First, there was the pelvic exam, which was largely demonstrated via a video (with the sound turned off) which an Ob/Gyn attending walked us through. It was odd sitting in a room with all these other people looking at a projected vagina larger than the lecturer's head.
Things learned, and fun quotes:
"So a few weeks ago my eighteen year old son, who is very dear and who's just begun dating, came to me and wanted to know about women's menstrual cycles...specifically how regular they are and what the implications are. And so, after I had a coronary and grabbed him and shook him until his fillings came loose..."
The 'inspection' portion of the exam, during which you inspect and palpate the external genitalia, went on FOREVER in the video. Quoth both Dr. W and Dr. S, "Don't ever stare at a woman's vulva for this long. I have no idea what's going on with this video...also, when doing the pelvic or breast exam, DO NOT make any comments on the patient's appearance. Not even compliments. ESPECIALLY not compliments. Especially if you don't want to get sued."
Put lube on your fingers, lube on the speculum...lube it all up. It won't interfere with Pap smear results, and it will make everyone more comfortable.
"Don't open the speculum until it's all the way in. Because if you get it halfway in, tentatively, and then open it up...(Every woman in the room winces and gasps). Yep, that's right. Every woman in here knows it. And guys, just imagine having something rammed up your urethra."
Be careful if you insert your finger before you insert the speculum...don't try to have too much stuff in there at once. Quoth Dr S, "There is a finite amount of space in most women's vaginas."
This is true--it's not like Santa's sack in there. It's not a clown car.
I was astounded the male GU and genital exams were actually demonstrated to us live. More on that after the jump.
Showing posts with label patients. Show all posts
Showing posts with label patients. Show all posts
Friday, February 26, 2010
Friday, April 24, 2009
The Level of Discourse
During our most recent "Practice of Medicine" small-group session, we were discussing interventions for a hypothetical obese pediatric patient. We started off OK, as we generally do, but it only took a few moments for people's real feelings about the issue to make themselves apparent. Let me make something very clear: I love my classmates, I really do; and I have great respect for the vast majority of them. However, even estimable people sometimes believe (and vocalize) less-than-estimable things.
Within ten minutes, we had gone from using the terms "obese" and "overweight" to 'fat;' within fifteen, 'fatty' and 'Porky' had been thrown out (I regret to say that our faculty preceptor was among those to use those epithets, though admittedly in jest). I felt like my head was going to explode, showering my tablemates with gray matter, if I didn't say something.
I raised my hand, and as calmly as I could, said that I would explain the need for change to the patient/family by emphasizing the importance of healthy eating habits and healthy exercise routines, and not necessarily focusing on weight or a need to slim down (In fact, in all but a few cases, it's best to try and keep overweight children's weights STABLE, and let them grow into their 'extra' weight--ie, let a 100 pound fourth grader become a 100 pound sixth grader; no weight loss necessary). I also said, through more or less clenched teeth, that I was not entirely comfortable with the level of discourse in the room, and that placing undue emphasis on weight rather than healthy behaviors could encourage or 'set off' an unhealthy relationship with food, particularly in girls. Another student (a guy!) agreed, and mentioned self-esteem issues, eating disorders, cutting--all those uglinesses that derive from body hatred. "We're going downhill fast!" the preceptor exclaimed, to general laughter, at which point I all but jumped on the table and said,
"We're acting as if precipitating an eating disorder is a remote possibility, as if an authority figure's judgement of a young person's physique carries no value. It does. Yes, there is an obesity epidemic. One in three kids is overweight. But by the time they reach college age, between one-tenth and one-quarter of women have an eating disorder. This isn't coming out of left field."
