By Will Smythe
I pushed open the patient exam room door self-consciously and entered, with the strange feeling that I had somehow just learned how to walk a few seconds earlier. The hard heels of my new dress shoes “clicked” embarrassingly on the tile floor as I cautiously moved forward. Luckily, the patient was seated on the exam table facing away from the door, with her head down – she didn’t seem to notice me yet despite the noise.
I stopped halfway in, and reached up and pulled on my collar. It was moist, and the dress shirt that I had purchased the weekend before for the occasion, the cheapest one at Sears, felt like it was made of unfinished raw canvas, rather than cotton.
This collar is too tight, dammit.
By telling me to go in, it felt as if my proctoring physician had put her high heel on my chest, grabbed my tie (30 year-old vintage psychedelic print – from my late father’s collection) and pulled it tight around my neck right beforehand. It occurred to me that they did something similar to bulls at the rodeo right before they come out of “the chute”, or the little mini-corral in which they are placed right before release into the arena – cinching up a leather band around their hindquarters to piss them off and get them to try to buck the cowboy off.
I had nothing to buck off, but it did feel as if something was sitting squarely and heavily on my back.
Did I tie this damn thing this tight?
I can’t breathe.
I was a second year medical student, and I was about to do my first history and physical exam on an actual patient.
My classmates and I had all been looking forward to this. Finally – a respite from the classroom. We had spent four or more years as undergraduates there, and an additional one as first year medical students, sitting and listening to lecture, after lecture, after lecture… now, finally, a chance to be a “real doctor”.
In the second year curriculum, we spent Tuesday afternoons in local “primary care” clinician’s offices, where we were taught the mechanics of interviewing and examining patients, and organization of our thoughts into written “History and Physical Exams” (H&P’s) which were graded for organization and accuracy – sort of documentation “practice runs” for what we would be placing on patient charts a few years later. As it turned out, like everything else we had been learning, there was a science involved, and by no means an intuitive one, to organizing one’s evaluation and subsequent thoughts about a patient and his or her presentation of some particular disease entity.
No less important, we had been coached that there was an art that had to be mastered in the interaction with the patient – how to approach another vulnerable human being, how to question in a manner that transmitted concern and not just data acquisition, and how to tactfully invade someone’s intimate space, and manually examine his or her body. There was painting, yes, but there were also the technique – the million brushstrokes that made up the final product, and there were colors that had to be carefully mixed on a palette as well, before applying them. It seemed as if there was little intuitive about this – but my intuition did tell me that this latter set of skills would take more time to acquire than the mechanical aspects of the H&P.
Crap…, why does my first one have to be a woman?
We had “practiced” on a few occasions with professional patients, individuals who for pay subject themselves to scripted interviews and all manner of physical examination.
One of the more uncomfortable moments of the first year of medical school was when two young men stood in front of the classroom and dropped their pants. We formed two lines, literally like the local hot dog stand, and did penile and testicular exams. Several in line, namely female students, were unfortunate targets of – “hey ________, are you in line again?” At least the “standardized patient” female pelvic exams that we would do later in the year were performed in a more private setting – I worried about that as I stood in the “hot dog” line, and waited to take my turn.
I walked up to the bedside in the exam room. I hadn’t noticed until now that a man with a clouded expression on his face was standing on the other side of the table, holding the woman’s hand. It wasn’t clear to me whether or not the look was fear, or loathing, but something was wrong. I shrugged it off – there’s always something wrong, or they wouldn’t be here, right?
I also noticed that they both seemed young to be in an internist’s office – all of the patients in the waiting room outside were older.
I glanced down at the chart in my hand, my nervousness impairing my ability to do simple math, such that it took me several uncomfortable seconds to calculate her age from her birth date, and to absorb the other demographic information printed in the corner of the first page.
She’s a twenty-nine year old black female school teacher from Bryan, Texas, I thought to myself – imagining the discussion with my proctor when I finished later, providing her with what we had been told was the classic “five part introduction” with which we were supposed to begin every patient presentation. I also thought that she was pretty, but noted that I probably shouldn’t relay that information as a sixth component.
She was wearing a loose white cotton sleeveless blouse, and blue jeans. Her toes, with red-polished, carefully manicured nails were visible at the end of her brown strappy sandals, her legs dangling off the end of the exam table. She had a shapely, athletic figure. We had been told that we shouldn’t notice whether someone was attractive, or repulsive for that matter. I wondered how many of these exams I would have to do before I didn’t notice.
