Physical Diagnosis

Medical School: Physical Diagnosis

Humility

The teaching system is structured in such a way that it eases a medical student into the process of doing a patient’s history and physical examination. The student then, although not expected to be brilliant in deducing diagnoses, is at least expected to begin to think about at least one diagnosis that can be isolated to a single major organ system.

We were first required to start with blindfolded examinations of each other; then write down what we felt to be significant findings, only then to suffer the double humiliation of the proctor not only pointing out everything we had missed, but also pointing out all our own personal physical flaws.

The first humiliation, for example, was that we all made gross assumptions that skipped important details.

For example, most of the medical students did not even first state the gender of the person. This was followed by our omissions of simple facts such as the fellow student we had just examined might be wearing glasses, had a beard, or wore earrings.

All of this underscored a basic tenet in medicine that one should never overlook the obvious and also that one should never assume anything.

When I began my first presentation of an examination of a fellow student, I was stopped after the first sentence.

  • So, first of all, was the person a male or a female? Even blindfolded you can tell if a person has breasts, or buttocks, or a penis or not.
  • Well, yes but….
  • Then why didn’t you first say that the person you were examining was a female? There are many important medical issues that depend entirely upon gender you know.
  • Uh, yes but…I didn’t think I should…I mean she’s a fellow student. Wouldn’t she object to being groped?
  • But nothing and grope nothing. This is an objective clinical exercise, not a course in sexual harassment. So just because you might be embarrassed about this means you can sit there and tell me that someday you might miss a breast cancer? The medical examination of the breast is entirely clinical and is not the equivalent of fondling. At least it had better not be.

When I told my mother about this experience she shrugged it off as being nothing that should bother me too much. She trivialized it as she reminded me that her near-sighted brother Bobby had also learned his physical anatomy by the Braille method, albeit at night in the back seat of a car, yet never once seemed to have any problems with gender identification. She said:

  • Forget the tits. That’s how your Uncle Bobby discovered that women have three holes.

The second humiliation came with the fact that all of us then had our own physical imperfections glaringly pointed out to us; dermal scars, a murmur, a curved spine, acne, a sloped shoulder, a missing pulse, an old fracture, crooked teeth, glasses, or braces; you name it. The worst part about it was that we were all only about 21 years old. By the time the proctor was through with me I thought I was should just cash it in and apply for the job of being a cadaver for the class of 1974.

It was the beginning of a lifetime dedicated to thinking morbidly of even the slightest personal ailment, a thought that unfortunately played back into my mother’s perverse tendency to always look for the worst in people.

Noticing all the things wrong with someone or painting worst-case scenarios for diagnostic outcomes does not make for an optimistic outlook on life. By the same token, it does also constantly remind one that life is indeed very short. This thinking can either work beneficially by making one always try to live in the moment or it can backfire by incubating a ridiculous urge to live life to extremes.

In my case, it did not take more than a few clinical deathbeds prompts to instill a desire to do everything I wanted while I was still young.

I did, in fact, try more than few risky ventures or at least  stupidly , attempting some of them twice; like scuba diving the 130-foot-deep Maracaibo reef in Cozumel with no prior experience, scuba diving an ocean inlet on an outgoing tide, sailing and tipping over a Hobie Cat in a full October gale without a wet suit in 60-degree water, taking psychedelic drugs; smoking hashish, trying cocaine or more than once,  then when I became a House Office, attempting to screw every nurse in sight, without condoms. Damn the V.D. Full speed ahead and fire all the torpedoes.

The second phase of Physical Diagnosis comes in learning to logically format and to then scribe all the elements of a comprehensive approach to diagnosis; Age, Gender identification, Vocation (or not), Chief complaint, Past Significant Medical History, History of Present Illness, List of Medications, Social History, Family History, Surgical History, Allergies, Review of Systems, Physical Examination, Differential Diagnosis, Plan for Diagnostic Testing, and Therapy.

