An exam of how I perform a physical exam....

Let me introduce you to my dear friend, Bates' Guide to the Physical Exam and History Taking. Our syllabus for Introduction to Clinical Medicine (affectionately known as ICM) states that, "Bate's Guide to the Physical Exam and History Taking" is the prescribed book for ICM curriculum. Now there are other suggested books, but this is THE book. Our exam in ICM today consisted of performing part of a physical exam and let me tell you Bate's was a lifesaver. If there was anything that I wasn't sure about or couldn't remember, Dr. Bickley discussed it in her edition of "Bates" and she also had a DVD so I could watch a master in action. There are videos of our professors performing the same exams, but they were done during class so you had to skim though an hour of stuff to find what you need; whereas, these videos by Dr. Bickley were five minutes or less (which is how long we had to perform the exam).

This exam is probably one of the most important things that we've learned how to do thus far in our training; however, the exam today was only worth 2.5% of our Behavioral Science grade. It is a bit of a bummer because it took so much time to master all of the exams (they are not hard, but there is a very specific order in which you are required to do them and according to the nurses and PAs in my class they are much more detailed than what is required of other professionals). Farley and I practiced the 14 physical exams at least 4 times each over the weekend, plus we did the exams that we were less confident about an additional two or three times; in other words, Farley did 56 exams on me plus the extra practice exams that he wasn't as confident about (and I did the same to him). I think we can safely say that our measurements of our JVPs are within normal limits, our carotid pulses are monophasic with a brisk upstroke, all lung fields are negative for bronchophony, negative for egophony and negative for whispered pectoriloquy, and finally the apical impulse is focal, in the mid-clavicular line of the 5th intercoastal space, it is tapping, full and lasting less than 2/3 the length of systole. Yes, Farley and I are healthy. Well, we are healthy as far as I can tell based upon the exams that I know how to perform at this time.

Speaking of the exam, it was rather amusing. So ten of us walked into the room, washed our hands and took our seats. A rather robust early 30s local woman was our patient. We had one professor grading us and one student a semester ahead of us as a second grader. Then the fun begin. There were 14 cards lying upside down on the table and as each of us volunteered to go, we had to pick a card then the timer started. You have six minutes to complete the tasks at hand, report your findings and answer questions regarding your findings. The problem with this set up is that some of the exams have 15-20 tasks necessary to complete them, such as "examination of the respiratory system excluding auscultation" or "perform a general abdominal examination" whereas other tasks have only four or five things that you need to so, such as perform an "examination for the presence of Ascites." I didn't want to go first, because I had never seen this professor before and I wanted to see how she was during the exam. To my pleasant surprise, she tried to help us by asking us the questions that should be at the end during the middle of the exam if someone got stuck and forgot to do something (for example if you forgot to check for edema during the "general survey" she might ask you what would cause edema to (1) get the question asked during the six minutes so you get the points and (2) try to remind you to check for edema). I think people were too nervous to notice that she was doing this. We were not only graded on how we completed our task, but if we were kind to the patient, if we explained the procedure to the patient and obtained consent correctly, if we dressed like a professional (or as I say, "dress like a pro so I can make them think I'm are already pro"), and if we answered our questions correctly.

I, unfortunately, had to take the blood pressure. Obviously, I can take a blood pressure, but I didn't want to have to fiddle with equipment during an exam. I was doing okay, but I had a heck of a time finding the brachial pulse on this very robust woman and I got flustered. I was so flustered, that I was shakin' in my stilettos! However, I was able to get back on track within about 10-15 seconds and I finished with time to spare. I'm sure I missed a point or two, but I'm pleased with how I did overall. If I was nervous, boy, some of my colleagues were scared to death. Everyone's hands were shaking, some of the gentleman's voices were cracking, one girl was shaking so hard that she could barely take a measurement, and one guy was so nervous that he didn't finish the exam because he had to stop and gather himself twice (he was about 30 seconds from finishing when the buzzer went off). But the worst, had to be the guy that was stating things that were not true. I think he was so used to practicing on his healthy friends that he just said the exam as if the patient was normal and she had a couple abnormalities; moreover, he stated that she had dullness in her stomach upon percussion and she didn't. The big problem with that was that when you percuss (you lay one finger over the patient and tap that finger with another finger) the whole room can hear what is going on; thus, the professor knew that he didn't know the difference between dullness in the abdomen and tympanic sounds (which are normal and what the patient had). Oh, it was a mess! On top of all of that, every time someone started his/her exam the student had to ask the patent's name and everyone of us said her name differently. It was all I could do not to start laughing. I'm still not sure what her name was, but I am sure she had high blood pressure and needed to go see a real doctor--not a medical student.

I think this exam was so nerve wracking because we have never done this type of exam before and we had to do it in front of our peers(no one wants to look like a dope), but next semester if we don't pass the exam of the physical exam we will fail the semester (we will have an entire class on ICM rather than having ICM part of our Behavioral Science class). I'm pretty sure it works that way from here on out. Moreover, as part of STEP 2 (the second set of boards that a physician must pass to practice in the US, which is taken after completion of four years of medical school) there is a physical exam. I'm not sure how it works, but I think you have to interview and perform a full physical. I believe that you are even graded on your "bed side manner" (as we were today). I'm not sure about the amount of time or anything specific, but I do know if you fail it, you cannot practice medicine in the U.S. until you pass it.

Farley and I took pictures last January once we got down to the Island. I called these our "Grey's Anatomy" pictures. Good lookin' but not really doctors. Well, I'm happy to say that we feel like we are in over our heads in medicine right now, but in reality being in our second year of medical school we are probably about knee deep. Nonetheless, we are really starting to think like physicians and we are well on our way to becoming excellent physicians!