Every Patient Tells a Story (25 page)

Starting in 2004, all medical students have been required to pass an exam that tests their clinical skills: their ability to take a history, perform an appropriate physical exam, and collect the data needed to diagnose and treat a patient. The United States Medical Licensing Examination—known as the USMLE—is the test physicians must pass to get licensed in most states. When I took the exam it was made up of just two parts. The first, given at the end of my second year of med school, tested knowledge of the basic sciences of medicine—anatomy, physiology, pharmacology, genetics. The second part of the test was given after graduation and focused on the understanding of basic patient care concepts—could I interpret the patient data that was provided? Was I able to formulate an appropriate differential diagnosis? What studies should be ordered based on what was known? Which medicines would be appropriate in the given setting? Which would be dangerous and must be avoided? Students must still prove their mastery of the book knowledge of medicine, but now, in addition, they will have to demonstrate their skill with patients as well.

In adding this component to competency testing, the USMLE is hearkening back to an older model. As early as 1916 the licensing exam included an evaluation of a real patient, observed by an experienced physician-grader. After taking a history and performing a physical exam, the students were questioned about what they found. This component was dropped in 1964 because of the lack of standardization intrinsic to this kind of test.

But twenty years later the licensing board was asked to design a new test of these skills that would be reliable. The National Board of Medical Examiners, which oversees the USMLE, spent another twenty years trying to develop a system for testing these skills that was fair and reproducible. The medical school class of 2005 was the first to have to jump through this additional hoop.

Medical schools didn’t exactly embrace this new test with open arms. The American Medical Association (AMA) was against it. So was their student branch as well as the student arm of the American Academy of Family Physicians. Opponents argued that most medical students already learn this stuff; and most institutions already test it, so what’s the point of repeating
this testing? To the students it seemed like just one more expensive test—they have to pay to travel to one of a dozen centers across the country, and the test itself cost over $1,000. But ultimately everyone takes it because that’s what you need to do to become a doctor.

Has it done any good? It’s still too early to tell if the test has made any real difference in what doctors do, yet if my own institution is any example, then I suspect it’s having a tremendous impact on how doctors are trained—at least in medical school.

Eric Holmboe now heads the department that evaluates medical residents at the American Board of Internal Medicine (ABIM), the organization that accredits doctors specializing in internal medicine. Until 2004 he was associate program director of the Primary Care Internal Medicine Residency Program at Yale. (That’s when he saw my patient Susan Sukhoo.) At a recent meeting of directors of clinical teaching from medical schools in the Northeast, Holmboe described Yale’s preparation for the clinical skills exam part of the USMLE. The faculty had arranged for all of the fourth-year medical students to go to the University of Connecticut in Farmington, where they could take the kind of test that Chris took as preparation for the real thing.

Before the test several of the Yale faculty traveled to northwest Connecticut to check out the facilities and the test. They chose seven clinical scenarios, giving them a few tweaks until everybody was comfortable with the setup. And students from Yale traveled up in groups of six to take the test over the course of several weeks.

When the scores came back, the faculty was shocked. Twenty percent of these fourth-year Yale medical students—seventeen out of eighty-five test takers—had flunked the test. Eric described the reaction when he presented the scores to the faculty. “It was god-awful—the grief reaction in spades,” Eric told me. “Kübler-Ross was hovering over the room,” referring to the anthropologist’s famous stages of grief. “It was anger, denial, and bargaining all rolled up in one.” There were concerns about the test—even though they had signed off on it before the students had gone up—and there was plenty of skepticism—this could not represent the real performance of fourth-year Yale medical students. But amid grumbling and skepticism, everyone agreed to view the tapes of the students who failed.