Then one must write a set of Orders to be carried out the actual implementation of the Diagnostic preposition and Care Plan.

At the end of this process I realized I had watched too many doctor shows on television because this was nothing at all like the relatively easy, carefree approach to medicine enjoyed by the likes of Dr. Kildare. It was also not even close to the equally irrelevant focus the actors had on each other, but not on their patients, in the complicated soap opera lives enjoyed by the likes of the cast on General Hospital.

These people spent all their time perusing sex when they weren’t screwing over all their other friends or relatives physically, emotionally or financially; but somehow never seemed to get down to the real business at hand: like taking vital signs and emptying bedpans.

  • Doctor. Your patient in Room 3 has a fever.
  • What was the exact temperature, nurse?
  • I don’t know doctor. But not as high as the hots I have for you.

Nothing at all like that, this new aspect of Medical School, being very difficult, was the first time I doubted my vocation. Unfortunately, it would only be the first of many self-doubting or soul-searching episodes as little did I know how bad things could ultimately be or how humiliating things were about to become.

First, when doing any clinical rotations, the student is expected to wear a shirt and tie, put on a short white jacket that designates the inferior rank of neophyte, as opposed to the long white coat that comes only when rising to the rank of an Attending Physician. One also then must carry around about twenty pounds of ancillary tools in a little black bag, or in the coat pockets of the white jacket, including a stethoscope, ophthalmoscope, reflex hammers, tuning forks, note pads, pens, calipers, EKG rulers and of course the Little Red Book.

I felt like a G.I. going off to battle or as uncomfortable as I was at any time I ever had to put on a tuxedo.

If I had ever thought a Cub Scout uniform was bad, having to dress like a cross between a Bus Boy and a Good Humor Man was nauseatingly stilted and made me feel as though I would be infinitely better off instead standing stiff legged still in front of a drill Sergeant. with a little round wooden dowel shoved up my rear end. Cinch tied like a wild bucking bronco under his first heavy saddle; and saddened by the reality of having to ditch my soft comfortable hippie togs for a suit that made me look like a fumigator, off I trudged to the hallowed halls of the hospital wards.

My first real test in clinical medicine was being rotated to a hospital to examine a patient with liver failure, after which I wrote up the findings per protocol and then presented the case to a proctor in front of a group of five other students.

I thought I had done a pretty good job. The proctor however, did not.

My paper was a monument to how much red ink can actually be held in a ballpoint cartridge and how close a graded paper can come to being a Jackson Pollock masterpiece. I had missed just about everything pertinent: spider angiomas, everted navel, ascitic fluid, liver size in centimeters, rhinophyma, etc.

Then to make matters worse, when I attempted a verbal defense in front of my fellow students, the proctor jumped down my throat like that drill Sergeant would have done anyway, as he proceeded to rip me a brand-new asshole.

If I ever did have that little plug up my butt, this was when it would have hit the ground with a hollow empty thud as my knees turned to jelly and sphincter tone suddenly failed.

He said:

  • Do you know who I am? Do you know who I am? You don’t even know who I am, do you? Well let me tell you, then. I am Dr. Frank Iber, and I am a full Professor of Medicine at Tufts University Medical School. So, when I speak or when I critique; you will remain silent and do nothing but listen and learn. Your examination of that patient was a disgraceful example of incompetence. As such, we shall now proceed to go back to show both you and your fellow students how superficially incompetent your evaluation really was. And when we are all done with that, you will take your paper back home, then you will re-write it, after which you will also memorize the section in DeGowan on all the signs of liver disease for a verbal quiz, which I will administer at my personal discretion.And so, we did. And so, I did. And so, he did.Bad enough I got the proctor with the bad temper and the inflated ego, but he also happened to be a national expert in Gastrointestinal Diseases who also wrote the textbook section on “The Liver.” I guess then this rotation was both the bait and the trap, eh?

