"Well, given the problems you've mentioned, I'm going to need to do a quick physical exam."
Now that I'm in second year, that's something that I've been able to do, and be confident doing: if a patient presents to me in clinic with an ear/nose/throat issue, a heart or lung problem, a musculoskeletal problem, or an abdominal problem, I'm able to do a focused physical exam before the doctor comes in.
"The doctor will come in and do an exam as well in a few minutes, but for now could you lay on your back and lift up your shirt so I can examine your abdomen please?"
I turned my back to wash my hands as the patient, a friendly, effervescent girl my age, set her backpack down from her lap and hopped up onto the exam table.
She had been explaining that she had been going #2 once every four or five days, and that was "normal" for her, and even though she had been that way for a while she constantly felt abdominal pain and fullness and bloating. So, after asking her a few more questions, I decided to put my new-found gastrointestinal clinical skills to good use and see if I could palpate any abdominal masses or liver enlargement.
I dried my hands, threw the paper towel away, and turned back to the patient. "I'll just start with a general visual inspection before I begin the exam, looking for asymmetry or scars or any abnormalities," I explained,
before I moved on to the hands-on part. Everything looked normal.
"Now, I'm going to do a procedure called percussing your liver, which basically involves me sortof tapping on your stomach. Your liver is a bit behind your rib cage so can I ask you to lift your shirt just a bit more?"
Her shirt was only half exposing her stomach, and in order to percuss the whole liver the shirt usually needs to be lifted up to right where the bottom of the bra is. (On a really good exam the patient would be in a gown and that wouldn't be an issue, but in clinic I'm not going to ask a patient to gown up for an abdominal exam.)
I always feel awkward asking a patient...especially a girl...especially one my age... to remove more clothing, so I try to explain myself really well. As well, despite what I've seen some doctors do, I always try to get the patient to remove their own clothing rather than 'help them out.'
She complied without hesitation, and pulled up her shirt a bit... but when she let go, it fell back down to basically where it was before.
Great, I thought. Now I have to ask her to lift her shirt again. Awkward.
I worked up the courage and asked again. "Um... could you lift it a little bit higher please? Just about an inch or two, just to expose the whole liver."
"Sure!" she replied. She grabbed the bottom edge of her shirt and promptly pulled it ALL THE WAY UP to her neck, revealing her entire chest, pink bra and all.
Call me a prude, or whatever you want, but I had a bit of a minor freak-out.
"Woah.... no, no! It's okay! Not that high!" I exclaimed reflexively. I almost grabbed her shirt and pulled it down.
"Um... Vitum..." she said slowly, almost condescendingly.
"Yeah?" I murmured.
"It's okay...
...You're a doctor."
Up until then I had never before been corrected for being too cautious, and it was a bit of a relief to have a patient remind me that while it is important to be respectful of a patient's privacy, it's also important to be thorough. That's what patients are expecting when they see the doctor, after all.
It's still gonna take some getting used to, though, being able to tell complete strangers to remove their clothing, and while this might not seem like that big a deal I still try to be very careful around issues like this. Hopefully I don't ever get too comfortable, though. And for now, I think I'll try to always err on the side of modesty.
Monday, November 05, 2007
Can't be too careful with physical exams...can I?
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11 readers cool enough to comment:
hee hee, that's kinda cute...
but i agree. it is better to err on the side of modesty.
Vitum, as a female patient I commend your thoughtful concern for a patient's modesty.
Here is a story you might want to read about what "not" to do when encountering a patient for the first time.
I was a surgical patient at a major teaching hospital. After the surgery I had monthly visits with the surgeon (gyn-onc) where a part of the visit included a pelvic exam. For several of the visits, a student came in to start things off, and that included the pelvic exam. (I should add at first I assumed they were doctors because they never volunteered their true hospital status) None of them bothered to learn my name, let alone what my medical situation was. They never came in with my chart, nor were they ever supervised.
Just came in unannounced and in 15 seconds I was asked to get on the exam table. And more than once I had to remind them to draw the privacy curtain.