When they met again, four weeks later, attitudes had changed. “The anger and denial had evolved into deep, deep depression,” Eric reported. In one tape, a Yale medical student who was planning to go into neurology completely botched the cardiac exam. He was listening for heart sounds in all the wrong places. When he was given this feedback by the patient-instructor, the student’s response was breathtaking in its arrogance and ignorance: he didn’t need to know the heart exam—he was going into neurology. Stroke, the most common neurological disease, is often caused by problems originating in the heart. “When he said that,” continued Eric, “it pretty much cinched the deal and suddenly it was Houston, we’ve got a problem.”

In response, Yale revamped the way the physical exam was taught. When I was a student, the physical exam was taught at the end of the second year, just before we began our clinical clerkships that took us into the hospital wards. It was a twelve-week course with lectures a couple of times a week. During the lecture the physiology of the organ system was briefly reviewed and the exam technique was explained and sometimes (but not usually) demonstrated. Essentially I learned about the physical exam the way I learned about sex and menstruation—I got a brief, very nonspecific chat and a book. And did I have any questions? No. Great. The end. All the real info I was left to gather on my own. I figured it out at puberty and I figured it out again in medical school. Essentially I spent hours roaming the halls of the hospital looking for medical students already doing their clerkships to ask them to show me interesting physical exam findings. Like everyone I knew, I learned what I knew about the physical exam on my own, with a patient, a book, and the help and “wisdom” of a student just one or two years ahead of me.

Now Yale begins teaching their medical students from day one. In the very first year there are classes on the techniques of interviewing and examination. Students meet in small groups weekly to review and practice these techniques for the first two years of school—first on each other, then on patients in offices and in the hospital. By the time medical students enter the hospital in their third year, they have the basics of these key data-collecting tools down. They are ready to build on a sound foundation. Unfortunately, there is frequently no one there to help them start construction.

I graduated from medical school with a set of physical exam skills that was spotty and idiosyncratic, and may have been considered unacceptable—had the doctors I then worked with ever observed me. I wasn’t worried, though. I figured I’d learn the proper way to examine a patient when I was a resident. I was wrong. Studies show that by the end of residency training a physician’s skill may be no better than the skills he had as a medical student.

Some of this is undoubtedly due to the time and access constraints already discussed. But some of this is due to an underlying attitude that the physical exam is already history. I accompanied Holmboe to a meeting with several directors from medical school and residency programs to discuss a new initiative to shore up the clinical skills of doctors in training launched by the American Board of Internal Medicine (ABIM). At this meeting Dr. Raquel Buranosky from the University of Pittsburgh voiced a common complaint. “Med students in our program get hours and hours of training in the physical exam in their first and second years. They do great at our final exam. Then they go into their clinical clerkships and, poof, it’s gone.” There was general head nodding around the room and many of the directors told similar stories. Eric added one of his own. A colleague had worked with a medical student several times and been happy with his skills. Several weeks into the student’s first clinical rotation—an internal medicine clerkship—the young student returned to have one last class with his teacher. The teacher watched him evaluate a patient and was horrified to see the student do absolutely everything wrong. He interrupted the patient’s story, he asked closed-ended questions, he examined patients through their clothes. He skipped much of the exam. The teacher couldn’t believe it. He asked the student what had happened since they last met. Oh, replied the student, “my resident says we don’t have time to do all that. I mean, what’s the point?”

Anyone who’s been through training won’t doubt the accuracy of this young man’s story. In residency, it often seems that no one cares if the patient is examined or not. Small wonder that many of the finer points of the exam simply slip away. And once they’re gone, it practically takes a miracle to get them back. And yet with a patient like Patty Donnally, these skills can unravel a mystery.

A Kink in the System

Patty Donnally is a youthful-appearing fifty-eight-year-old woman who has had high blood pressure since she was a teen. And no matter how many medications she’s taken—and she has taken many—it’s never been well controlled. Her internist tried for years to tame it. He put her on every combination of medications he could think of. Her blood pressure came down—but was never normal. Not even close. Occasionally he wondered if she was even taking her medicines. But she came to all her appointments, was aggressive in following up, even read up on her problem. That wasn’t the behavior of someone who didn’t take her meds. And when asked, she could recite her most current medication regimen no matter how many times it had changed. No. It was clear—this lady took her medicines. But her blood pressure remained high. After almost a decade her internist gave up and referred her to a specialist in hypertension. The specialist was baffled too and eventually he referred her to the hypertension clinic at Yale.