    It was stupid of me to have been mollified into assuming everyone was like the jocular, philosophical proctor who taught us all to be HIPPAYs. In retrospect, I guess that professor, with his pleasant affect and his all- forgiving non-offensive mentoring personality must have been a Psychiatrist.

    To make matters worse, I really did not know who Dr. Iber was until I looked him up in the school directory, and thus learned a painful lesson about the mysterious hierarchies of the world of Medicine. Some people are, in fact, more important than others and obviously not ashamed to let you know it. Doing background research ahead of time, if nothing else, could have at least ensured me a few ingratiating brownie points.

    I was hurt, humiliated, embarrassed, demoralized, angry, and ready to quit school. However, Michael propped up my badly bruised ego, having encouraged me by the reassurance that everyone goes through it, and that after the first time it can only get better.

    It was just another game that had its own set of rules, with a peculiar set of standards that had to be learned; such as the correct timing for self effacing groveling or the tossing of dust on and over ones bowed, scraping head. Once you know the rules, it becomes infinitely easier to play the game.

    I was not so sure, but then again, the alternative would have been meeting a real U.S. Army Drill Sergeant and having to trade in my Little Red Book for a Big Brown Duffle Bag along with a one-way ticket to Southeast Asia.

    It did take a while, but I got over it and I did improve.

    My roommate Michael said it was just like learning to drive. Scary at first, and you might hopefully have only a few minor accidents, or get a few tickets, but after you get the hang of it and learn to play the game, it’s just as easy as learning anything else.

    But to me the length and breadth of medical knowledge seemed as insurmountable as a successful climb to the peak of Mount Everest; even with the added benefit of having some extra oxygen canisters on board.

    Michael also helped with the proactive part of things by proceeding thereafter to point out the best clinical rotations to take in the third year of school as well as the pitfalls of each one, the peculiarities of the proctors, the nice ones, the mean-spirited ones along with all the important signs, symptoms, facts, or trick questions to anticipate as each one came along.

    When you come to think of it, the scary thing is that in just over twenty-two months of clinical training, the Medical student goes from the floundering, blubbering naive state I found myself under the hawkish scrutiny of Dr. Iber, to becoming an Intern in a hospital where he or she has the responsibility of making decisions that can mean the difference between life or death.

    Because Internships begin in the summer, there is an insider’s facetious mantra in all the academic medical training programs that is unknown and secreted from the general public:             “Just don’t ever get sick in July”

    The failsafe here is that the rigid pecking order ensures constant supervision at every level. The Attending supervises the Fellows and the Residents; then the Fellows and the Residents supervise the Interns.

    But Interns will always at times find themselves in situations in which the decision to be made must be expeditious and solely his own responsibility. That is when the “Yell for help” becomes the credo of not only the real neophyte; but also of everyone else in the teaching hierarchy.

    Then the more he is exposed to disease, dilemmas and disasters, the better trained the physician becomes as he slowly rises to the top of the medical food chain and finally gets to wear that long white coat: Full Attending Physician or Professor of Medicine.

    One thing I came to learn for sure was that there is no shame in admitting “I just don’t know” because in Medicine when pride supersedes humility the unintended consequences might be permanent harm or even death. No one in medicine knows everything. But everyone does know something.

    And just as is it at the highest levels of any professional performance, there is always someone who is better at something than anyone else is.

    Even Tiger Woods could lose and eventually every icon becomes old, tarnished or simply out of date. Just ask Jack Nicklaus what he thinks about that.

    At least I got the drift that when finally getting to the top of this academic world, I could still reserve the right to be somewhat nice or pleasant about it; and also learned that compassionate constructive criticism was probably a better way to teach a subordinate than abject self-promoting narcissism.

