During our medical training, taking a proper history and doing a thorough clinical examination within a limited time period are the two skills that we are expected to master perfectly. Our teachers tell us that a good history gives you 75 percent of your diagnosis and the clinical examination gets you 90 to 100 percent of the diagnosis.
But what is a good history? A good history consists of all the positive findings, the important negative findings, family history, social history, marital history. And the fact that you need to obtain all this information means that you can’t be talking about things that has nothing to do with the patients’ medical condition. You can’t be spending five minutes discussing the game last week or what the patient’s son has been up to lately. We are supposed to stop our patients and direct them back to the problem at hand. We expect a person to disclose all their details to us — what they ate last night, how many times they went to the bathroom, when was the last time they had sexual intercourse, if they smoke or drink, who they live with — after we tell them nothing about ourselves except our name and designation.
A very widely accepted statement when beginning an OSCE (objective structured clinical exam) station is: “Hello Mr./Miss (insert name) , I am (insert name), I am a medical student. I would like to ask you a few questions so that we can have a better understanding of what’s going on with you in order to help you. Is that okay?”
We begin by saying that we are here to help them and we always expect them to answer in the affirmative. What do they have to complain about? After all, we are here to serve their purpose: antibiotics for the infection and analgesics for the pain. So we feel entitled to it. But have you ever considered exactly how much we are asking of them?
It is normal for us, medical professionals, to ask these personal questions on a regular basis. But for the patient, we are strangers. They are not used to discussing their life stories with everyone and yet, we think it’s unreasonable if they refuse to disclose a detail. We fail to understand why it might be awkward for a person to talk about how stressful their work is or how their living conditions are, when they only came to the emergency room for an episode of loss of consciousness. More often than not, patients have to disclose this information in front of a room full of people: the medical student taking the history, the second student who is taking notes, the nurse who is putting on a dressing , the phlebotomist who is drawing blood for labs. Later, we return with the doctor, two interns and three other students, and present our case. The patient lies quietly in bed while we disclose their entire life — the fall they had as a child, the bottle of wine they finished the night before, where they work and where they live — to an room full of strangers. And while we do this to people on a daily basis, how willing are we to have the same thing done to us?
A few weeks ago, during one of the teaching sessions, the doctor wanted to demonstrate how to do a diabetic foot examination. One of my friends volunteered to be the surrogate patient. The doctor first did a general examination and then proceeded to do the foot examination while we all crowded around the bed to watch. She later told me that it was one of the most embarrassing moments of her life. Why? Because there were 10 different people watching while she was being examined; her feet and legs were exposed to the knee; she felt awfully self-conscious to be lying like that in front of so many people and have a person describe her feet in great details to an audience. Yet, we complain about those patients who refuse to let us do a physical on them, the patients who refuse to let us expose them in front of a total stranger, and be touched and poked and auscultated. After all, if we don’t practice and we don’t learn, who is going to treat them? But then why is it that when we are the ones being put in the same position for the sake of education, we complain?
There is no denying that this is the only way to learn. The more we practice, the better physicians we will become. But we must remember what we take from our patients during the process of learning. Because no, we are not entitled to the details they give us. We are privileged. No, the patient isn’t just supposed to let us invade their personal space. We are supposed to apologize for exposing them and explain why it is absolutely necessary. It isn’t just us who are doing them a massive favor by diagnosing and treating them; they are doing us a favor by letting us practice on them and learn.
It is very easy to forget during the long years of training and later during our years of practice that there isn’t much of a difference between ourselves and the people we treat. The people we socialize with outside the hospital are the same people we encounter in the hospital. They deserve to be treated with the same amount of respect. Our patients aren’t diagnoses or a bunch of interesting clinical findings. They are people who deserved to be thanked for allowing us to examine them, apologized to for the discomfort we are causing them, and empathized with when they refuse to allow us to do so. Always stop to think: if you were the person lying in a hospital bed in pain, instead of being the person doing the questioning, how would you like to be treated?
“The Making of a Medic” explores that which transforms the head of a high school graduate to that of a medic, shedding some light on what the life of a medic is really like, away from the myths and speculations. This column focuses on the reflections of personal experiences rather than the scholastics of medical school.