Stepping Up To The Plate

Recently, I’ve started shadowing a fantastic geriatrician. In my first blog post, I talked about being more engaged when shadowing as a medical student. Now, we’ve learned how to take an HPI and perform most of the basics of a physical exam, so we actually get to interact with the patients directly to practice these steps. However, I’ve been struggling with the idea that while it’s an honor to be learning in such an amazing teaching hospital, as a first-year medical student I really haven’t learned enough to be of any real help to the patient – I’m just going through the motions of what I learned in class. The real physician comes in right after me and basically re-asks the questions I’ve asked and performs the relevant steps of the physical exam herself. I mean, I understand that this learning step is necessary so that we know enough one day to help our own patients, and that the patients we talk to now gave consent for us to “practice” with them, but these patients are real people, and they’re here right now to see the physician to get real help. I’m just hindering that process without bringing anything to the table.

I was especially anxious about this idea the second time I shadowed the geriatrician (I’ll call her Dr. G). I followed Dr. G into the room and she explained to the patient, Mrs. T, that I was a first-year medical student (“she’s brand new!!”) and that I would be asking her a few questions. Would that be okay?

I remember that Mrs. T’s daughter was also there, and she said, “Oh,” in a way that sounded disappointed to me. I suddenly realized that my first mistake was to follow the physician directly into the room, because it put a kind of pressure on the patient to say “yes” to letting me practice on her, the alternative being that she would have to say “no” to my face. I wanted to back out of the room in case Mrs. T felt uncomfortable that I was there, but it was too late. I just stood there in a white coat that was too big and smiled in a suitably polite way. Look at this brand new, harmless face.

Before we had entered the room, Dr. G had explained to me quickly all the things that had happened to Mrs. T since her last visit here, including an incident of low blood pressure listed in her records.

I could tell right from the start the Mrs. T didn’t want any nonsense. I started off by asking her how her health had been lately (start broadly, I had learned). When asked what brought her in today, she said, “I don’t know, I set up an appointment and you guys asked me to come in today.” That’s fair.

Then I asked her about how they’d told her she had low blood pressure at one point, and how her blood pressure was lately. Any dizziness or fainting recently? At this point, Mrs. T’s daughter cut in. “Her blood pressure? That was so long ago – it must have been at least a year ago! Of course it’s normal now.” Oops. I guess that visit had been longer ago than we had thought.

I continued to ask the questions that I had been taught to ask. “So how has your health been since your last visit? Has anything changed? Anything you might want me to tell Dr. G about?”

Finally, Mrs. T seemed to want to tell me something. “Yes, you see, I get really tired easily from walking or raising my arms now, and it wasn’t happening before.”

I perked up. I knew what to ask next. “Can you describe what you mean? Do you get short of breath?”

“No, it’s not that I can’t breathe, it’s my arms and legs. They get tired, you know, when I walk up some stairs or if I’m trying to comb my hair, like this.” She put her hands behind her head to demonstrate.

Should I press further? If this was her main complaint, I wanted to make sure I understood what she meant. “Okay, so do you feel pain when you do those motions? Do you get sore?”

Mrs. T started to get exasperated. “No, no, it doesn’t hurt, I just get tired.” Then she paused and stared at me, as if realizing that I was rather incompetent. “Haven’t you ever felt tired before?”

I didn’t know what to say. I laughed a little, then cut it short in case she thought I wasn’t taking her seriously. I hurried to explain, “I’m asking all these questions because I want to know exactly what this tiredness is like, so that I can explain it to Dr. G.” In addition to learning how to ask the right questions, we have to learn how to respond appropriately to every comment a patient makes. You have to show that you’re empathetic, without pretending to know how the patient feels (how would you know?), and you have to laugh at all the right times, nod at all the right times, and say “that must be difficult for you” at all the right times.

Anyway, I started struggling to think of what questions I should ask next, without knowing her full medical history and for fear of asking questions that would waste her time. What I should have done was ask about her social surroundings: how things were at home, who she lived with, how her day-to-day life was, if she was able to take all her meds, all things that are extremely important for geriatric patients. But in the end, I left the room after what I felt was too short an amount of time, thanking her for talking to me and promising that I would bring Dr. G with me.

After Dr. G came back in and asked Mrs. T all the questions I had just asked but in a better way, I observed that Mrs. T started opening up more about what other things had been bothering her recently. At the end of the visit, Mrs. T even stood up and hugged Dr. G. I was in awe at how much Dr. G cared about her patients and how much they loved her back. At the same time, I was feeling a little like an extra on a TV show. On your cue, you walk across the screen, maybe do a little something, say a few things, and then off you go. Back to the real show.

Then, Dr. G asked Mrs. T, “Well? How was our student today? Did she treat you okay?” I felt unexpectedly nervous. But Mrs. T turned, opened her arms to me and said “Come on over here!” She hugged me and kissed my cheek, then said, “Every time I come to this hospital, I always feel so welcomed. You all treat me so well.” It’s almost ridiculous that I’m even writing about this because the hug was such a small event and I’m sure it wasn’t an uncommon occurrence. But both Dr. G and Mrs. T will never know how much it meant to me to be included like that. I am part of the team, if only for this afternoon, I thought happily.

What I realized is that even though we’re not even close to the diagnosis and treatment step of the job yet, we still have an important role as first-year medical students. First of all, we represent the hospital system as a whole. If even the students at the bottom of the ladder genuinely care about the patients’ well-being, then it must mean that the entire team is truly invested in their care. If the patient has a bad experience with a medical student, they might leave the session thinking, “I had a bad experience at this hospital today.” We aren’t just background characters in this regard, because we have a real responsibility to present ourselves well.

Second of all, once in a blue moon you get to actually do something for the patient. I can’t tell you how excited I was the most recent time that I was shadowing Dr. G, when one of the patients suddenly turned to look at me directly. “Honey, do you think you could get me a little bit of water? I’m actually quite thirsty right now.” I almost leaped out of my chair in my hurry to oblige. Where had I just read that by the end of medical school, we’ll all be very good at getting patients water? I felt so happy that I was able to do something for the patient while I was there, no matter how small it was. Maybe I shouldn’t mention that I then proceeded to walk back into the wrong patient’s room without knocking and, mortified, had to ask a nurse which room Dr. G was actually in. That’s from my bad sense of direction, which is a whole other story altogether.