After this the preceptor sort of propitiated me, saying that in his experience girls with eating disorders actually start out slightly overweight. We reined ourselves in a little bit. I was still struck, however, by how glibly we treated what is for many people a lifelong and seemingly unwinnable struggle against weight issues, and how we assumed that obesity is largely the result of laziness and gluttony--how quickly we turned a medical issue into a moral one, patting ourselves on the back for eating five servings of veggies a day and deriding those who cannot, as we can, run five miles a day. I wanted to say that actually, having had an eating disorder for more than half my life, it would be much healthier for me to have carried around an extra twenty or even thirty pounds than to have done all the things I've done over the years (and still, unfortunately, do sometimes) to control my weight--things that have lead to arrythmias and seizures, things that have screwed with my reproductive and skeletal systems, and most importantly, with my brain. As students at one of the top medical schools in the country (as we are repeatedly reminded), we have a responsibility to become competent physicians not only in the realms of diagnosis and hard science, but in the realms of ethics and communication as well.
Within ten minutes, we had gone from using the terms "obese" and "overweight" to 'fat;' within fifteen, 'fatty' and 'Porky' had been thrown out (I regret to say that our faculty preceptor was among those to use those epithets, though admittedly in jest). I felt like my head was going to explode, showering my tablemates with gray matter, if I didn't say something.
I raised my hand, and as calmly as I could, said that I would explain the need for change to the patient/family by emphasizing the importance of healthy eating habits and healthy exercise routines, and not necessarily focusing on weight or a need to slim down (In fact, in all but a few cases, it's best to try and keep overweight children's weights STABLE, and let them grow into their 'extra' weight--ie, let a 100 pound fourth grader become a 100 pound sixth grader; no weight loss necessary). I also said, through more or less clenched teeth, that I was not entirely comfortable with the level of discourse in the room, and that placing undue emphasis on weight rather than healthy behaviors could encourage or 'set off' an unhealthy relationship with food, particularly in girls. Another student (a guy!) agreed, and mentioned self-esteem issues, eating disorders, cutting--all those uglinesses that derive from body hatred. "We're going downhill fast!" the preceptor exclaimed, to general laughter, at which point I all but jumped on the table and said,
"We're acting as if precipitating an eating disorder is a remote possibility, as if an authority figure's judgement of a young person's physique carries no value. It does. Yes, there is an obesity epidemic. One in three kids is overweight. But by the time they reach college age, between one-tenth and one-quarter of women have an eating disorder. This isn't coming out of left field."
After this the preceptor sort of propitiated me, saying that in his experience girls with eating disorders actually start out slightly overweight. We reined ourselves in a little bit. I was still struck, however, by how glibly we treated what is for many people a lifelong and seemingly unwinnable struggle against weight issues, and how we assumed that obesity is largely the result of laziness and gluttony--how quickly we turned a medical issue into a moral one, patting ourselves on the back for eating five servings of veggies a day and deriding those who cannot, as we can, run five miles a day. I wanted to say that actually, having had an eating disorder for more than half my life, it would be much healthier for me to have carried around an extra twenty or even thirty pounds than to have done all the things I've done over the years (and still, unfortunately, do sometimes) to control my weight--things that have lead to arrythmias and seizures, things that have screwed with my reproductive and skeletal systems, and most importantly, with my brain. As students at one of the top medical schools in the country (as we are repeatedly reminded), we have a responsibility to become competent physicians not only in the realms of diagnosis and hard science, but in the realms of ethics and communication as well.
Wednesday, October 8, 2008
A standardized test?
We had our first standardized patient session today, something for which I felt woefully unprepared. It was supposed to focus primarily on communication skills and history-taking (right up my alley, no? You'd think...) but there was the addendum of the physical exam that made everyone a little...squirrely. Nervous, edgy, though of course everyone does their best to hide those things (I can't be the only one hyperventilating, can I? Of course, maybe I can). Some of the things we were supposed to know how to do hadn't been covered in our small groups at all; the best summary I can give of the 'musculoskeletal exam' I was taught would be, "Have them move things around and see if it hurts. Then you move them around and see if they hurt. Also, there are lots of bony landmarks you should be aware of, and everyone hurts their ankles and knees at some point so you should probably know what to do for those sorts of injuries." Standardized patients, by the way, are actors who are paid to come in, sit in exam rooms, and serve as fake patients. They give the histories from the scripts the medical school provides; they act out all the physical findings you're supposed to see (limps or tenderness or stiffness or whatever). The woman today was quite convincing; I found myself actually worrying that I might be hurting her. Some standardized patients really get into it deep, from what I've read: here at this Slate article I learned there are even those who let medical students try out their newfound pelvic exam skills (there's. not. enough. money. in. the. world. to make me do that).