How do you not notice?
We exchanged pleasantries, and I informed them that I was a “student doctor”. I didn’t tell them that this was my first physical examination, or that I wasn’t actually a “doctor” at all yet. I was anxious about what was about to happen, but I was more concerned that they might turn me away. Thankfully, the fact that I was a student didn’t seem to faze them in the least. The young woman continued to look down. I noticed that the man’s hand, holding hers, was shaking.
I launched, with feigned cheeriness, into the scripted medical student H&P questions I had been taught previously, “so, what brings you to see the doctor?” The woman looked up and over at her husband, and then at me, with what struck me as a blank expression.
“I just don’t feel well,” she replied, “I’m just really tired”.
This became my “Chief Complaint” – the single explanation of why the patient felt that he or she had sought care, and the first piece of information I was supposed to elicit. I wrote this down, and immediately started a “differential diagnosis” in my head…
I wonder if she’s depressed, I thought…, blank expression, head down, monotone voice…, maybe that’s it?
I then launched into the “History” part of the interview. Here I was supposed to try to find out more about the symptoms – how long they had lasted, how severe, how they were characterized, and whether or not they were associated with any other similar, or dissimilar complaints.
I felt good about things so far, I was moving along smoothly, asking everything in the right order. I was relaxing.
“I don’t know”, she replied distantly, “how long I have been tired like this… a long time, I guess.”
There wasn’t much more forthcoming…, she had no associated symptoms, she didn’t know if she had felt like this before, she couldn’t remember whether or not it came on suddenly or slowly – she was just “tired”. I was frustrated. This was going to be hard.
Maybe it was actually depression after all…, we hadn’t learned much about the psychiatric exam yet…, we don’t talk about that until next year…
I decided to move on the “Review of Systems”. This was a series of scripted questions, facilitated by a handy copied chart I had with me, with boxes to check. The review of systems “systematically” (focusing on grouped body systems, for example, the respiratory system – “have you ever had asthma”, “have you coughed up any blood”, “have you been short of breath, etc…”) attempted to solicit additional symptoms or other problems or conditions a patient might have experienced recently, but that they didn’t remember to tell you about, or that they might have felt not associated with the primary reason for coming in. Often, this information would provide clues to the diagnosis that the “History” did not. I went down the list… neurologic – nothing, gastrointestinal – all answers were “no’s”, cardiac – negative, respiratory – nada, gynecologic – nothing, etc., etc… nothing, nothing, nothing.
“I’m just tired, really, that’s all”, she said, once the questions stopped, “none of those things you asked me about are bothering me”.
I said that I understood, hesitated for moment and moved on to the next part of my carefully rehearsed script… “I would like to examine you now, would that be okay?”
“Sure,” she said, laconically.
I had asked the proctor earlier, Dr. Mukhopadyay, if I needed to do a pelvic exam, and she had told me that would not be necessary, noting that the patient had been seen recently by a gynecologist who occupied an office in the same building, but I knew that I would still need to ask the nurse to come into the room when I examined the patient’s breasts. However, I decided to save that for last, as I was worried most about it, and didn’t want to have the nurse watching me the entire time. I had just met the nurse in the clinic, and had no idea what sort of person she was, but I imagined for some reason that she would be behind me, tapping her fingers loudly and impatiently on the metal instrument tray – with pursed lips, and squinty, disapproving eyes.
I asked the patient to change into a cotton gown, and that I would be back in a few minutes.
I walked outside and shut the exam room door to find Dr. Mukhopadyay waiting. She was about sixty years old, and had been a proctor for hundreds of students before me. She was pleasant and seemed to be engaged in this activity, one that obviously added a great deal of inefficiency to her busy day, but was also very matter-of-fact, all business.
She held a sheaf of papers in her hand, and didn’t look up at me when she asked, “so, about to do physical exam?”
“Yes ma’am,” I replied.
“Your differential based on the interview?” she asked, turning pages in her hand, and adjusting her reading glasses.
I fidgeted, and looked down at my notes.
“Well?” she asked again, impatiently.
“I’m not sure, I think she might just be clinically depressed,” I replied, with an obvious lack of confidence.
“Hmmmm,” she said. I sounded and looked like she had a bad taste in her mouth,“that’s a waste basket diagnosis…, did you characterize the complaint?”
“I asked her everything, but she kept saying that she was just tired,” I replied.
