Missionary Orthopod in the Making

This week so far has been a painful but helpful reminder of my title for this post. This week I had my Integrative OSCE and my Complete Physicial Exam. The Integrative OSCE is where they have a standardized patient (an actor) who you have to see. They give you a little sheet with their 1) Name 2) Chief Complaint and a clip board with a blank sheet of paper. You are expected to walk in, make the patient feel comfortable, take a good history, and do a focused physical exam all within 20 minutes. Its actually a pretty cool concept. After you are done, you can evaluate your video, and then a bunch of doctors sit with you (and some other classmates) and they go through the basic science concepts that we should have been thinking about as we went through our exam.

When I walked into my patient’s room the lights were off, and the room was pretty dim. My patient was lying on the examination table with her hands over her eyes, not really saying a word. I greeted her and asked her how she was feeling. She told me that she felt terrible. After talking with her I discovered that she had begun to have a terrible frontal headache about 3 day sago. Nothing made it better, but any type of light made it worse. At this point I wasn’t quite sure what she had, but I kept asking questions. When she said that moving her head or neck made it worse lights started to go off in my head pointing to meningitis. After the history was done I proceeded to do the focused neuro exam. I started off with listening to her heart (but not her lungs, which I should have done too). When I started testing each cranial  nerve, skipping a couple of them now that I think of it. I couldn’t really test cranial nerve 11 because it really hurt her to bend her neck side to side, however I definitely forgot to test it by asking her to raise her shoulders. I tried to do a eye exam with the ophthalmoscope, but the light hurt her eyes too much, so I backed off. I tested her reflexes and they were about +1 or +2 (she was a good actor). I tested her gait and she could barely walk without feeling like she would fall. When I finished the exam, she asked me what I thought was wrong with her. I told her I’m not quite sure, but I think she may have meningitis. I told her that a couple of tests, including a possible lumbar puncture would have to be done. I thanked her and then I walked out cause my 20 minutes were up.

As myself, about 6 classmates, and about 3 doctors began our meeting after our exams I started to see how far I was from being any kind of good doctor. First, I realized that I have a serious 1 track mind. When I was writing up my SOAP note after the exam, it was very hard for me to think of what else she could have except meningitis. Now granted, she probably did have meningitis, but the doctors made me realize that she could have had encephalitis, a neck tumor, non-communicating hydrocephalus, and a host of other things. Now I know that I’m still a 2nd year med student, and that my differential diagnosis skills are pretty low because I just don’t know about many diseases yet, but I really felt almost incapable of thinking of other diseases once I had decided on meningitis during my examination. Now my 1 track mind may be great if I get the disease right every time, but what about when I don’t? Anyways, it better to realize my problem now, and work at it.

I also had my Complete Physical Exam this week. This is where me and a partner (another med student) do a complete physical exam on each other within 45 minutes (meaning head to toe except for major orifices). My partner and I had practiced a couple of times and we felt pretty confident about the exam. On the day of the exam I decided to go first since he went first last year. So the doctor evaluating us walks in and I begin my exam. The first part is the vital signs where I am supposed to take his blood pressure. I’ve done this a bunch of times so I take the BP cuff, put it on his arm, find his brachial pulse, and then I begin pumping up the cuff. But every time I started to pump it up, the air would quickly rush out of the cuff. I thought I had forgot to close the hose on the pump, so I closed it, and tried again. Still the air rushed out. I thought that maybe I had turned the knob on the hose to the left instead of to the right, so I turned it to the right this time and started to pump it up. Still the air rushed out. By now I’m getting really flustered. This is the first part of the exam and I’m obviously doing something very wrong. Eventually the doctor gets up and tries it and we realize that the BP cuff has a hole in it. So we changed cuffs and I continued with the exam, however this incident really made me anxious and my confidence started to leave me quickly. Because of my anxiety, I started making stupid mistakes which I corrected after about 10 seconds each time, but they still looked bad. For instance, when I was supposed to be taking his pulse by palpating his radial artery, I started palpating his ulnar artery instead. Or when i was dong his breast exam (yes guys need breast exams too), I did it only in the 4 corners of the breast instead of the whole breast. So yeah, overall the exam was going pretty badly early on, so the doctor stopped me, asked me to speak with her outside the room, and told me that I would need to repeat it. I was pretty devastated at the time; I’ve never had to repeat anything academic in my life. And the worst part is that I knew my stuff more than my partner and he did fine. I felt terrible; I felt like I would never be a good clinician. After about 6 hours I cooled down, and prayed, and the Lord told me something that is obvious but that I really need to hear:

“Doctors are TRAINED not BORN”

The truth of the matter is that yes, my clinical skills are bad. I realized that I had just been going through the motions as I practiced and I hadn’t actually practiced to see if I could “really” feel the popliteal pulse or whether I could really call out the 3 visible waves on the JVP. These are things that I was very weak on, but they are things that I can practice, which is the great thing about medicine. If you aren’t good, you can always get better. I’m sure there is some type of spiritual lesson I can tie into this but I’m very tired and I need to go to bed.