We saw a physician where we’re rotating yesterday, and it presented a whole other level of uncomfortable challenges to face. My classmates went into her room (we’ll call her Maude) to take an initial history and practice the physical exam, and they were done within three minutes. Maude had a friend visiting, but they only got a few questions in before Maude politely said “It was nice talking with you,” promptly ending the exam. As we’re still preclinical students, and not responsible for Maude’s care just yet, my classmates took it as a sign and said goodbye. (Our preceptor later pointed out to us that you have to press on; you have to know all of the patient’s problems if you want to help them, or see if they’re getting better or worse under your watch.)
When we went back with our preceptor, it was a slightly akward experience. Maude had fallen, and clearly had some neurological deficits (memory and attention problems), and it seemed strange to try to elicit things on the history and physical exam with Maude as a physician–she would know exactly what we were doing. If we had tried to do a mini-mental on her, she’d know what to expect. It’s not that we trick patients on exams, but we do certain tests to try to elicit certain responses to check if things are within the range of normal (whatever that is). Physicians would generally know why we ask patients to sah “Ahh,” or stick out their tongue, or raise their hands above their head.
I didn’t realize how secretive I’ve been interpreting the history and physical until now. With other patients, they don’t generally know why I’m asking certain questions or listening certain places, but with Maude, she may have known exactly what we were doing (with or without the neurologic deficit). Part of it was concern that she’d know if I was doing something wrong, or asking the wrong questions, but part of it was that she could feasibly evade, dodge, and parry. I’ve got to learn to think of the history as getting answers, not revealing secrets or details that patients wouldn’t normally tell me if they knew what I needed to know.
An interesting aside-our preceptor told us to be vigilant when caring for other physicians; it’s easy for either physician or patient to minimize symptoms and disease, as they’re “one of our own.” Physicians are also more likely to be smokers and drug-abusers, lead more stressful lives, and don’t get regular checkups, so their disease may be more severe by the time they present for care. Heal thyself!