We weren't even being graded, per se, on this encounter; I really shouldn't have been nervous. But we were kept standing outside the little exam rooms for almost 5 minutes, just giving us time to get more worked up (of course, some people would see this as time to 'collect their thoughts,' I suppose--cognitive restructuring, man, make it something positive!), and suddenly as I went in I could feel my face go numb and everything sounded echo-y and yes, I did a focused history and exam, and I didn't drop the stethoscope or lunge at the patient to feel her posterior lymph nodes (nothing like putting your hands around someone's neck without giving them warning), and I did wash my hands before and after thankyouverymuch, since failing to practice good hand hygiene is one of the few ways you can actually fail an encounter. I can't say too much more, since not everyone in my class has had their standardized patient experience yet (and there's an honor code saying you won't pass on information, that the exam suite is a secure testing environment, lah ti dah), but my patient did tell me that I "didn't do terribly at all," which hardly sounds like a ringing endorsement--but wait.
"You were just so nervous. I could feel your hands shaking as you were taking my pulse." Oy veh. But she went on: "You really have the personality for this. I can tell you'll be great at this, you just need to get over your nerves and then you'll be fine." Which I know is true; when I worked with Dr. B. doing preliminary interviews of his patients, they always told him 'what a nice girl' I was. Never mind that a 20 year old isn't really a girl, or that they were mostly geriatric patients who really needed someone to talk to, even if it was an inexperienced college student taking down their past medical history and medication information (but who was also willing to listen to them talk about their fears, and their grandchildren, and their gardens). Their bar for 'such a nice girl' wasn't very high, is what I guess I'm saying--just someone to smile, and listen, and care a little. Everyone needs to feel heard. Maybe that's what I need to focus on...maybe if I focus on that connection, everything else will fall more easily into place.
We weren't even being graded, per se, on this encounter; I really shouldn't have been nervous. But we were kept standing outside the little exam rooms for almost 5 minutes, just giving us time to get more worked up (of course, some people would see this as time to 'collect their thoughts,' I suppose--cognitive restructuring, man, make it something positive!), and suddenly as I went in I could feel my face go numb and everything sounded echo-y and yes, I did a focused history and exam, and I didn't drop the stethoscope or lunge at the patient to feel her posterior lymph nodes (nothing like putting your hands around someone's neck without giving them warning), and I did wash my hands before and after thankyouverymuch, since failing to practice good hand hygiene is one of the few ways you can actually fail an encounter. I can't say too much more, since not everyone in my class has had their standardized patient experience yet (and there's an honor code saying you won't pass on information, that the exam suite is a secure testing environment, lah ti dah), but my patient did tell me that I "didn't do terribly at all," which hardly sounds like a ringing endorsement--but wait.
"You were just so nervous. I could feel your hands shaking as you were taking my pulse." Oy veh. But she went on: "You really have the personality for this. I can tell you'll be great at this, you just need to get over your nerves and then you'll be fine." Which I know is true; when I worked with Dr. B. doing preliminary interviews of his patients, they always told him 'what a nice girl' I was. Never mind that a 20 year old isn't really a girl, or that they were mostly geriatric patients who really needed someone to talk to, even if it was an inexperienced college student taking down their past medical history and medication information (but who was also willing to listen to them talk about their fears, and their grandchildren, and their gardens). Their bar for 'such a nice girl' wasn't very high, is what I guess I'm saying--just someone to smile, and listen, and care a little. Everyone needs to feel heard. Maybe that's what I need to focus on...maybe if I focus on that connection, everything else will fall more easily into place.
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