The pupil and the teacher,
one just a little ahead of the other. William Osler
Don’t Get Caught Listening to Your Patient!
D. Micah Milgraum, MS4, Philadelphia, Pennsylvania
Abstract: A fourth year medical student blunders while learning not to take everything a patient says at face value.
Keywords: pityriasis rosea, medical student, tinea, listening, medical lingo, pimping, embarrassed, ringworm, patient presentation, lesson learned, herpes, dyshidrotic eczema
During the fourth day of my first dermatology rotation, I enter one of the clinic’s patient exam rooms to meet a 42 year old man sitting on the examination table holding his palms out towards me.
“What brings you into clinic today?” I ask.
“I have herpes on my fingertips. Well, I know that I have anal herpes and am being treated for that by a ‘rectum guy’, but every few months I get these blisters on my hand. I’m pretty sure its herpes so I just need treatment for my herpes.”
Simple enough. I thought. I spend the next few minutes asking detailed questions about his problems.
“How many spots do you have? Does anything you do make them better? What makes them worse? Who is the doctor managing your anal disease? How is that treatment going?”
After our conversation, I exit the room and prepare my thoughts. I find the resident assigned to this patient and confidently present a shortened version of what I had learned. I detail his anal problems and associated conditions making sure to mention the relevant facts.
“That doesn’t make any sense!” he tells me, after which he continues to ask me a series of questions which I stumble through with some “Uhs “Ohs and “I don’t knows.
“The anal disease was likely caused by a different virus. The warts wouldn’t only occur on one finger if it was related and he wouldn’t be having these recurrent episodes that he is experiencing.”
He walks in the room glances over the patient palms and fingertips and quickly says, “Dyshidrotic eczema,” which he confirms by asking the patient a few questions.
“We will give you some steroids to treat the flare and some to keep for when it comes back. Also we want you to wash your hands less and avoid irritating chemicals. Most importantly, we want to reassure you that it is not contagious and is not something to be embarrassed about.”
Lesson learned. Don’t listen to your patient.
A few days later as a wiser medical student, I walk in to a different patient’s room and ask what brings her to the office. This time it is a 29 year-old woman and the chart only noted that she had come in for a rash.
“You see I work with kids, and one of them gave me ringworm a few weeks ago. I went to the emergency room and they started treating me with some cream. For the most part it got better, but then other spots started popping up all over the place. I started putting the cream on those spots and I want to make sure I am doing the right thing.”
The story is definitely plausible. I thought. But then I look at her rash.
“First it started here behind my knee and then it spread. I have spots on my back, my arms, legs and few spots on my belly.”
On exam, I see round patches of darkened skin with some peripheral scaling. I look at her back and the lights turn on in my head as I see a Christmas tree pattern of lesions in front of me.
“This isn’t ringworm I tell my patient.”
Excitedly, I run down the hall to tell my resident my findings. I had learned my lesson to think through the context of the history and physical and not completely rely on what my patient says.
“This is a 29 year-old African-American woman who was recently treated for suspected ring worm, but …”
The resident cuts me off: “We don’t say ‘ring worm’. If you are talking to a medical professional use proper medical language.”
“Oh … um, okay … tinea corporis.” I said feeling a little embarrassed.
“The patient is being treated for tinea corporis, but I think she has Pityriasis Rosea,” I tell my resident trying to recover from my blunder and present my findings correctly.
We see the patient together. The resident asks a few questions clarifying the timeline of the eruptions and together we leave.
Before presenting to the attending the resident turns to me.
“Good job picking that up. Next time just remember to use medical words. Part of being able to diagnose and treat your patients properly is being able to communicate effectively with your colleagues and supervisors. “
Darn. I thought. Next time I’m not going to listen to my patient at all!
Author Bio: Micah Milgraum is a fourth year medical student at Drexel University College of Medicine in Philadelphia. His professional interests include compassionate care for children and adults with developmental disabilities, diseases of the skin with a focus on melanoma, and medical ethics. When not on the hospital floors, Micah can be found studying (obviously), swimming, painting or playing tennis. He is supported in his endeavors by his loving parents, siblings and army of nieces and nephews.