Monday, August 30, 2010

Human Guinea Pig

Part of Emory's new curriculum is the small group concept, where we are all assigned to a group of 8-10 students who meet with each other and the same faculty member throughout all four of our years here. Right now we meet twice a week for a course called "Becoming a Doctor." (BAD for short.) This is the setting in which we are learning our physical examination skills - so far, we have just practiced on each other, or watched a real doctor examine a real patient, as we did two weeks ago when they brought in a one-month old baby and we learned how to give a well baby exam. And by learn I mean we just watched and cooed at the baby's every move.

In our small groups, we also have assigned readings every week, and we usually have really interesting (and occasionally not-so-interesting) discussions reflecting on the pertinent topic. My roommate derisively refers to this aspect of the new curriculum as our "talking about our feelings" time (she is in her last year of med school, and part of the last class to go through on the old curriculum.) And while there is definitely a bit of truth to that description, I love it, because (a) it isn't science and I don't have to study for it, and (b) I really do agree with and appreciate Emory's effort to design a curriculum that will produce more humanistic physicians, ones with actual people skills and real compassion.

The following is another assigned reading for our BAD course. I'm pretty sure I don't have the right to be reproducing these pieces without permission, but since I am also pretty sure that about two people read this (one of whom is probably my mom - hi mom!), I figure it is fairly harmless. I just think the pieces they have given us to read are pretty good, and maybe you would enjoy them too. The last one I posted made me cry when I read it, but this one I thought was just hilarious.

Originally posted on

Oh, no! I'm the first patient these 23 medical students have ever examined.
By Emily Yoffe

Over the course of three days recently, I had 23 head-to-toe physicals from 23 second-year students at the Georgetown School of Medicine. I was the first person these would-be doctors had ever fully examined on their own. Some were shaking so violently when they approached me with their otoscopes (the pointed device for looking in the ear)that I feared an imminent lobotomy. Some were certain about the location of my organs, but were stymied by the mechanics of my hospital gown and drape. And a few were so polished and confident that they could be dropped midseason into Grey's Anatomy.

Georgetown allowed me to be a "standardized patient", that is, a trained person who is paid $15 an hour to be poked and prodded by inexperienced fingers, so that med students can learn communication and examination skills before they are sicced on actual sick people. In Human Guinea Pig, I try things you might want to do but don't have the time or opportunity. However, even if you had the time or opportunity, you probably wouldn't want to be examined by 23 medical students.

The concept of the standardized patient has been around for decades, but only in recent years have medical schools made training with them a regular part of their curriculum. I talked to a 50-ish physician friend about my experiences, and he said when he was in medical school and it was time for the first rectal/genital exam, the students were told to pair off and examine each other. "So, do you pick someone you like, or someone you don't like?" he recalled. "Either way, it's lose-lose."

Now there are standardized patients trained for genital duty (they're called GUTAs, for genitourinary teaching associates), but I signed up for something less invasive. Mine was the simplest possible assignment. I was to sit on the edge of a padded table in one of those awful, flapping hospital gowns, in a room equipped with recording devices in the ceiling. Each doctor had 30 minutes to conduct a standard head-to-toe physical: from my vital signs, to my nerve function, to my reflexes, etc. Then I was to go to a computer and check off whether they'd done all 45 parts of the exam ("Palpated for fremitus," "Auscultated carotids"), and write my comments on their bedside manner.

There are some obvious things you hope no doctor ever says to you, but on this assignment, I discovered there are a few others:

"I have to admit I have some butterflies."
"I've never felt anyone's liver."
"I'm so sorry! Are you all right?"

I actually was charmed by the students who acknowledged their nervousness, and it was adorable the way most of them would stop after finishing one body part, look upward as if at a floating textbook, mumble some mnemonics, then continue the exam. Before he left the room, Dr. K (although they can't yet call themselves "doctor," I'll call them that here; they're so eager, they deserve it) ran his eyes over me and said, "Let me check if I forgot any major systems. That would be bad." But nervousness in a doctor can be dangerous. Dr. F had a relationship with her instruments that reminded me of Edward Scissorhands. She apologized profusely after stabbing me with the otoscope.

