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A Simple Question


Last weekend, I had an opportunity to participate at a community clinic in conducting physical examinations that includes a thorough male genital check for inguinal herniations.  It was an organized event which occurs yearly “to promote the well-being of high school and college student athletes by providing comprehensive physical screenings, free of charge, to all students participating in interscholastic athletics or allied activities” with the help of healthcare student volunteers (medical, dental, nursing, or physician assistant students). At the clinic, I was assigned by an attending physician to help out any students who might need a quick demonstration to refresh any examination technique since some students probably had only performed on a standardized patient.

Everything seemed to go smoothly until I observed a high school student who refused to undress when a female examiner politely instructed him that he needed to disrobe to have his genital area be examined. I approached the student and asked him if he had had an inguinal herniation procedure conducted on him before. The young man, probably a freshman or a sophomore student, based on his stature and facial appearance, slowly shook his head. The examiner quickly interjected: “I told him that he has to do a herniation check and he consented to it.”

I signaled the examiner to the corner and asked her if I could quickly talk with the patient. She agreed to let me speak with him. I approached the young man and asked him, “Have you been to a family physician or a doctor’s office before?” He mumbled, “Yes, I have … many times … but I didn’t have to do this!” I proceeded, “Do you know why you have to do an inguinal herniation check today and do you know what to expect?” The young man’s eyebrows furrowed into a half frown and shook his head. Realizing that he may have no clue what an inguinal herniation is or even why he is in here for, I started to explain to him the risk of having an undetected inguinal herniation — should he decides to play contact sport — and about the procedure. Lastly, I asked him if he was okay with a female examiner. After a quick one-minute chat, the student replied that he had no issue with a female examiner and was willing to subject to the full genital examination.

Subsequent to that situation, every time an examiner accompanied a patient in the room, the first question I asked the patient was, “Have you had an inguinal herniation check done before?” If the patient shook his head, I told him, “Your examiner will explain it to you,” and turned my head toward the examiner to signal to him or her that this patient needed to be instructed about the procedure.

Throughout my years as a pre-medical college undergraduate and now a medical student, I have read and heard countless stories about ethical erosion issues, bad bedside manner, and even frivolous lawsuits from patients who demand millions of dollars in punitive damages due to an unexpected outcome of a minor procedure. Undoubtedly, there are cases of gross negligence and botched procedures. However, I believe that in most cases, the lawsuits brought forth by the patients, or their family member, stemmed from a simple misunderstanding.

As a proud student from a well-esteemed campus, where classroom teachings are built upon patient-care centered curriculum, I am always aware about my role as a healthcare provider and the impact of quality care on my patients. Though we may stressfully face a daily expectation to succeed from our clinical faculty, a yearly tuition raise that is a constant reminder of our insurmountable financial debt, and a number of congressional reforms that may negatively affect the future of healthcare, we cannot forget why we chose healthcare as our professions in the first place. Despite all the forewarned advice about the hardship of being a medical professional, we still chose this career because we are here to serve and to provide care to those who need us — let it be a cancer-stricken individual or a high school student in need of just a simple physical examination.

A recent article in the New York Times has brought forth the issue of third-year ‘ethical erosion’, where ‘students’ sense of bedside manner deteriorates and many begin to refer to their patients as disease, ‘that dehumanizing shorthand of the wards’ (Chen 2012). Meanwhile, there are also plenty of proposed changes to clinical curriculum, from ‘longitudinal integrated clerkship’ to ‘continuity as an organizing principle,’ as sweeping education reform that may improve the quality of care to patients, by ‘better training’ our medical undergraduates. (Hirsh et al. 2007, Strasser and Hirsh 2011). But very few of these articles address how this ‘ethical erosion’ or ‘bad bedside manner’ even began. When does the strong passion to serve our community and patients start to fade away?

There were several occasions during the clinic event when I asked the examiners if they had explained about the inguinal herniation check that was about to be conducted on their patient; the response I received sometimes was not a pleasant one. Some student doctors would feel irked when I asked the question, as if I was undermining their clinical ability. Some even replied that they did not need to explain about the procedure because the patient ‘should know why he is here.’

During those moments, I asked myself if I was doing the right thing. Was I stepping on my classmates’ — and possibly future colleagues’ — toes by insisting on ‘educating’ their patients about a simple two-minute hernia check? Then I thought, “what if I were the patient, brought into a private examination room and suddenly asked to disrobe for a genital check, who thought this was just a routine heart and lung physical check-up because I had no idea what a general physical examination may necessitate?” I am sure that in most clinical settings, a nurse or physician assistant would probably have explained everything to me before I walked into the examination room. But would it inconvenience the physician, or take too much time out of his schedule, if he or she simply asks, ‘Do you understand the procedure I am about to perform?,’ I wonder?

After all, that patient-physician trustful relationship is built upon a mutual understanding. As a patient, would you have the same trust towards your physician if he or she does not even attempt to explain what is about to happen – even if the explanation maybe beyond our ability to understand? A simply question of “Do you understand…?” follows by a brief explanation about the steps that a physician is going to conduct may only take a couple of minutes, but that gesture can go a long way to make the patient feel comfortable and trusting towards us – their chosen physicians.

Author’s note: This article is an opinion towards a public event. The portrayed view by the author is a literary expression and should not be affiliated with the institution which he is a current student at the time the article was written.

Jimmy Tam Huy Pham Jimmy Tam Huy Pham (4 Posts)

Columnist and Editor Emeritus: Former Medical Student Editor (2012-2015)

Arizona College of Osteopathic Medicine

Jimmy is residing in Phoenix, Arizona. He received his undergraduate degrees from California State University of Long Beach. Actively involved in research, his interests include internal medicine, cardiovascular medicine, and medical humanities.

Jimmy also volunteers at local community events and non-profit clinics in the Phoenix, Arizona and Orange County, California areas. Web: