Can You See What's Wrong With This Doctor Visit?

by Jason Spears

Mitt Romney at Doctor's Office Cartoon

Mitt Romney at Doctor's Office Cartoon

Can you spot what's wrong with this picture?


It's Saturday morning and what's a kind to do... watch cartoons. Well, I came across this comic and it will be a teaching moment. Let's put politics aside, although I was a Political Science major in undergrad we're only going to focus on the medicine.

Here we go!

First thing I notice is patient modesty is not being protected. You are always supposed to drape and gown your patient. Only expose parts of the body you are currently examining while asking for permission first. Afterwards cover up the exposed area before moving onto the next area. Oftentimes in clinical practice this is not done but doctors are trained how to do this during medical school. Additionally, we are to offer assistance to patients moving them from position to position and to perform our exams in a manner that requires the least amount of movement.

Now onto the doctor.

Notice how the doctor is touching his mouth. Anytime you touch your face. You have to rewash your hands. Matter of fact anytime you contaminate yourself you will have to wash your hands or use hand sanitizer. Did you know you cannot go the whole day using just hand sanitizer? After a number of uses it is recommended to actually wash your hands using soap and water.

Let's applaud our radiology tech.

Whoever took these images were able to capture cervical, thoracic, lumbar and pelvic views all in one image. Although I'd question the lumbar region because there appears to be some artifact/boney growth which the radiologist will note along with "clinical correlation recommended." This is a statement that radiology would like the physician to examine, test, etc further to provide more conclusive evidence as to what was found on the imaging study.

Our patient may have a case of acromegaly due to the proportions of his ears, chin, nose, etc. and would need an endocrinology workup. Your differentials would include growth hormone vs sex hormone among many others.

Also from the picture I cannot tell if there is bony or soft tissue growth bilaterally on the patient's patella.

Even our doctor would be noteworthy for a case of microcephaly (brain does not develop properly, resulting in an abnormally small head).

For the students especially the medical students this part is for you.

Remember, you cannot treat what you don't know!

Spend time now building your foundation of knowledge and have fun when you start seeing patients. I remember being in medical school and preparing for my Board Exam where you see standardized patients and are given a set amount of time to take a history and focused physical exam and tell the patient your differential diagnosis. Then you have to immediately leave the room and go to a computer and write your entire note
on the patient visit under timed conditions.

One of the physicians at the hospital overheard us talking about our Board Exam and he said this, "What are you guys stressed about? You see patients everyday and you've been doing ever since you started your clinical rotations. Don't over think this as it is what you've already been doing." Very true indeed.

With boards there is a specific way they want us to examine patients and there is a bit of nerves because you don't know what type of case you will be given and the worse part everything is timed so you have to be very fast. Plus, in medical school you learn the proper way to conduct a physical but when you are seeing patients you work a bit more efficiently, not necessarily taking shortcuts but not as rigid as how you are taught according to "Bates" (you'll know what that is once in medical school).

Here's a story about my first OSCE of medical school.

This was supposed to be a simple case where meet a standardized patient and take their vitals along with blood pressure manually.

I'm a bit nervous but have been practicing with my first year medical school classmates for this.

I get in the room do what I need to do and am sure to ask the patient which arm would you prefer me to use for the blood pressure reading. He told me one arm and then I begin setting up the blood pressure cuff on his opposite arm (remember, I'm a nervous medical student and looking at the patient so his left/right is actually the opposite). I catch myself, apologize to the standardized patient and switch to his other arm effortlessly.

In medicine you can make a mistake like this but it is always best to own up to it, acknowledge it and course correct. Patients will respect you when you do so. Plus, this error would not have harmed the patient, whereas other mistakes can be fatal.

Lastly, as I am writing this I'm thinking about how much I have grown.

You come into medical school and taking the vitals of a standardized patient is a big deal, that can be nerve-wrecking. Then by the time you graduate medical school you are completely comfortable seeing all types of patients and doing a complete history and physical. I could honestly walk into a room without knowing what is going on and be perfectly fine coming up with differentials on a patient I had never seen before.

One day you will reach the same level of competence although it may seem far off in the distance it will happen. You will be able to walk into a patient room, introduce yourself and state, "How can I help you today or what can I do for you?"

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