     

     

     

    Ask and it shall be given unto you

    Seek and you shall find

    There is assurance of salvation

    And blessings when you knock

    (The Bible. Hebrews 11:6)

     

     

         Jesus:  http://www.carmelwagga.org.au

     

     

     

 

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Medical School: Year Two

Clinical Exposure

Physical Diagnosis is a medical school course that overlaps the conclusion of basic sciences and is given at the end of the second year.

Students are required to buy the “Bible of Physical Signs” other wise aptly known as: Physical Diagnosis, a little red leather covered book by DeGowan and DeGowan, which they are then told to memorize and carry with them in their little black leather bags for the rest of their lives. Memorizing it is easier said than done. After all, it is a Bible and if the Bible itself is all you must memorize, then perhaps over a lifetime you might become successful at regurgitating it.

Just ask Billy Graham, or any other Bible toting evangelist. Pose a question. Receive a parable in return. No real thought required. Problem solved. Or problem only temporarily shelved:

  • Go in peace my son; I know that your life really sucks, but keep praying to God for eternal salvation. Things might seem to be bad right now, but ultimately, they can only get better.
  • But that’s the same thing my stockbroker told me when I lost all my money. Twice.
  • My son. Do not ever confuse the secular world of monetary greed with the promise of joyous everlasting life in the next world.

Unfortunately for physicians, we must memorize a few dozen Bibles, as the solutions to our problems can often be so obscure that even invoking the name of God does not always result in a comforting resolution.

  • After this terminally ill patient finally does rest in peace, we’ll say perpetual Novenas to the Gods of Malpractice that we never get sued.

There is a rigorous approach to the Physical Diagnosis course stressing the basic elements of abnormal physical findings that my instructor boiled down to what he thought would be a jocular contemporary mnemonic to assist us getting through it: HIPPAY; which stands for History, Inspection, Percussion, Palpation, And…. Yell for help!

He thought he was being funny. We thought he was being idiotically insulting. After all, we were the nuclear radiated mutant hippie class, were we not, so why keep rubbing it in?

Medicine is replete with mnemonics that are designed to prompt memory and remain useful cues if they are appropriately applied; but not like the singsong one traditionally used to teach children the alphabet. It took my mother quite some time to force my understanding that LMNOP (ele-mena-pee) does not stand for one single letter or a single-minded desire to evacuate the bladder.

This point illustrates that in learning anything, Rote is not necessarily equivalent to Right, unless logical thought processes use the Rote in the Right way.

For example, using MOST DAMP as the mnemonic cue used to treat the internal drowning of congestive heart failure has a rational application, if it is used with a certain clinical panache. If not overzealousness automatic use of all of these elements may sometimes do more harm than good. Sometimes you only need M&Ms to treat heart failure: a little Merck (Lasix) and a few drams of Morphine.

This was only one of the reasons God invented narcotics and why a leading research Cardiologist at the Columbia–Presbyterian Hospital orientation program gives his first-year Fellows a button to wear on their white coats that reads: Lasix kills. This teaching point being not to treat every patient with a cook-book recipe as opposed to an analytical thought process with subsequent careful medical titration.

P: for Phlebotomy did not even work out very well; when in the Middle Ages leaches were used to bleed patients half to death, having subsequently been abandoned as an ancillary therapy for heart failure.

  • Yes. Once we leach out all his malodorous phlegmons, your husband will hardly be able to speak, much less ever be able to stand up or possibly even walk again. But he will be better.
  • Thank you doctor. I’ve been trying to get him to shut up, sit still and stop chasing after my ass for the last thirty years. I’ll be sure to remember you in his Will.

Mnemonic learning is also helpful in medical training because the body of medical knowledge is so overwhelming. But this method eventually becomes abandoned as clinical experience adds a base of reality testing to rote learning.

Yelling for help is always sound advice for the same reason. One cannot possibly remember everything and so asking a colleague for a consultation or advice or personally consulting text and literature can often be vital. Unfortunately, some egocentric doctors seem to forget this tenet; or worse they sometimes forget that they forgot.

