MSHQ 098 : Time to Get Touchy Feely – Let’s Talk Physical Exam

Session 98

Session 98

In today's episode, Ryan is joined by the lovely Allison who is celebrating her birthday today, as they get touchy-feely, talking about physical exams.

In their search to figure out the topic for this week, Allison came across a great, beautiful piece featured on The New York Times written by Dr. Danielle Ofri, an associate professor at New York University. The most recent article she wrote, The Physical Exam as a Refuge, raises a number of great points that speak not only to physicians but to medical students as well. In this episode, the powerful duo will try to dissect these points for the listeners as well as share their insights so students will walk away with better understanding about this topic.

So how do you view your physical exams going from medical student to doctor?

Here are some key points that Ryan and Allison discussed in this episode:

  • Changing the mindset as physicians and advisors in the way they view medical exam.
  • Learning the physical exam on your first year at medical school.
  • Physical exam as part of the medical school curriculum.
  • Students entering the wards and seeing physicians, their mentors barely examining people at all.
  • Electronic medical record duties
  • Things you need to do when a “complicated” patient comes into your office.
  • Realizing that time spent in direct patient care is relatively short.
  • Other things you need to do aside from direct patient care: ordering new labs and tests, reviewing old ones, writing notes, talking to other team members.
  • Dealing with the guilt and longing as doctors for skimping some parts of the exam or not doing it well.
  • 3rd year students having the most time available to spend with the patient and being the go-to for patients.
  • The challenges during residency having so many things to do at so little time.
  • Diagnosing the patient through history and physical exam.
  • History as the hallmark in figuring out what’s going on with the patient.
  • The upside of 90% history and 10% exams.
  • The number of test ordering done in practice vs. residency.
  • The beauty of the neurologic exam that they do that other branches of medicine don’t
  • What is a good neurologist?
  • What drives the need for a number of tests being done?
  • Dealing with lawsuits: Just a matter of “when”
  • Annual exams turning into a not so comprehensive one
  • Allison’s pet peeve
  • The good news – bringing back the importance of physical exams
  • Not letting all these pressures to allow the skills you’ve honed to disintegrate through your fingers.
  • Non-romantic intimacy with patients

Some pieces of advice for premed students:

  • Start from the history and the physical exam and everything else follows.
  • Fight with the pressures everyday and keep up the fight.
  • Take Ryan’s and Allison’s knowledge and experience as well as the Dr. Ofri’s piece, as you’re doing your physical exams.
  • Don’t get disillusioned to not pushing through with going to a medical school.
  • Do not type a note as you’re sitting with a patient.
  • Stay true to who you are!

Links and Other Resources:

  • Free MCAT gift – 30+ page report all about MCAT tips and strategies plus discount codes for some test prep

Transcript

Dr. Ryan Gray: The Premed Years, session number 98.

Hey, this is Z-Dog MD; rapper, physician, legendary turntable health revolutionary, and part-time gardener. And you're listening to the Medical School HQ Podcast, hosted by the irredeemably awesome, Ryan Gray.

Hello and welcome to the Medical School Headquarters Podcast; where we believe that collaboration, not competition, is key to your premed success. I am your host, Dr. Ryan Gray, and in this podcast we share with you stories, encouragement and information that you need to know to help guide you on your path to becoming aphysician.

If you are taking the MCAT soon and you haven't yet, go to www.FreeMCATGift.com and download our awesome free resource all about the MCAT. This week I am joined again by my lovely cohost, Allison Gray.

Dr. Allison Gray: Hello everyone.

Dr. Ryan Gray: Wow, that was much more tamed from last week.

Dr. Allison Gray: You told me I was too silly last week.

Dr. Ryan Gray: I don't know about too silly. How are you doing Allison?

Dr. Allison Gray: I'm great, how are you?

Dr. Ryan Gray: I am doing well. This week as we're releasing this podcast it's a special week for you, isn't it?

Dr. Allison Gray: Who me? Oh, yeah, yeah.

Dr. Ryan Gray: It's your birthday week.

Dr. Allison Gray: It is my birthday week.

