Wednesday, January 16, 2008

If I Can't Be a Doctor, at Least I Can Try to Act Like One

I wound up getting the pharm learning objective for PBL again this week. It's about warfarin, and that is A-OK with me. Our seminar today was terrific. We went over to the anatomy lab and had a pathology session there. There were two pathologists. First, they gave us an intro in the classroom, and then we went into the lab and they showed us all kinds of hearts and parts of hearts. At one point, one of the pathologists took this bucket full of heart valves and just dumped them out all over the table for us to look through them. That was so cool. Most heart valves are supposed to have three cusps except for the mitral valve, which normally only has two. We saw some valves with one cusp, a bicuspid aortic valve (which should be tricuspid), and even one valve with four cusps. We also saw hearts that had hypertrophied. Some were big enough that they could have been cow hearts. There were also some hearts from young kids who had congenital heart defects and had died, which was kind of sad. But overall, this was a great session and it was awesome to see in person all the heart pathology I've been reading about in Robbins. I hope they'll do some more sessions like this.

I got a really nice compliment today from my standardized patient for communications. We were doing motivational interviewing. My actor was playing a patient who had an alcohol problem, and I was supposed to help him realize it. The story was that his wife had insisted he come in, but he didn't think anything was wrong. I wound up getting him to talk all about his family and work and how he'd been more stressed at work, and he hadn't been spending as much time with his daughters as he did before. He came to the conclusion himself that he should spend more time with his family, and that maybe drinking was getting in the way. My preceptors commented that I didn't push him as hard to get help as I could have, because he was clearly ready to stop drinking. Well, I didn't do that because he was supposed to be only pre-contemplative (not knowing he had a problem and not planning to change), not contemplative (knowing he had a problem and that he might want to change)!

When class was over, my group was heading out of the library. My "patient" was leaving at the same time, so I went over to him and thanked him for his help and told him that he was a very believable "patient." He told me that he had felt really comfortable talking to me and that he thought I was going to be a terrific doctor. I was surprised and also a little touched. He was only pretending to have a problem and I was only pretending to help him, but I had gotten deeply enough into playing my part that it had seemed real, and I tried to do and say what I really would have done and said if he'd been a real patient. I have to say that his compliment means way more to me than any positive feedback I've gotten from either of my preceptors.

It's a good thing that communications went well, because my cardiology exam practice session was rough. Since I didn't have time to review the cardiac exam video before class today, I was not well prepared, and I had the bad luck to wind up being in the first room by myself. The preceptor said, "Go ahead and do a cardiac exam like you normally would, and then I'll go through it with you." Oh boy, was I ever screwed. In clinic, I usually just take the patients' pulse and blood pressure, then auscultate (listen with a stethoscope) their hearts. But there are all kinds of other things that we're supposed to do for a full physical, most of which I only vaguely remembered. So I fumbled through the exam as best as I could, but it wasn't very good. I did remember to take the blood pressure by palpation first and do the exam from the right side, and the patient was super nice. But I definitely did not wow this preceptor with my cardiac exam skills. Fortunately, I had a couple of other students in the room with me for all the other stations, and I did a lot better once I had gotten my wits about me again. We spent time listening to murmurs in some of the other rooms, and that was really helpful. Again, the faculty had found some patients with overt, easily audible murmurs.

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