“Are there any causes of fatigue that aren’t depression, young man?” she asked, sarcastically. At this point, she looked at me for the first time, over the top of her glasses. She dropped the papers to her side in her right hand, as if exasperated, and placed her left over her mouth. I wanted to know if she was hiding an amused smile, or perhaps her disgust – there was no way to know.
“Uh, yes,” I replied, embarrassed, “lots of them, anemia, chronic infection, neurologic disorders like multiple sclerosis, many others…”
“Better,” she snapped, “go back in and see if you can figure it out. I haven’t seen this patient yet, so let’s see how good you are…” She then turned abruptly, and headed to another exam room, her high heels striking the floor with sharp staccato reports. She didn’t see me shake my head yes. I moved away quickly, before she could come back and grab my tie.
I knocked on my patient’s exam room door, and opened it a crack.
“Are you ready?” I asked.
I walked over and told the patient what I would be doing, starting with a neurologic examination, and “checking her all over” for anything abnormal. She shook her head up and down. I looked over at the man, and he looked back at me. His hands were now in his pockets, but he was standing in the same place.
“I’m sorry,” I said to him, “I didn’t ask earlier if you were related, or if it would be okay with Ms. Smith for you to stay in the room.”
“I’m her husband,” he replied, nervously. His voice sounded shaky as well.
“It’s fine, doctor,” she said.
I put my cheat sheet of the steps required to complete the physical examination down on a table behind me, so that I could turn and look at it if need be, and reached into my pocket to grab my reflex hammer. I was going to start with the neurologic examination, which included tapping the joints to test for reflexes.
Like all other medical students, I had been duped into buying several hundred dollars of “stuff” that I was told I needed to examine patients, and an expensive black leather bag in which to put them – feeling sheepish about carrying the small suitcase-sized bag around, I had stuffed all the things I had purchased into the few pockets of my short white coat – stethoscope, ophthalmoscope with otoscope fittings, tongue depressors, tuning fork, reflex hammer, portable blood pressure cuff, etc., etc… As I fumbled for the various devices in my pockets during the exam, I became aware of how silly it looked, and how all these things “clanged” together whenever I moved. It struck me that I sounded like some sort of medical “tinker” – those people that in the past carried around with them on a rolling cart a load of cooking utensils that needed fixing, all banging together as they traversed bumpily early american cobble-stoned streets, rather than someone that should be working at fixing patients.
After what seemed like several hours, we got through most of it, with me dropping the device I had purchased to look into patient’s ears, the otoscope, on the floor – relieving it temporarily of batteries, and a spring that held them in place. I had to get down on my hands and knees, feeling incredibly professional in the process, to retrieve them from underneath the exam table, and the spring as well – it had miraculously bounded away into a corner ten feet away. Another notable moment was the point at which I was unable to remove the stethoscope from my left ear smoothly, where it dangled for a time, as I grappled with it for several moments as I tried to make small talk – like a garish, techno-fashion earring.
Everything was stone-cold normal, at least to my inexperienced eye. She seemed like a very healthy young woman. It was perplexing.
I began to worry about my next conversation with Dr. Mukopadyay, and remembered with a little spike in my baseline anxiety that it was time for the dreaded breast exam.
“I need to do a breast exam now – to be complete. I’m going to ask the nurse to come in,” I said.
“Okay,” she replied, again, with little emotion.
I opened the door and poked my head into the hallway. The nurse was waiting – she wasn’t a novice either. She ambled down the hall, gave me a tired smile and a nod and came inside. I asked Ms. Smith to lie back and told her that I would examine one breast at a time, again, as I had been taught to do. She lay back on the table, and the nurse grunted at me, as she pulled out the sliding support for the patient’s legs.
“Ya know, she’ll be more comfortable this way,” she said, loud enough to let the woman and her husband know that I would likely never reach her level of compassion or expertise, despite my best efforts over the next several decades.
I gently guided the patient’s left arm up and placed her palm behind her head. I pulled the gown up to the center of her chest to expose her left breast only, and palpated it in concentric circles, starting wide and finishing by examining her nipple for discharge or abnormal thickness – all normal. I moved to repeat the same steps on the right, telling the patient as I moved forward what I was doing, I placed her left hand back by her side, and pulled the gown away from her right breast.
I leaned over, and caught a whiff of something unpleasant.
What’s that smell?