Dr. Ryan Gray: You'll be thirty something. Right?

Dr. Allison Gray: So are you, you're thirty something.

Dr. Ryan Gray: You're a female though, I'm not allowed to say how old you are.

Dr. Allison Gray: Okay.

Dr. Ryan Gray: That's the rules.

Dr. Allison Gray: Yes, it's my birthday week.

Dr. Ryan Gray: Awesome. Happy birthday.

Dr. Allison Gray: Thank you, thank you.

Dr. Ryan Gray: This podcast comes out on your birthday. So if you're listening to this on Wednesday, October 8th, 2014, when this podcast comes out, go wish Allison a happy birthday on Twitter which she won't read because she's not on Twitter.

Dr. Allison Gray: I will read it if I get tweeted.

Dr. Ryan Gray: Do it. @Allison_MSHQ. Or you can send her a birthday email, Allison@medicalschoolhq.net; that'd be awesome.

Dr. Allison Gray: Aw, gee, thanks.

Dr. Ryan Gray: So this week we are going to talk about getting a little touchy feely.

Dr. Allison Gray: I guess you could call it that. Most people call it the physical exam.

Dr. Ryan Gray: Touchy feely. It's catchy, I like it. It's going to be our title. So tell us about what we're going to talk about.

Article by Dr. Danielle Ofri

Dr. Allison Gray: Well we- well in our search to figure out this week's topic, I came across a great piece that was written by Dr. Danielle Ofri who is an associate professor of medicine and New York University in Bellevue Hospital. And she's written multiple books. This most recent piece that she wrote is entitled ‘The Physical Exam as a Refuge.' And was again, a piece that was in the Times, and it was in July of this year so not too long ago. And reading it, it just really struck me- I think she raises a number of really great points in the article. It's really a piece, it's more sort of an essay, not really an article per say. And I think it's really profound and it speaks to all of us as physicians, and also to medical students. There's a lot in there about what changes really and the way we view the physical exam going from medical student to doctor, and whether or not that's a good thing. So I think it's great, I think it's a really great topic.

Dr. Ryan Gray: Yeah, it's a good piece. Again one of those different things. Most of the topics that we cover are premed topics. We've covered some medical school stuff, and we've covered just doctoring stuff. And this kind of goes along the whole doctoring aspect. But it's something once we start talking about it you realize this is something- it's almost like a mindset that you have to get in from day one and hopefully we'll help you with that mindset with this.

Dr. Allison Gray: Yeah I think as practicing physicians now, when we see things happen in the medical world, we as advisors to you all are trying to provide as much information as we can to help you on your path, and to hopefully prevent you from falling hazard to some of the things that we see that are not great about our profession.

Dr. Ryan Gray: Yeah, and hopefully you won't be- I was browsing one of the forums yesterday and there was a topic. Has a physician told you not to apply to medical school, or something along those lines? And it was just post after post after post of, ‘Yeah, this doctor told me not to,' and ‘yeah this doctor told me not to.' So hopefully listening to this podcast and hearing some of these things and listening to us talk about it kind of opens your eyes a little bit more, gives you a little bit more information as you begin your journey so that on the back end you aren't as frustrated and disillusioned maybe.

Dr. Allison Gray: Yeah, absolutely.

Dr. Ryan Gray: So why don't you start off by talking about this essay that you call it?

Learning the Physical Exam

Dr. Allison Gray: Well it begins by her discussing what happens to the physical exam as you go from medical school and onward. So in some ways this may sound sort of like a mini book report on her essay, but we're sort of framing it that way because she is- and if you read this article, I absolutely recommend that you do, she raises as I said a number of really great points. So we're just going to sort of dissect the piece and talk about our thoughts about what the points she raises and then add some of our own comments at the end. So just to give you kind of a framework.

Dr. Ryan Gray: Okay. So I'm going to start by talking about learning the physical exam. In most medical schools the general timeframe for starting to learn physical exams is really freshman year.

Dr. Allison Gray: Freshman, I love that you said freshman.

Dr. Ryan Gray: Did I just say freshman?

Dr. Allison Gray: You did, wow.