Sometimes it was hard for me not to laugh. Dr. A was so sweetly flustered that in a perfect Chaplinesque slapstick, he would drop his reflex hammer on the floor, bend to pick it up, and then discover that his pen had fallen out of his white coat. Dr. N wasted the first eight minutes of the exam trying repeatedly to get a blood pressure reading. The panic in his eyes seemed to say, "She appears to be alive, yet she has no vital signs." He finally solved the dilemma when he realized he was listening to my arm with the wrong side of the stethoscope. (My blood pressure readings, which require technical skills on the part of the doctor, varied from 87/60 to 125/90.) Sometimes it was hard for the student not to laugh. Shy and mousy Dr. B, after peering into my eyes and ears, said, "Now I have to look up your nose!" and let out an embarrassed snort.

From the moment petite, blond Dr. C came in the room, she took command. Before she started, she briefly told me what the exam consisted of, then explained each procedure before she did it. Her touch was confident, and she did all 45 parts of the exam without hesitation. She asked me to tell her if anything hurt or made me uncomfortable. After she listened to my abdomen and proclaimed, "Good bowel sounds," I felt gratified I was able to please her.

Dr. C made me wonder what it is that makes some people glide elegantly as swans, while others stumble awkwardly as mud hens. My main mud hen was Dr. I. He began poorly by asking me where the recording camera was, then addressed all his findings to it. For example, after I successfully stuck out my tongue, he said to the ceiling, "Patient's cranial nerve No. 12 is intact."

Like many of the students, Dr. I was baffled by how to assess my heart and lung function without breaching the fortress of my bra. Most students, while listening through the stethoscope to my back, simply worked around the bra. But Dr.I informed me he needed to unsnap it (no, he didn't use the one-handed technique). Then he stood in front of me, looked at my gown like a colonel contemplating an incursion, and struck. He peeled off the top of the gown, dropping it into my lap, slipped the bra off my shoulder, and left me hanging while he protractedly listened to my heart. (Dear Male Readers: Doctors don't strip their female patients.)

I sat there, as the tape ran, debating whether to stop the exam. Sure he had on a white jacket and was using a stethoscope, but in reality, Dr. I was no doctor, but just a pimple-faced kid who'd taken off my bra. My pondering was interrupted by an abrupt knock on the door. We looked over, and standing there was the real doctor in charge of the program.

"No breast exam!" she said firmly to Dr. I. He was left sputtering as she closed the door. I redid my bra and put on my gown. Dr. I gamely tried to continue, but he was so shaken he forgot to take my blood pressure, and before he could get to my reflexes, an announcement over the PA said the time was up. He had to put down his hammer like a contestant on Top Chef forced to drop the spatula before plating the side dish.

After every three exams, standardized patients take a break in a private lounge. There were about 20 of us divided into two groups. My group was undergoing the physicals, while a group of older SPs were pretending to have hurt themselves in a fall. Almost all my fellow patients were professional actors who supplement their income by appearing in a repertory circuit at the medical schools of Georgetown, George Washington, and the military's Uniformed Services University. I envied that some really got to exercise their acting chops. One told me she recently portrayed a depressed alcoholic with irritable bowel syndrome who wasn't even supposed to know she was depressed and alcoholic-the medical student was supposed to figure that out.

An older SP had recently been at George Washington, where she had to portray a sex-crazed senior citizen. Her story was that she had been frustrated during her entire marriage because she wanted sex daily, but her husband would only satisfy her weekly or monthly. When he died, she moved to assisted living, where she cut a swath through the remaining men and ended up with a sexually transmitted disease. She says of the students required to take her history, "They were freaking out with embarrassment."

When I went back to my examining table, I tried to think what my reaction would be to my students if they were real doctors and I was a real patient. In response to most I would have thought, "This is disturbing." A few would have made me wonder whether I was in an episode of Punk'd. But a handful were so ready, so ordained to be physicians, that I simply would have been impressed by my young doctor.

Sometimes I got to see their excitement at playing doctor while I played patient. Dr. S, a future McDreamy with a hand in a cast from a rugby collision, moved in close with the ophthalmoscope to examine the fundus (OK, the interior lining) of my eye. Just as we were almost touching he said, "There it is!" with the same delight a sailor would cry out, "Land ho!" Some tried making doctorly conversation. "Have you ever had a physical before?" one asked. I nodded yes, but wanted to add, "Lately, I get one about every half hour."