It was amazing as my career in medicine moved along, as to how many colleagues seem to have forgotten that the story a patient tells is about seventy-five percent of the diagnostic battle, the physical exam adds another fifteen percent; and with a good synthesis of both, a seasoned clinician can then direct a limited number of lab tests that should hopefully finish off the job.

That is unless the disease entity is so obscure as to baffle even the best minds, which is why we have places like the Mayo Clinic or other Meccas of academic excellence. When in real doubt: Punt.

It is also unfortunate that many physicians do not care to take the time to listen or do not know how to peel back the onion-skin of the patient’s story to get to the core of the problem. This is a skill that takes years of practice to develop and even more years of practice to ensure that it can be done in a short framework of time.

For the most part, physicians do not have the luxury of the infinite amount of time that Marcus Welby seemed to have when as week after week, not only did he have only one patient to attend, but also found himself purposefully inserting himself into that patient’s personal life and then becoming the family’s best friend.

Better than having a family dog, just go out and get your own personal M.D. and although in real life it simply does not go down like that, some of my patients still think nothing of having me entertain their queries while I am shopping for food or practicing putting.

  • Doctah, doctah. I know you’re relaxing on your day off, but do you think you can take just one tiny little minute to take one eensy little peek at my teensy little new skin rash?
  • Oy vey. As you know, I am not a Dermatologist. But if I were going to guess, it looks to me like it might be case of genital herpes. So, you can put your clothes back on now, then go ahead and pay for your groceries.

Shortcutting the non-essentials is also critical to saving time. For example, when seeing a patient and asking when the chest pain problem first started, one is not interested in retorts that catalogue every action the patient did from birth or tedious monotonous histories such as:

  • I woke up today at 5 a.m. I usually wake up at 4:50 a.m. I knew right then I was in for trouble. Then I had a bagel for breakfast. That’s not what I normally eat. Normally I eat granola and yogurt. Then my coffee pot broke and I need my coffee and my normal food so that I can have my normal bowel movement. If I don’t get my normal bowel movement I know my entire day will be off and I will just be logy and tired and miserable all afternoon or maybe even have to take a nap even though I really don’t want to. So, against my better judgment I gave in and had a Sanka. Then when I finally had my bowel movement, later than I usually like to have it, it wasn’t like the normal one. Usually it is short, fat, tubular, dark and brown, then breaks into pieces and sinks to the bottom of the bowl. This one was long, thin, light and yellowish; about 18 inches total, stayed all in one piece and floated. That was when I knew I was really going to be in for a bad day. So, then I had to get dressed when I normally don’t get dressed and….

Prattling on and on and having nothing to do with the fact that this person is being evaluated for the new onset of chest pain; it took me years of experience to learn how to re-direct a patient’s thought process and expedite getting quickly to the point without being undiplomatic or making the patient feel as though I was rushing them.

  • Why don’t you just think about what’s happening in your case as being bad constipation in your coronary arteries. Now tell me about your chest pain.

Unlike the legal system, in which time, like a running taxi meter is endless, where time also then equates to  money, and additionally where the truth can be hopelessly perverted, ignored or purposefully obfuscated, in Medicine time is of the essence, money is discounted and the truth is the vitally important element that can mean the difference between life or death. I came to believe that the universally appropriate gift for a Law School graduate should be a tie tack shaped as the Infinity Sign.

After all: Time is infinite. And legal time means infinite money.

 

(Reminds me a little bit of the 3-Cs (prior post: Cornflakes, Coffee, and Cunnilingus). Except that now everyone is getting fucked, but no one is getting laid)

As a countervailing issue, in the modern era of medicine there is often too much reliance on the shotgun approach to lab or procedural testing, while too little emphasis is placed on basic logical thinking. Accessibility and availability of advanced technology as well as excessive malpractice litigation has sent the cost of medical care through the roof.