Something was wrong. Her right breast, hidden earlier by her own loose blouse and now by the examination gown, was twice, almost three times the size of the left, and there was a gauze pad covering an area just lateral to the nipple on this side. It had some discolored dried material on it – reddish brown. I lifted the gauze gently off the surface of her breast – there was an open weeping wound, about the size of a golf ball, with heaped up edges, and crusted with dried pus and blood. I reached down and felt of the breast around the wound – rock hard. There was a grapefruit-sized mass in her right breast, and it had eroded through her skin. I was mortified.
I glanced over at her face, and she looked back at me – with no change in her expression. The husband, who had backed away to the wall a few feet away during the breast exam, inched toward the table.
“Something wrong?” he asked. His voice seemed calm, but I could tell it was higher-pitched than before. He had been expecting this.
I looked at the nurse, standing at the end of the table. She looked back at me with both eyebrows arched, and her eyes wide open. My heart was racing. I tried to speak, but my voice didn’t come out right. I cleared my throat.
“Ma’am…, how long has this been here?” I asked.
I gently repeated the positioning step, placing her right palm under her head, her elbow out. When I did so, the mass looked even bigger, and there were several nodular densities that I could see under her skin in her armpit.
Lymph nodes, I posited silently, that’s bad.
She turned her head toward her husband, away from me. “A while”, she replied, “I know I shouldn’t have waited, but I was just too scared…, too scared…”
She started sobbing. Her husband moved in, and took her hand again. He looked down at her, and didn’t look up again. He was breathing hard, his chest moving in and out, and his shoulders up and down, convulsively. I gently covered her right breast back up with the gown, moved her arm back down to her side, and cleared my throat again, trying to seem as calm as possible.
“I’m going to ask Dr. Mukopadyay to come in, okay?” I said in a soft voice, “she’ll be right in.”
Ms. Smith continued sobbing, looking away from me, and her husband didn’t move or answer. I looked at the nurse who nodded to me, and then at the door. I went out and found Dr. Mukopadyay.
“I think you should come in and see her,” I said, “there’s a problem.”
“What problem?” she asked, but didn’t wait to hear my answer, brushing past me to go into the room, the bottom of her lavender sari billowing out beneath her long white coat as she moved. She motioned me to follow.
I sat at the clinic nurse’s desk a couple of hours later, waiting on Dr. Mukopadyay, who had spend a good hour or so with Ms. Smith, and then had made several phone calls to arrange for her to see a surgeon and a medical oncologist. Everyone had left the office except for us. She came over, and plopped down into a chair across the desk from me.
“So sad, so sad…,” she said, wearily. She was looking at the bell on her stethoscope, as if she had never seen it before, rolling it back and forth between her thumb and index finger. Her glasses were pushed up on her forehead, the chain attached to its arms dangling behind her head.
“I have seen this before, this waiting…, this waiting until it’s too late.”
She hesitated for a moment, then continued, “you can turn in your H&P to me, and I will read it later. I’m too tired to discuss this with you right now, to be honest.”
“What will happen to her?” I asked. I thought I knew, but wasn’t sure. “Was that a breast cancer, a tumor?”
“Yes, yes it was,” she said, still not looking up at me, now tapping the bell of the stethoscope gently on the desk in front of her. “I am virtually certain.”
“So, what are her chances, you think?” I asked.
She looked up, and then back down at her stethoscope again, squeezing it tightly in her palm now. The fluorescent lights above glinted off of her glasses as she moved, the chain dangled behind her head. It was very quiet in the office, as everyone had left – the electric wall clock on the wall above her head ticked ominously for several seconds.
“Chances?” she laughed, without smiling, and shook her head from side to side. “Her chances came and went months ago.” She paused for several more clicks of the wall clock, which seemed even louder now, and then took the bell of the stethoscope and whacked it hard, down on the desktop – “BANG!!”…
“It seems like we are too far along for this, we are TOO FAR ALONG for this thing to happen, you know, this THING, this WAITING thing to happen to a woman…, a young…, woman.”
I felt as if I should say something to acknowledge her, but nothing seemed appropriate. I shifted uncomfortably in my chair.
“Now she is dead…, dead,” she added, deflated. She plopped back in her chair, letting the stethoscope fall into her lap, and waved her hand in front of her face, as if to dismiss the entire episode.
She looked back up at me, took her glasses off of her forehead and put them into her large side coat pocket. She took the stethoscope, folded it neatly onto itself, and placed it into the other one.
She closed her eyes and rubbed them with the back of her hand, hard, and asked, “so…, how was your first day as a real doctor?”