Finally, I felt privileged to be there at the beginning and help send these healers on their way. So, to you Drs. A through W (even you, Dr. I), I hope your nerves settle down when you examine your patients' nerves, I hope you never get sued for malpractice, and I hope you make a lot of people better and even save some lives.

Saturday, August 28, 2010

Women's Health Training Day

I spent today at school, at a women's health training session, put on by a group of students (mostly second-years) who are starting a new student-run clinic to serve the local population of homeless women. The clinic will open in October, and this training was mostly for students who hope to be able to volunteer there, and also for students who are just interested in women's health issues.

Despite being the large part of a Saturday, it was by far one of the best days I have had here so far. (Interesting that it was not part of the curriculum, nor was it put on in any way by the faculty...) The schedule was packed and fast-moving... we did not have nearly enough time for all the things they had arranged for us to learn. We got to learn pelvic exams, speculum and bi-manual, on simulator models (which are just plastic dummies from the waist down and the mid-thigh up... pretty funny-looking), we learned about STIs and how to identify them by symptom and microscopy, we learned about urinalysis tests and how to read the dipsticks, we talked about how to take a sensitive sexual history and how to identify women with risk factors for abusive relationships, we talked about all the different contraceptive options and why each would be good for different patients, and a few other topics. It was all so interesting and fun. But the best part of the day, for me anyway, was learning how to do a sonogram.

There are three pregnant second-year students who volunteered to come in and let us learn on them. One was 13 weeks along, one was 33 weeks and one was 36 weeks. We had an ER doc and a radiologist helping teach us how to hold the wands correctly and how to orient ourselves to the images onscreen. It was SO amazing... I got to practice doing a sonogram on the 13 wk and the 33 wk, and I was able to find the heartbeat on both of them. The tiny one was just a barely visible little flutter on the screen, right in the middle of the small shape that is starting to vaguely resemble a baby, and in the bigger one, you could actually make out all four chambers of the heart, like in the picture below.

It was literally one of the coolest things I have ever gotten to do, and made me so excited about all the things I get to learn how to do in the very near future. I wish every day could be like today... lectures about basic cell biology and epithelia and early embryology are just not quite as exciting, and I am having serious issues getting motivated to do the reading and studying involved for this unit. Hopefully I will be able to pick it up soon. I hear there are some tests I need to pass before anyone will be letting me do the cool stuff on actual patients for a living. :)

Wednesday, August 25, 2010

[Student] Dr. Baldwin

Last weekend I got to go to Birmingham for Marielle's White Coat ceremony at UAB. It was so much fun to see Martin and Marielle and her family! She has worked so hard to get here... I am really glad that I was able to be there for this event. Just wish they were even closer to Atlanta!

Tuesday, August 24, 2010


Michael D. Burg, MD
Fresno, Calif

JAMA. 2004;292:1935-1936.

I know you’re talking about me. I can hear you in here, in room number 3 near the nurses station. You’re talking about some of the others too but mostly you’re talking about me. There’s "the hip" and "the tweaker with the MI," a "bleed" and "high 5 with PCP." I’ve figured them all out while lying here. The last one gave me the most difficulty but I finally got it: HIV translates to "high 5" as in "high" and the roman numeral 5 combined. PCP is apparently some kind of lung infection. The "high 5" in your medical slang makes it sound like a reason to celebrate but it’s hard to believe that you think an AIDS diagnosis is grounds to throw a party. To hear you all jabber on here there’s plenty more just like them here in the ER, but those are the ones I’ve heard about so far.

I’m the "septic gallbladder." Occasionally one of you calls me just "sepsis" or "the gallbladder." Sometimes my title is "the nursing home patient" or "the old guy" with "septic" or "gallbladder" tacked on like an academic degree. You mix up the terms a bit, maybe to keep your clever chatter interesting to yourselves, but I can tell when you’re referring to me. No doctor has yet to call me "Mr Pruitt" or even "Robert." If you’d asked I’d have told you my friends call me "Pru." "Bob" would have been rude to my way of thinking, but considering the situation now I could hardly take offense. The last people to call me "Mr Pruitt" today were the ambulance drivers and the nurse’s aide I met when I arrived. They could teach you a thing or two about civility.

The first one of you who came to see me made a brief attempt at being the kind of doctor I’m used to. You never did introduce yourself or ask my name or how I was feeling but you got right to business, which I appreciate somewhat. That appreciation went away pretty quick though.