Dr. Ryan Gray: Wow.

Dr. Allison Gray: There's no such thing as freshman year in medical school but I guess you could call it that if you want to call it freshman year.

Dr. Ryan Gray: Well why can't we call it that?

Dr. Allison Gray: Because it's not. You're a freshman in high school, you're a freshman in college, that's it. End of story.

Dr. Ryan Gray: I am going to start a kickstarter campaign to call it freshman year of med school.

Dr. Allison Gray: Oh jeez. No and I'll tell you I don't want that. It should be freshwoman, there's no freshman. I don’t need that.

Dr. Ryan Gray: Let's not even get there. Anyway. So your first year of medical school, you start learning the physical exam. I remember- was it our first year where we were doing eye exams on each other?

Dr. Allison Gray: Uh huh.

Dr. Ryan Gray: I cannot have light shined into my eye- shone?

Dr. Allison Gray: Shined.

Dr. Ryan Gray: Shined into my eyes. I'm a pale redhead and I have very sensitive eyes because of that, just my general complexion and Irish nature. And we were doing physical exams on each other and that's what you do in medical school, you become very close to your friends because you're doing exams on each other. And I had to sit there and hold my eyelids open with my fingers so that somebody else could look into my eye, and I don't know how good of a patient I was at that time.

Dr. Allison Gray: Well and don't forget that you also were crying like tons and tons afterwards and during.

Dr. Ryan Gray: I wouldn't call it- my eyes were watering, that's not crying.

Dr. Allison Gray: It was a faucet. Okay.

Dr. Ryan Gray: So the physical exam you start learning very early on, it kind of goes hand in hand with anatomy lab; you just start learning the physical exam. It's important, and we'll talk about the importance as we get there.

Dr. Allison Gray: A lot of medical schools call it your physical diagnosis class, or- and a lot of schools too, they will have you go into the clinic to start working on obtaining histories and practicing the physical exam from day one.

Dr. Ryan Gray: Yeah. So it's obviously built into the curriculum, it must be important, so it's something that we practice for the rest of our life.

Dr. Allison Gray: Well it is and also not only do we really work so hard in the first two years of medical school at perfecting this exam, I remember- and I'm sure you do too, Ryan, that at some point in our medical school years- and I think it was toward the tail end of our second year, we were tested on the physical exam and we had a standardized patient and there was someone in the room with a clipboard and that person was watching everything we did. And this was the full physical exam, literally from head to toe. Minus rectal and genital exams and everything. But it was really, really in-depth and it's amazing to think about how long that whole physical exam was because it was at least I mean ten solid, fifteen probably solid minutes of just examining a person. And you think about- this is exactly what this article is talking about, how much time is spent doing the exam later. So that segues into her whole first part of this piece is talking about how these- like as we were saying, the first two years in medical school you're training so hard while your anatomy class and your biochem class, and pathology class; and you're learning how to do the physical exam. And do it really skillfully. Then fast forward to your ward years which are in most traditional medical school curriculums your second two years, so your third and fourth year. So she talks about how medical students, they enter the wards and all of a sudden they see physicians around them; their mentors, their teachers, barely examining people at all. So what is going on there?

Dr. Ryan Gray: I don't know.

Dr. Allison Gray: Well so why do we not-

Dr. Ryan Gray: I do know but that was my dramatic pause.

Dr. Allison Gray: It's really sad though. So I mean this is the art- it's the craft of medicine. And what is happening? Well, what do we have going on in residency and practice that is if you ask the insurance companies and everybody else so just as important or more important than the physical exam. We have our electronic medical record duties.

Dr. Ryan Gray: Yeah.

