Of Physical Diagnosis and John Cleese Puns

A week before our final didactic exam of first year, we had a wholly different experience: our final assessment in Physical Diagnosis. I’ve written quite a bit about “PDX” this year because it’s invariably where the best stories come from, and the exam was no exception.

We learned about a month out that the exam would consist of a graded patient encounter lasting about 45 minutes. We’d have to go into a room in our simulation suite, do a “focused” history and physical, figure out what’s wrong with the patient, and then present to a physician. The physician, by the way, has been watching the entire thing on video.

It’s kind of terrifying.

The rest of the exam included two short ungraded cases – the results went into our file for future reference, but didn’t count toward our grade – and a few online quizzes afterward.

The days leading up to the exam featured many spontaneous classmate-on-classmate physical exams, which led to some awkward encounters: a friend came up to me when I was opening my locker and asked to listen to my heart (I have a benign heart murmur and she wanted to practice). We were standing in the hallway with her hand up my shirt, motionless and silent, when a PhD student came around the corner. He looked at us, stopped, turned around and walked away. Back to your physics textbook, PhD student, nothing to see here.

On the appointed day, I put on my costume – shirt, tie, ridiculous white coat announcing me as a walking reckless endangerment lawsuit – and went to the simulation center. We got a brief review of what we had to do and were assigned an order: I had the graded long case first.

Entering the hallway, I went up to the assigned door to see a man sitting at the desk, writing a note. I can see my name at the top of the page.

The physician glanced up and… oh, God no. He looked EXACTLY LIKE JOHN CLEESE. Shit. I was going to start laughing. I did start laughing.

john-cleese-pic1

He introduced himself as a surgeon – name redacted in case John Cleese finds this blog and comes raging after me with a scalpel and a poor 360 degree assessment with my name on it – and told me to begin when I was ready.

Ready. LOL.

Time to foam in. Antibacterial foam, as I’ve mentioned before, is my archnemesis. I can never figure out how much to squeeze out, but you’d think after a year practicing I’d be– SPLAT. Nope. A bit of foam laid atop John Cleese’s head. He did not appear to notice. I did not appear inclined to notify him.

Thus lubricated, I went in to the room and introduced myself. Oh no. It’s a woman.

Now, before you call me a misogynistic jerk, know three things about caring for female patients: 1) THEY HAVE BOOBS. 2) They cover these boobs with “bras.” 3) Our actor-patients have an unusual propensity for wearing sports bras, which aside from providing superior protection during vigorous activity also make it impossible to perform a cardiac exam. I’d have to cross that Rubicon later when it was time to do the physical. Ugh.

Unfortunate gender issues aside, within a couple of minutes I settled into the routine. I’ve seen enough patients on my own that I can get a bit of a flow going with taking a history, and I forgot I was being spied on by the obnoxious French castle guard from Monty Python and the Holy Grail. “GET YOUR DIAGNOSIS RIGHT OR I SHALL TAUNT YOU A SECOND TIME.” Ugh.

Anyway. As the “patient” told his story, I had to resist the urge to stand up and do a giant Tiger-Woods-pre-fleeing-enraged-golf-club-wielding-wife fist pump. I knew the diagnosis.

Of course, since our PDX director is perhaps the nicest faculty member in the medical school, we all knew something straightforward was coming. But still. Small victories for most are big victories for me.

I can’t actually tell you what the diagnosis was, because we were sworn to everlasting secrecy under threat of having to watch endless seminar videos on patient safety. But by the time the physical exam portion was done (after a fun and awkward song and dance about moving bras around), I was sure of the answer. I resisted the urge to yell “I KNOW WHAT YOU HAVE!” and drop the stethoscope as I dramatically swaggered out of the room to tell John Cleese what’s up. That would be poor professionalism. Instead I reasonably explained to the actor-patient what I thought the diagnosis was, but that we would need some more testing. I think I was right about the testing part.

I exited the room and Monty Python informed me that I had exactly 2 minutes to “collect my thoughts” before presenting to him. I had completely forgotten about the presentation, and scariest of all I realized I needed a list of possibilities – a differential diagnosis, ordered by likelihood. I had no idea what came second or third on my list, so I just made them up. I am not even sure one of them is a disease.

I joined Q from Die Another Day in the exam room after my 1 minute and 57 seconds had elapsed. All he said was, “go.” Surgeon all the way.

“Mrs. X is a 54-year-old female with a past medical history significant for hypertension who presents today with a chief complaint of…”

543_MustardSSThe presentation went fine until The Black Knight – bet you didn’t know John Cleese played that role, too! – started asking me questions about my diagnosis. “Why would you want this test? What would you expect to find? Why not go straight to surgery? How soon does this patient need treatment? Tis but a flesh wound… Have at you!” I felt like I was being pimped on cardiology by Colonel Mustard. Nor did I have any idea if he was pimping me for fun (yes) or for my grade (no).

The moral of the story: I passed, survived my first unnecessary pimping encounter, and am terrifyingly going to be loosed on the poor patients of our obstetrics and gynecology department in September. Heaven help all those reaching term this fall.

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