October 12, 2010

Getting Physical

that's me in an apple tree!

friends at an apple orchard showing off all the yummy apples we picked.

This past summer I read Cutting for Stone, by Abraham Verghese, a fictional novel about a mission hospital in Ethiopia. I found myself envying the main character, Marion Stone's, introduction to medicine through learning to differentiate different pulses and what diseases they suggested. It's a technique used by many eastern medical practitioners, including Ayurveda. Some important types of pulses that we glazed over in my class, but if read correctly, signify serious disease include:

-pulsus alternans = alternating strong and weak pulse = usually signifies a problem with left heart systole (the major pumping action of the heart) and carries a poor prognosis.
-pulsus paradoxus = when there is an exaggeration in how much the BP decreases on inhalation = can signify COPD, cardiac tamponade (when the sac that the heart is in fills with fluid)
-pulsus parvus e tardus = the pulse is weak and late, relative to expected = signifies aortic stenosis

While we do learn physical exam skills along with every unit of material, and while our approach is very much learning how to fit together the pieces of the puzzle, I sometimes wish we had even more hands-on puzzling things out and that there was more emphasis on that process. Because how do they know we're listening to a heart correctly? Or counting the pulse correctly? No one really checks...

Last week, I practiced my first full history and physical on a standardized patient. It took almost two hours, including the feedback session afterward. It's designed to prepare me for next week when I do the same full exam at the family practice office where I work. Although we had learned and performed all of the exams before, I found that having to go through all of them all together was great practice because there's some awkwardness in transitioning from "okay, now I'm going to look into your ears" to "now I'm going to listen to your heart" to "now I'm going to stick my fingers all the way up in your armpit to feel for your lymph nodes now" or "now I'm going to press my fingers into your stomach - all over your stomach. All of these are incredibly important exams and in order to do them well, you have to be comfortable listening or feeling until you ACTUALLY hear or feel something, which often requires some patience and tolerance of awkwardness on the side of the patient, but also from us (especially at this point in the learning process, but probably forever).

Too many medical students (including me) and doctors have a hard time with that. In a new article in the NYT this week, Dr. Verghese argues for the importance of a good, solid physical exam. In the article he talks about diagnostic gaits, silver stool samples, requests patients make that can suggest a certain disease (if someone says, "hey doc, don't bump the bed" - consider peritonitis, an infection of the abdominal cavity lining), and the power of standing at the bedside of a dying patient (something no test can do). My personal favorite parts of the article are his questions to the residents working with him:
Best line in the article?
"Doctors and writers are both collectors of stories, and [Dr. Verghese] says his two careers have the same joy and the same prerequisite: “infinite curiosity about other people.”

yup. and that's why I like having a blog.

And in a tribute of sorts - two of my favorite quotations from Cutting for Stone:

"You live it forward, but understand it backward."
-Abraham Verghese

"The key to your happiness is to own your slippers, own who you are, own how you look, own your family, own the talents you have, and own the ones you don't. If you keep saying your slippers aren't yours, then you'll die searching, you'll die bitter, always feeling you were promised more. Not only our actions, but also our omissions, become our destiny."
-Abraham Verghese

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