At Yale she was seen by Dr. Bill Asch, a young enthusiastic hypertension fellow whose cheerful disposition often made her forget the frustrations of her apparently untreatable disease. His wit made the schlep to New Haven almost worth it. So she was disappointed and a little annoyed when a new doctor walked through the door.

“Where’s my regular doctor?” she asked the young woman who entered the tidy exam room. A trace of annoyance colored her voice, and the lines between her brows deepened in the top half of a frown. Dr. Shin Ru Lin sighed inwardly. She had finished her residency training a few weeks before, and had just started at Yale’s hypertension subspecialty training program. She was getting to know the patients she inherited from Asch, who was doing research this year and not seeing patients. Serious and shy, she’d been a little hurt by the disappointment expressed by more than a few of his patients when they found that she was now going to be their doctor.

And she was more than a little intimidated by this case in particular. Ms. Donnally was on six potent hypertension drugs, and yet, according to the nursing note on the front of the chart, her blood pressure was still too high.
The patient had seen many doctors, had had scores of tests. The chart was inches thick, and still no one understood what was going on. Lin had only just begun her graduate fellowship in hypertension—how was she supposed to figure this out? What could she possibly have to offer?

“When were you first diagnosed with hypertension?” the doctor asked tentatively.

“I’ve had it forever—you know, it’s all in my records.” Patty waved toward the thick chart. “My blood pressure is too high, I’m always tired, and my legs hurt when I walk. Nothing changes—except my doctors.”

In a specialty clinic like this one for hypertension at Yale–New Haven Hospital, patients have already been to several doctors, and often they are as frustrated as the physician who referred them. Each specialist, each series of tests, eliminates more of the likely causes of the problem, and the diagnostic question seems increasingly difficult to answer. And in an academic medical center, patients are often seen by trainees, like Lin, who change every year.

Lin was overwhelmed. Waiting outside the exam room as the patient undressed for the physical exam, she opened the thick chart. She knew it would take her hours to go through it properly and she still had several more patients to see. Lin scolded herself for not reviewing it more thoroughly before meeting her for this first visit. She quickly paged through it. High blood pressure—okay. Also high cholesterol. She took a medicine for that. She didn’t smoke or drink. She carefully kept track of her blood pressure at home. Before the doctor could get much further, it was time to go back in.

On exam, the patient’s blood pressure was—as expected—very high. But there were unexpected findings as well. As Lin listened to the patient’s neck over the carotid arteries, she heard a soft rhythmic whooshing noise over the normally silent vessels. This sound, known as a bruit, is caused by an unnatural turbulence in the flow of blood. It often indicates a narrowing of the arteries caused by atherosclerosis, commonly referred to as a hardening of the arteries.

She moved her stethoscope down to the chest. She heard more unexpected noises. In between the lub and dup of the normal heartbeat there was a brief, harsh murmur—like the snarl of an angry animal. Was this a new
symptom? She would have to check the chart. It was audible everywhere she placed her stethoscope on the left side of the chest, though it seemed loudest at the top. Atherosclerosis could affect the valves of the heart as well as the arteries. This raspy murmur suggested that the disease may have narrowed the patient’s aortic valve, one of the four valves of the heart. Could that be driving her blood pressure up? It seemed unlikely.

Then, in the abdomen, she found yet another noise: a soft shush-shush over the renal arteries. As she completed the exam, Lin remembered the patient’s other complaint and examined her legs and feet. They looked fine—no lesions, redness, or rashes—but she couldn’t find a pulse at either ankle. Was this more evidence of hardened arteries diminishing blood flow to her feet? That could explain the pain in her legs.