an easy rapport.  My partner and I talked through the exam, helping out one another.  Of course it didn’t feel natural, but at least it didn’t feel as scary as the first time.

The third time, I was excited.  By then, I was more familiar with the exam, more trusting of my partner, and more confident in my skills.  An hour before, however, I learned that my partner was sick and would not be able to come that week.  My certainty deflated instantly.  Would I be required to do the entire history and exam on my own?  I felt comfortable interacting with a patient alone, but I certainly did not feel ready to perform the physical exam alone.

The third time, then, I was incredibly nervous, but I was determined to do my best.  To say it was easy would be an egregious misstatement.  The patient was not at all talkative, answering most of my questions, even the open-ended ones, in single words or phrases.  His accent and quiet voice made it even more difficult for me to understand and interact with him.  When I had exhausted my mental stockpile of questions, I moved on to the exam with a new rush of nerves.  He knew that I was a student, but at the same time, I did not wish to appear inept.  I tried my hardest to appear as though I had done this sort of thing many times before.  Since he was a chronic liver failure patient, he had seen his share of medical students.  As I performed the exam, he told me about a time he did not feel comfortable with the student.  It did not seem to him that the student knew the right exam procedures.  I paused.  Was he hinting that he didn’t trust me?  I looked him in the eyes.  He went on, “But you – you’re all right.”  Not wanting to violate his trust, I asked his permission before I proceeded with the rest of the exam, to which he replied, “Of course.”

I’ve only participated in the physical examination of three patients, but I’ve learned so much already.  I’ve realized that it is natural and even expected to be nervous for these powerful new experiences.  I’ve also realized that as nervous as I may become, I can do it.  I can establish relationships with patients, and I can work through my own apprehensions to learn the most important skills we’ve been taught in medical school thus far.  Some exams will be more difficult than others, but that’s why I chose medicine.  I wanted to interact with people – people whose disease processes, medical histories, temperaments, and ultimately lives are all different.   I’ve been nervous, but I’ve also been privileged.  I can’t wait to continue to experience the miracle of interaction throughout the rest of my career.