Every Patient Tells a Story

by Lisa Sanders

  Many doctors and researchers are troubled by this shift. They complain about the overuse of expensive high-tech tests and decry the decline of the skills needed to conduct an effective physical exam. Yet despite this uneasiness, doctors and even patients increasingly prefer what they perceive to be the certainty of high-technology testing to a low-tech, hands-on examination by a physician.

  Measuring the Loss of Skills

  In the early 1990s Salvatore Mangione, a physician and researcher at Thomas Jefferson University Medical Center in Philadelphia, began studying how well doctors were able to recognize and interpret common findings on one fundamental component of the physical exam, the examination of the heart. He tested 250 medical students, residents, and postgraduate fellows specializing in cardiology from nine different training programs. The investigation was straightforward enough: students and doctors were given an hour to listen to twelve important and common heart sounds and answer questions about what they heard.

  The results were stunning and controversial. A majority of the medical students could identify only two out of the twelve sounds correctly. The other ten were recognized by only a handful of the students. Surprisingly, the residents did no better. Despite their additional years of experience and training, they were able to correctly identify only the same two examples. Perhaps most disturbing of all, most of the doctors holding a post-residency fellowship in cardiology were unable to identify six out of the twelve sounds.

  In a similar test on lung sounds, Mangione again found that students and residents couldn’t identify many of the most common and most important sounds of the body. If letter grades were being handed out, all but a handful of these participants would have gotten a big fat F.

  In the years since Mangione first published his studies, editorials and lecturers have bemoaned this loss of skills and warned that if action isn’t taken to remedy the problem, we’ll end up with teachers who know no more than their students, a case of the blind leading the blind. A recent study suggests that that day has already come. Jasminka Vukanovic-Criley, a physician at Stanford, compared cardiac exam skills of practicing physicians to those of medical students and residents. First-year medical students correctly answered just over half of the questions. Graduating medical students were a little better—correctly answering nearly 60 percent of the questions. But after graduation from medical school, all improvement stopped. Residents, their teacher-physicians on the faculty, and doctors in the surrounding community did no better than graduating medical students.

  How did we get here? How can we have generations of doctors who make it through residency and sometimes subspecialty training without improving their skills in the physical exam? Mangione surveyed medical training programs about their curriculum in these areas and found that only one in four offered structured teaching of basic physical examination skills. Routine observations of trainees performing the physical exam were rarely done. Perhaps, Mangione suggests, doctors don’t learn this because programs don’t teach it.

  Historically, residency and fellowship programs rarely taught these skills outright, as a separate course of instruction, because this kind of teaching happened informally, throughout the day, while taking care of patients. At one time, a “resident” actually lived in the hospital, literally resident, so that he might learn his skills via total immersion, like a Berlitz language class of the body. Part of the total immersion was to pick up the physical examination skills of the older doctors as the resident watched the pros working from room to room.

  After every call night, teaching physicians would see each newly admitted patient along with the resident, the interns, and the students. Together they would review the story of the patient’s initial presentation and then examine the patient, reviewing significant physical findings noted (or not) by the team. In addition, three times a week, the attending met with residents and medical students for a ninety-minute educational session. During these classes attending physicians were expected to incorporate instruction in the nuances of the physical exam—at the bedside, with the patient.

  These types of unstructured, informal teaching sessions, based on the pathology of the patients, were the principal methods of teaching the physical exam along with other aspects of patient care.

  Several trends completely unrelated to education have eroded these traditions. First, the rising cost of hospitalization has focused efforts on shortening patients’ time in the hospital. Those with significant heart murmurs, the kind that make good teaching cases, are in and out of the hospital within days. In 1980 the average length of stay in a U.S. hospital was more than a week. In 2004 that had dropped to just over three days. So there is less opportunity to do bedside teaching—a triumph of medical economy that only slowly has been recognized to have come at the expense of education. Patients zip in and out of the hospital too quickly for residents to learn from their exams.

  These days, the residents who care for the patients also zip in and out of the hospital. The eighty-hour workweek, mandated in 2004 by the Accreditation Council of Graduate Medical Education (ACGME), the organization that oversees medical education, means that the time that doctors-in-training are allowed to spend in the hospital is limited. Eighty hours may seem like a long workweek, but there’s plenty to fill it; the amount of work hasn’t decreased, only the time available to do it in. What this usually means is that residents spend less time with their patients. In a recent study done at Yale, interns were found to spend less than ten minutes a day with each of their patients.

  As an intern, I used to allow two hours to see my patients first thing in the morning, before work rounds when I presented the patient to my resident and the attending. This gave me plenty of time to talk with the patient, examine him, check his labs. With the eighty-hour workweek, interns in our program are not permitted to come into the hospital any earlier than one hour before work rounds. Given the dual demands of patient care and education—which are, after all, the purpose of residency—something had to give. Unfortunately, what’s given up is the time doctors spend with the patient.

