Monday, November 05, 2007

Can't be too careful with physical exams...can I?

"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.


frylime said...

hee hee, that's kinda cute...

but i agree. it is better to err on the side of modesty.

Anonymous said...

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.

Anonymous said...

If she's your age, she's a woman. Unless you're a boy?

jysika said...

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 :) ).

DrWes said...

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.

incidental findings said...

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.

Anonymous said...


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.

Anonymous said...

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.


"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.

Anonymous said...

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

Anonymous said...

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.

Anonymous said...

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 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.

MER said...

I see that these comments are almost a year old. I post with the hope that you're still checking.

I, as others, praise you for regarding modesty as a valid issue. I notice that the new generation of doctors and nurses seem more open to even discussing this.

Now that a year has gone by, I'd be interested in knowing if you've become more comfortable with modesty issues during physical exams and procedures. And -- what techniques do you use to assure patients make them feel more comfortable.

Also, from a psychological/sociological point of view, I find it intersting that your above post is a male medical student's perspective regarding examining a female. I've read few posts like this from female students doing exams for males, but the research I've found suggests that both male and female doctors, generally, feel more comfortable examining same gender. And, they spend more time with their own gender during exams. I'm not suggesting that doctors shouldn't examine opposite genders -- I'm just interested in how they handle the modesty issue, especially if a patient really resists and there isn't another doctor available.

Maybe you've discussed these issues more in a later post, or, as one person suggested, posted some observation on Bernstein's or Sherman's blog.

If you're still around reading old posts, let me know where you are now on this issue.

Again, thanks for you concern and your willingness to bring up subjects like this.

Anonymous said...

It just goes to show you can't be too careful

Anonymous said...

I think American doctors need to be very careful if they ever choose to practice overseas. I saw the comment made by the 40 year old woman that implied she was a veteran of the pelvic exam. I'm also aware from my American colleagues that womens medicine is not evidence based in the States and women are pressured from their teens to have routine and very invasive annual gyn exams, including the use of stirrups.
I also know doctors routinely deny women access to the Pill until they agree to gyn exams that are not medically required for the safe use of the Pill. (or anything else)
This amounts to coercion and negates any consent. The only exam required for the Pill is a blood pressure check.
All of the gyn exam is not evidence based - they are of no proven clinical benefit, but there is evidence they are harmful. (further unnecessary diagnostic work-up, even surgery)
The smear test is a cancer screening test that has risks and benefits and informed consent is a legal requirement of testing. Only the individual woman can say that the benefits exceed the risks or vice versa.
The test helps a small number of women, but should never be used before 25 or even 30 and never more often than 3 or 5 yearly. The States has the highest number of excessive colposcopies/biopsies in the world due to inappropriate and excessive testing. Some women end up with mental or physical problems as a result.
My friend's mother who lives in New York has had more than 55 smears in her lifetime and this useless and harmful excess continues at age 70!
The most pap smears any woman would have in my country (including very high risk women) would be 5 to 7 in her lifetime.

Routine gyn exams are NOT recommended in many countries and if a Dr even suggested it to me (when I'm asymptomatic) I'd assume s/he was some sort of pervert or totally insane, leave and call the Police.
At 45 I've never had a routine breast, pelvic or rectal exam - never. My Dr also assessed my risk of cervical cancer and as a result of my very low risk, I declined smears - far too many false positives and unnecessary treatments and biopsies to cover my risk. (which is near zero)
Even with responsible testing somewhere between 30% and 55% of women will be referred for work-up. (most for false positives) Whereas 95% of your women are assured of follow-up due to excessive testing.
The excess in your system is harmful.
I also think it shows huge disrespect to women.
No wonder your women have 600,000 hysterectomies every year, the highest number in the world. (by miles)
All of my US colleagues now receive evidence based health care in Europe, Australia or HK and rarely see American doctors.
If you're actually sick, you have some of the best doctors in the world, but if you're well, stay away!

Anonymous said...

I agree with the last poster.
I was amazed to find around 60% of women in my Uni class have already had some sort of treatment for an abnormal pap smear. I think there must be few women left in the States with an intact cervix. Most have been tested yearly since they were 16 or 17. Pure insanity!
When you know this cancer is rare, (and incredibly rare in young women) it's a crazy and sick way to treat healthy women.
In my country, these women wouldn't even be offered smears until they're 30...why?
Because they get false positives and end up unnecessarily losing some of their healthy cervix.
Looking around at my American friends, I thank my lucky stars that ours doctors put our health ahead of money.
Of course, all of these women think the test saved them. I guess that suits doctors as well, keep them afraid and obedient. When only 1 or 2 women in a million in this age group would get this cancer, hard to see how all these women were saved, most had normal pathology as well. Dr's also use LEEP because there is no pathology after that treatment, the cells are destroyed, in that way, they can hide the unnecessary nature of this damaging procedure.
I really think American women have been brainwashed to put their trust and bodies in the hands of people who are determined to harm them and make as much money as possible.
The vanishing American cervix...
The open acceptance of coercion to get women to have these exams and to test is disgraceful - to think a civilized society allows doctors to deny women the Pill until they meet their unnecessary and harmful demands is appalling.
I fear for my American friends.

Anonymous said...

Our doctors actually boast about the misuse of their prescriptive powers. My Dr told me the gyn exam is not medically required for the safe use of the BCP, but she holds onto it to get me in for these checks because SHE thinks they're a good idea.
She agreed with me though when I produced an article by Stewart that the routine pelvic and rectal exam are not all that helpful and useless in overweight women and carry some risk. Some women end up in surgery or having hysterscopes needlessly. A friend's sister lost a healthy ovary after one of these exams, the Dr "thought" she felt something.
She also agreed the breast exam was not all that helpful and could lead to excess biopsies.
Basically she agreed with the English doctor I saw on vacation, but still refused me BC without the well-woman - we should call it the sick-woman exam because it's sick and evil to put us through this just so you can bill us for extra exams and procedures. It's all about over-servicing and our doctors basically admit that....otherwise why continue to do something so offensive to women when it's unnecessary and can harm us?
It means I have lost respect for our doctors and don't use them any more. I also won't have pap tests, while In the UK I heard some doctors being interviewed and followed up reading their research, basically a handful of women are helped and the rest of us get biopsied for nothing and then have issues when we want to have children.
Women's health is harmful, it's terrifying what these people are doing to females.