After 40 years of getting pelvic exams, it didn't take long to figure out that these people were novices. Besides taking 10 times longer to perform, they were really hurting me. When I complained, they said it was my fault for not relaxing. For the first time in my life, a medical person lectured me, and they were 1/3 my age. One of the exams was performed by someone so inexperienced, that once on the table he left the room and brought in a nurse to show him what to do. I actually had these 2 people between my legs whispering to each other, of course I could hear. The nurse literally was guiding him through the procedure step by step. He was sweating at the end.
That was the last straw. I finally complained to the attending, and as I was a private patient, he took over the reins and never sent in a student again.
I'm only telling my story to let you know that most patients would be very understanding with people in training, but just be honest. Once we know we are being deceived, disrespected or patronized in any way, you will lose our trust and cooperation.
good luck, from your blog stories, I feel you will be a very kind doc.
If she's your age, she's a woman. Unless you're a boy?
It's good to err on the side of modesty.
I'm kinda shy with my doctors so it's just better if they tell me what to do.
(Oh. You'll probably be asking who is this? I'm a friend of Xavier's. I'm in the same program as her at the same university. I found your blog off of hers and I am not a stalker :) ).
You are wise to be cautious. But having a female nurse or tech present during these exams might also be prudent. Further, it might keep the "flashes" to a minimum.
I have had many, funny episodes of patients flashing me. It happens. Far funnier (and embarrassing) for me was during peds when I'd have 14-15 yr old girls come in and their moms pulling their daughters' shirts off for rashes, etc. "Show the doctor, honey!" OMG, flashbacks.
Adorable.
Personnally I like a Doctor who tells me what and why they are doing what they are doing. Keep it up you are your way to being a great Doctor.
Chuckled at that one. You were both learning.
I once had severe hives due to a reaction to a med I'd been put on, and went back to the prescribing internist. He wanted to see if there were any spots on my legs, and I told him there were not. It was all upper body.
"Drop your pants."
Notice, not, here's a gown, I'll walk out and see you in a minute, but, "Drop your pants." And I was wearing jeans. Great.
"NOW?!"
"Yeah. Drop your pants!" While he looked on appreciatively? Excuse me? I did what he said--he's the doctor, right?--but I held his eyes tightly with my angry ones, to convey that, dude, if you glance down for one single nanosecond while I do so sir you are toast.
He never overtly apologized, but the next time--and there was only a next time because I'd known him for long enough to know that this was an aberration, why, I don't know, but an aberration--and he was extremely humbled and sorry sounding and circumspect. Good. Otherwise he would never have seen me again. And I have no doubt he knew that.
Like you said patients expect you to do everything you need to do, EVEN if it makes them feel uncomfortable, though it usually doesn't because lifting her shirt isn't a big deal. The big deal is usually everyone ogglings, what it means about her showing her stuff, the perversion, etc....but in this setting those perceptions about it don't exist and I wager it's similar to her lifting her own shirt up in her room. She'd probably take the bra off too if needed it...of course some people are extra why...but I think she was just typical.
Remember, you now have status as a doctor. We trust doctors. I saw a Firefighter Medic in the ER almost start stripping to show a doctor a rash
So nice to hear that Drs in training are human too :) The fact that you are so thoughtful about this and other situations- shows you are going to be a great Dr. Bedside manner; thoughtfulness, consideration, respect, these cannot be truly measured or marked. I just hope there are more of you out there :) Great blog- thx.
I also would like to commend you on your approach to taking care of your patients emotional as well as physical needs. To often in the medical community treat this as routine and secondary causing patients unnesecary anxiety and stress there fore increasing the liklyhood they will not seek attention as quickly as they should. There is are a couple interesting blogs you might be interested in one by a Dr. Joel Sherman under Patient Privacy, and a couple by Dr. Maurice Bernstien one "patient modesty a more significant issue". I know your contribution as a new Dr. would be greatly appreciated...you will have no idea how much your concern will mean to many of your patients. I had such a bad experience during a screening procedure conducted by a nurse, I refused to go back for further diagnostic work. After I stumbled on these blogs and realized I didn't HAVE to do anything I didn't feel comfortable with, I took charge of my care and had the other procedures completed. fortunately it was nothing serious...but it could have been. Good luck and I hope you look at the other blogs, you will see it is an extensive and serious issue.
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