  Our successes in medicine have taken their toll as well. Many diseases are caught early, before the severe consequences are manifested. In the 1990s when I did my training, I was exposed to far fewer types of murmurs and other heart sounds than the generations of doctors who preceded me. Rheumatic heart disease used to be commonplace. In this disease, a strep infection of the throat or skin can cause the immune system to attack the heart, destroying the valves. The unexpected link between this painful but not life-threatening infection and potentially lethal destruction of the valves of the heart was recognized in the early twentieth century. Now physicians routinely check for strep when patients come in with a fever and sore throat. Those with positive tests are treated with antibiotics. The drugs don’t do much to shorten the illness or lessen the pain of the infection, but they prevent the development of rheumatic heart disease.

  It’s been a very successful strategy. Rheumatic fever was one of the most common diseases in America through the 1940s. In 1950 approximately 15,000 people died of rheumatic heart disease; in 2004, that number had dropped to just over 3,200. It’s a dramatic decline, but we didn’t wipe out the disease, so doctors still have to recognize it when they see it. It’s just that now there are a lot fewer patients to learn the symptoms from—an unintended consequence of good medicine.

  There are many diseases that are now routinely treated early, often before patients ever need to come into the hospital. It’s a success story in medicine and a blessing for patients, but a problem for education based on chance patient encounters in the hospital. The old system of informal teaching, based on learning at the bedside, doesn’t work anymore. And medical education has been slow to come up with alternate ways to teach doctors the critical skills necessary for a thorough physical exam.

  This loss of skills has resulted in a loss of faith in what the physical exam can do. The official line in medicine is that the physical exam i
s important. But what you quickly pick up in the “hidden curriculum”—the values and beliefs of medicine as it’s practiced—is that the physical exam is mostly a waste of time. On rounds in the hospital, as a student or intern, you might proudly describe a murmur you picked up on exam, but it doesn’t take long to realize that it’s only the report of the “echo” (shorthand for echocardiogram —an ultrasound of the heart) that anyone pays attention to. And because the physical exam is not valued, you soon learn not to pay attention to it and all further learning stops—replaced by the kind of learning you know those who are in charge will value. What did the newest high-tech test say? What is the most current research on a particular therapy? These are the questions physicians are now being trained to ask—not the more traditional questions, such as, What did you see when you looked at the patient? What did you feel? What did you hear?

  These structural changes in modern medicine—where doctors and their patients zip in and out of the hospital with an ever changing variety of diseases—are expressed at the practical level in this hidden curriculum. But I suspect there is one more reason that the exam has lost its once central position in the evaluation of the patient. In contrast to the cool answers provided by technology, the physical exam feels primitive, intimate—even intrusive. Even when the patient is available and willing, conducting such an exam is psychologically daunting for the physician. It’s a truth I learned early in my own medical education.

  Palpable

  “Do you want to feel my cancer while it’s still here?” Joan asked me one wintry afternoon as we sipped coffee in her kitchen. “You’re going to be a doctor. Shouldn’t you know what a breast cancer feels like?”

  My husband and I were visiting his oldest sister one February weekend in 1993. It was spring break at the Yale Medical School, where I was in the middle of my first year. The week before, Joan had gone for her regular mammogram. As she was getting dressed after the test, the radiologist, an old friend, burst into the room. “She looked at me and I could tell something was wrong,” Joan told me.

  The radiologist arranged for her to see an oncologist, who, in turn, sent her to a surgeon for a biopsy. Our visit caught her before she’d heard the results of the biopsy but well after Joan had accepted the likelihood of the diagnosis.

  Joan sighed and tucked a wayward blond curl behind her ear. “Wouldn’t it be helpful to know what to look for? Wouldn’t it?” she persisted. After the needle biopsy, she’d located the tiny nodule that was going to change her life and found herself touching it several times a day, the way you sometimes can’t stop fingering a painful sore or replaying a difficult conversation in your head—acting on some need to remember where the pain was coming from.

  I didn’t know what to say. I had no idea what a breast cancer would feel like and she was right—it would be useful for me to know. And I was wildly curious.

  But I knew immediately that I couldn’t do it. Touching my sister-in-law’s breast was inconceivable. Joanie was able to imagine me in the role of a physician—a group given permission to ignore the traditional zones of privacy when necessary. But it wasn’t a mantle I was ready to put on. At that point in my training, I had not yet examined anyone. Until that moment I hadn’t really envisioned how strange and unnatural it would to be to violate the zone of privacy each of us occupies. I couldn’t touch my sister-in-law. In fact, I wasn’t sure I could touch anyone.

  The act of placing your hand upon another’s body is, in many ways, the hallmark of the physician. And yet, though simple, it is an act riddled with complications. Who are the people we touch in our lives? Our lovers, certainly; our children, naturally. And as a sandwich generation, perhaps even our parents, eventually. No one else. I don’t count the hug and cheek-peck hello, the hand on the shoulder, the slap on the back. This is touch as a form of communication—it speaks of fellowship and affection, support and concern. This type of physical contact lies well within our expectations of social intercourse. It is by convention brief, by practice unobtrusive. A hug or touch that lasts a little too long or is a little too close sets off alarms because we understand the rules of social conduct.