You assumed that because I am old and don’t speak much I must be deaf so you leaned in close and shouted in my ear, bellowing really. Your breath stank of barbequed potato chips and coffee. Don’t you own a toothbrush or some mouthwash? I remember thinking. I didn’t mind the wait while you ate dinner, so another few minutes to clean up wouldn’t have made any difference to me. You seem real busy out there. There’s lots of shouting mixed with the laughter and the jokes that float in to me from the doctors’ and nurses’ work area. But anyway, you did try. I tried too. You asked what hurts and I tried to tell you. I guess my age, my illness, and the Parkinson disease got the best of me. I couldn’t answer fast enough for you so you kind of groaned ("Oh jeez" is what I heard), muttered something like "goner" and "dog lab," and left the room.

You must have checked my medical records because when you came back in you had a medical student trailing you. You seemed to have me all figured out because you started showing him some stuff about me that interested you. You never asked my permission, you just started in doing it. The student seemed kind of ashamed but I knew he was afraid to say anything. He looked so young with his wide eyes, smooth cheeks, neat hair, and freshly pressed short white coat. You could take a few lessons from him about personal grooming.

Now at least I know I have something called cog wheeling and a Murphy’s sign. That second one hurt the first time you did it, but the medical student needed several tries—with your assistance—to get it right. That was nearly unbearable. He looked strong, like a college wrestler or something. He stuck around after you left and asked me lots more questions, but I was so fed up with you and felt so bad that I only answered a few of them. If you’d started off on the right foot, I’d have answered them all. I actually know my medical history right down to medications, hospitalizations, operations, the lot. You couldn’t be bothered to wait for me so forget it. I’ll let you figure it out on your own.

It didn’t used to be this way. Back in my day I could have told you to shove off and made it stick. I was once straight and tall and strong. I spent my life building things, first in construction—bridges, dams, and roads—then as an engineer. I had a family too. I married a sweet girl from my neighborhood and together we raised four boys. Sarah’s gone now but we had 54 great years together. The boys are gone too. Not dead, just moved away, Boston, New York, DC, Baltimore. They’ve got lives of their own. They’d care for me if I let them but I never wanted to leave Los Angeles for the cold of the East Coast. My life is here.

My friends used to be around but they’re long gone as well, either dead and buried or moved. I looked after myself as long as I could but after my fourth fall someone decided I was in too much danger on my own so I got "placed."

What a word, "placed"; it’s like I’m a used part on a storeroom shelf, "placed" there, gathering dust. So now I live in a nursing home. When I got sick and stopped eating they shipped me to your hospital and you’re my ER doctor; we didn’t choose each other; it just happened that way. Time, illness, and the damn Parkinson tremors wore me down; now you’re standing over me with your stinking breath and know-it-all attitude and no-time-for-answers medical so-called care.

You’re smart with the antibiotics and the IVs; I do feel a little stronger, thank you for that. An explanation about why the Tylenol had to be shoved up my rear end would have been nice but since I don’t speak well you guessed the rest of my mind had failed, so you rolled me on my side, no explanation, and did it. My temperature is down and I feel slightly better, but where did you (or did you at all) learn how to treat a human being? How about asking permission for things or giving an old man a chance to answer a few questions?

Keeping your voice down would have been nice too. The shouting in my ear wasn’t the worst of it, although that was bad enough. The discussion you had just outside my door with that nice young medical student about how I might "box" before the surgeons got to me was horrible. I’m not afraid to die; I nearly did once before, but the idea that my life was in your hands scared the hell out of me. You seem smart enough, but where’s your human touch, Doc?

I can’t imagine—and I really hope it’s not true—that all your days are like this. You’ve just forgotten that voices really carry in the ER, especially to those of us who have little to do but listen. What’s off-hand slang or shorthand lingo for you really packs a wallop when it reaches a patient’s ears.

Anyway, I’ve had my life. But I’m wondering: what kind of existence is this for you when you can’t even spend a few extra minutes listening to me or talking to me? I won’t keep you with my personal details; those are my memories anyway. I’ll give you just the facts if you want. I’m pretty weak and not feeling too well, so I’m not much in the mood for reciting a long-winded story. Someday if you’re lucky, somebody will ask you about yours. I hope you’ve got something good to tell so they’ll stay around long enough to hear it.

A Piece of My Mind Section Editor: Roxanne K. Young, Associate Editor.
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