With the fear of the Medical Malpractice legal vultures always circling overhead; on wisps of doubt, as well as the fact that it does not cost a physician anything to order a test, we are now living in the era of medical errors of commission. Lawyers have taught us that if one can think of a test to do, one should simply do it. Meanwhile as always viewing issues from the perspective of Monday morning quarterbacking and self-righteous hindsight they constantly feed off the carrion of imperfect outcomes.

When asked to see some patients in consultation, where the requesting physician has omitted many elements of basic training, including a good history and physical examination as well as a dearth of logic or common sense having been applied to a morass of useless information, I rely on an axiomatic statement taught me by an attending physician who supervised us during those first years of training in physical diagnosis:

  • Ladies and Gentlemen, when all else fails, why don’t we just begin by examining the patient?

However, there is a certain degree of psychic trauma that accompanies the beginning clinical training as the second-year medical student leaves basic book learning behind.

This is a Right of Passage in which rote memorization does not help unless facts can be synthesized, in which introverted, socially isolated intellects actually have to meet, touch and talk to real people disadvantaged by illness and where quantitative analysis breaks down at the level of qualitative evaluation.

It is a time when multiple choice test questions become replaced by a differential diagnosis and when a patient may face the additional problem of dealing with multiple concurrent illnesses. Guessing wrong on this test runs a gamut of far different potentially negative results than only receiving a poor numerical grade.

  • Oops, sorry, it was a really a heart attack and not just a bad case of indigestion.

It is a time when deductive reasoning reigns supreme; but also, when a naïve student begins to develop a personal inventory of logic that only comes with continued experience and clinical exposure. The patient becomes a book that has a limitless number of pages, but a book that also does not have an index or chapter headings.

Every patient becomes a new black box. The student then must logically deduce what is potentially wrong with a person who cannot necessarily explain it well and who may also be covered with dirt, crust, scales, rashes, odors or sometimes even with insects. One also must be able to do it expeditiously; without regard to race, color, creed, personality, sexual identity or personal bias, and preconceptions; not even withstanding the deeper layers of the physical exam than can include a rectal or vaginal probe, or both.

It is a time when the art and science of medicine is a blank palette in a student’s hand and is also a time where the cornerstone of the Hippocratic oath is placed in the foundation of the medical student’s career. But as  with any potential building, some cornerstones and some foundations turn out to be more solid than others.

Being shyly xenophobic to begin with and since I had never even wanted to speak to strangers; much less then even having to touch them, I struggled to overcome the barriers I needed to expeditiously become superficially intimate with perfect strangers in a short period of time.

Medical training requires the ability to become intimate while at the same time maintaining a certain professional barrier that should preclude becoming friends. Because once a doctor truly befriends his patient, he tends to lose the ability to think objectively and thus the serious potential pitfall to provide a disservice.

One of the great failures of medical training programs and a disservice to humanity in general is to guide or to allow the student, Intern, or Resident to enter medical disciplines that do not suit any or all of his individual talents, his personality, or his individual skill sets; as well as failing to inform some of these individuals that they should seek career choices in another discipline altogether.

  • Son. Surgery is not your forte. But you are good with a knife, so you might want to consider a career as a butcher.

It is very hard to do this after a student has come so far and for so very long. But similarly, the mustard of medicine is often very difficult to cut and not every student really gets truly seasoned by the time he graduates.

Some physicians I know who did make it all the way through, unfortunately should have never even been allowed to lay a hand or a scalpel on a cadaver; much less to later lay either of these two tools upon the body or flesh of a live human being.

 

 

Swedish Aphorism

Vhere iss Yorgay?

Yorgay is in da bootcher shop practicin’ to be a doctor.

Vhere den iss Svengay?

Svengay is in da medical school practicin’ to be a bootcher.

Und vhere might den be Ingrid?

Ingrid is in da haystack practicin’ to be  a nurse

(Swedish Aphorism/courtesy of Michael)