  In medicine, at the bedside, on the examination table, we touch those we care for—but it’s a different form of touch, and a different kind of care. Medicine requires intimacy but one characterized by an intellectual and emotional distance. You don’t expect your friends and loved ones to assess you with a knowing and impartial eye. We allow them to occupy an intimate space physically and emotionally because we know they see us through a filter of love.

  The intimacy of the physical exam is far removed from that between friends and family. In the physical exam, that filter is gone. Doctor and patient are often strangers to each other. It can be uncomfortable—for the patient, and often for the doctor as well. And there is, at the heart of this sometimes awkward intimacy, a fiduciary relationship, an implicit bargain: the patient will let the doctor see him and touch him and in return the doctor will share her knowledge for the benefit of the patient. When Joan had her cancer, I knew I wasn’t ready to live up to my end of the deal. I had nothing to offer: I knew a lot of anatomy, some cell biology, a good deal of genetics, but I didn’t know anything about medicine. Not then.

  Moreover, I didn’t know how to do it. Literally. I hadn’t been taught. That was something I would learn in my second year. Perhaps even more important, I hadn’t yet learned how to occupy that permitted space between physical intimacy and intellectual distance that is fundamental to touching as a doctor. That part isn’t on the written curriculum; there weren’t any lectures on it (or at least not in my medical school), and yet you can’t be a doctor if you don’t learn how to negotiate this deeply personal territory. Medicine—to the extent that it can be called a science—is a sensual science, one in which we collect data about a patient through touch and the other senses according to a systematic method in order to make a diagnosis. Most patients are willing to be touched by their doctor. They expect it. I certainly expected to touch patients. But, as I realized that afternoon in my sister-in-law’s kitchen, first you have to learn how.

  In medical school, starting with anatomy class, doctors are taught to understand the body by taking it apart, one piece at a time. What you walk away with, at the minimum, is an uncanny ability to objectify the hell out of even the most intimate body parts. For anyone else, this might be considered disrespectful, but for doctors, a clinical and objective view of, say, a female breast offers us the chance to see it isolated from its other, often sexual, contexts. We are taught to handle a breast as a separate object.

  And so when you examine a breast, you notice that the smooth skin and soft layer of fat beneath give way under your fingers to reveal highly organized, dense layers of glandular tissue below. Beneath the skin, trapped by the investigating hands, the breast is so much more orderly than the wildly mobile appendage it appears. I learned how to examine the breast in the middle of my second year. A patient-instructor—a layperson trained in the techniques of this exam—walked me and the three other students who made up my physical exam group through the methodical examination using her own breasts as the models on which we learned.

  As the class began, I felt again that same discomfort I’d felt in Joanie’s kitchen. We were four medical students, dressed in our still creased short white coats, our shiny name tags pinned to our lapels, and brand-new stethoscopes folded into our pockets, trying hard to appear relaxed as we sat in a semicircle around a half-naked middle-aged woman. The teacher sat comfortably on the exam table. The robe she had worn when we entered the room was pushed down around her waist to reveal the subject of this class, her breasts. I tried to relax my face—to at least appear at ease. I wasn’t quite sure where to look. I pulled out a notebook to take notes as she talked about the exam. I could feel the tension emanating from the students on either side of me. None of us said anything at all. Greg, the earnest, well-meaning liberal from New York’s Upper West Side, appeared to be studying
his shoes. Lillian, the exuberant effusive life force in our class, fidgeted quietly with her hair. No one made eye contact with the teacher or one another. The four of us silently struggled to figure out a way to manage our discomfort. I knew then that those skills were part of what the class was supposed to teach us.

  “First you inspect,” she told us. “The breasts should be symmetric.” She raised her hands above her head, and her breast stretched upward as well. Then she placed her hands down on her hips, spreading her elbows wide to stretch the chest muscles and the breasts. “This gives you a chance to see any abnormalities that affect the shape of the breast or the texture of the skin.”

  As she ran through her orderly presentation the tension in the room began to fade. Her matter-of-fact demonstration communicated an ease with her role as a patient and her expectations of us as doctors. I realized later that she was not only teaching the basics of the breast exam, she was demonstrating a technique we could use in our own encounters to bring a naturalness to the awkward physical intimacy between a doctor and a patient.

  “I’m going to demonstrate how to examine my breasts and then each of you will do it.”

  We crowded around the table as she lay with one hand over her head and the other performing the examination.

  “Start at the midline. Use the pads of your fingers. Press them lightly on the breast and make a circle. I like to anchor my fingers to each spot and move the skin along with my fingers so that I know that I’m examining the same spot. You do that three times at each spot, each time applying just a little more pressure so that you can feel all the different structures under the skin.”