On clinical DGAF

On Monday, I met the first patient that I didn’t like.

I walked into the room and she didn’t make eye contact with me. I introduced myself and she didn’t respond. Her adult son sat in the corner of the room and played games on his phone and also refused eye contact with me. At first I thought they both might sit somewhere on the spectrum, but after hearing her responses to my questions, I realized that she simply didn’t want to talk to me.

I tried to build a decent history of her most recent hospitalization and subsequent non-healing ulcers on her foot. She crossed her arms and answered my open-ended questions with either two words or a sassy and childish “I’m not sure what you are asking.” She seemed combative and almost like she wanted to upset me.

I won’t lie, she did a good job.

After a solid attempt at the history, I moved onto the physical and donned a set of gloves. With her permission, I inspected the ulcers on her foot. After gentle palpation and requests for feedback regarding pain, the encounter seemed to change in tone. She started to respond in sentences rather than words. I moved into a kneeling position on the floor to better visualize the ulcer on the ball of her foot, the wound giving her the most pain and trouble.

At the time, I barely noticed the change in her demeanor. Physical contact is a pure interaction, others can observe but they cannot truly participate like the two people involved. The physical exam can create a small tunnel where only the physician and the patient exist, the surrounding room and anyone else in it falls away.

Additionally, a competent physical exam brings a patient to ease, almost more so than a thorough history with the necessary reassurances. I love watching videos of highly skilled individuals completing technical tasks: the hands moving in concert with tools, the economy of movement honed through hours of practice and fatigue, and the clear focus of the practitioner. Then as the patient, to have your own body be the focus of that skill is humbling and entrancing. I observed this with Dr. Mishriki, the local Obi-Wan Kenobi of the physical exam.

Once I wrapped up with this patient, I brought in my attending physician. We walked in together and he immediately cracked a joke which eased the tension in the room and got her laughing. This was, I realized, the first time I saw her smile. He reassured her that the wounds would heal and especially if she got her blood sugars under control. Afterwards, he reassured me that my frustration was justified and essential: we may not like all of our patients, but we do need to care for them.

Most folks, I can warm up with the interview and some conversation regarding their condition. A bit of empathy here and some rapport there. Others, it seems, are best served by some physical contact that speaks more than words, an unspoken promise that I am doing my best and that I actually care about them even if I don’t like them. Now, I have an additional tool in my belt: starting the physical exam earlier than normal in order to break down barriers between myself and a patient.

I don’t always know their background, I don’t usually know where they are coming from, and I rarely know what their home life is like.

But, I do know what happens when I walk in the door, greet them as a medical student, and close the door behind me.

Long Form Sundays

On Death Podcast

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