Skipping Pieces of Exam

Dr. Allison Gray: So she talks about how you have a patient coming in, a complicated patient; Ryan, I'm sure you've had experiences like this, I've had many where you have a complicated patient. And what I mean by that is a patient who has multiple, chronic medical problems. They come into your office and they're there with an acute issue. And in primary care this is different than it is for me in neurology but it's the same kind of concept. They come into the office, they're there to talk about this acute issue, and by the way you need to review their medications- or as we call it, reconcile their medications. You need to review their labs, you need to provide education, counseling, you need to document all of it in the electronic medical record; that part of which I do later. But anyway- and, and, and if you skip any of this, and if you skip these reconciliation of meds or the reviewing of the labs, it can not only affect your productivity, I mean you can get dinged, it could affect your bonus, your reimbursements, and you could get in trouble with the organization where you work. I mean they actually run sort of queries where they look at all the physicians and make sure everybody is dotting their I's and crossing their T's about this stuff.

Dr. Ryan Gray: Yeah they're auditing the records, and it all goes back to coding and making sure that you're billing properly, and there's a whole science behind that and that's really out of the scope of this podcast in general. So we won't dig too much into that, but it's one of those things that there are so many other duties as a physician that you need to accomplish- and that's part of why we're talking about this, is because you need to realize that when you become a physician, it's not like you're going to spend 100% of your time talking and touching and doing exams and operating, and whatever else you're doing with patients. The Johns Hopkins study that talked about the time spent in a hospital, the intern spent in direct patient care, is 11%. Right?

Dr. Allison Gray: Yeah, 11% or 12%, yeah.

Dr. Ryan Gray: Yeah, it's nothing. So there's so many other things that need to be done, and you've hit on a couple of them. There's ordering new labs, ordering new tests, reviewing old ones, writing-

Dr. Allison Gray: I didn't even talk about ordering, I was just talking about reviewing.

Dr. Ryan Gray: Writing notes, talking to the nurses, talking to physical therapists, talking to all of the other team members.

Dr. Allison Gray: Your medical assistants, exactly. Yup. And she has this quote in here that is just so sad but it is something to think about. She says, “In practice, performing the complete physical exam including stepping out of the room to wait for the patient to undress and again at the end for the patient to redress, is a luxury available only to open-ended teaching sessions with students.” So if you're a medical student out there or if you're a premed student out there and you're thinking, “Well you know, I'm working so hard to become a physician and some day I'm going to get in there and-” that just must sound so deflating. But-

Dr. Ryan Gray: So I'm going to play devil's advocate.

Dr. Allison Gray: Well I was going to say though that it's not necessarily the case, and we'll get to that later, but please play devil's advocate.

Dr. Ryan Gray: So for the most part- and I do primary care, that's what I do as a flight surgeon. I don't have a need to undress the patient all the time.

Dr. Allison Gray: Neither do I, just their shoes and socks.

Dr. Ryan Gray: Okay. If somebody comes in with elbow pain, I don't need to undress them. Someone comes in with belly pain, I don't need to undress them I can have them pull up their shirt.

Dr. Allison Gray: True, but devil's advocate to you, those are acute issues.

Dr. Ryan Gray: Correct.

Dr. Allison Gray: So what about your annual physical exam?

Dr. Ryan Gray: I deal with the unhealthy people.

Guilt at Skimping on Exams

Dr. Allison Gray: Okay so Ryan, you're smiling, this is going to segue beautifully into our next topic- our next comment or statement in her piece here which is about the guilt we feel, right? So she talks next about the guilt we feel as doctors for sort of glossing over or skipping over this part. So in medical school they actually teach you that you are never, ever supposed to put your stethoscope onto a patient's chest over their clothes.

Dr. Ryan Gray: I have this awesome skill that- and it's a special-

Dr. Allison Gray: You're supposed to be a good role model.

Dr. Ryan Gray: It's a special stethoscope that lets me hear through shirts.

Dr. Allison Gray: Okay, Superman, anyway.

Dr. Ryan Gray: I won't listen through a sweater or a sweatshirt or anything. But just a regular cotton shirt?

Dr. Allison Gray: No, no, no. So anyway she says- and again I'm just going to quote her one more time here because I think this is so poignant. She says, “All doctors have, though we typically don't like to talk about this because it stirs an awkward mix of guilt and longing within us.” She's talking by the way about again, skipping over the exam or really just doing it very hurriedly. She says, “We recall wistfully our rounds as students when our bow-tied and starch-coated attendings unhurriedly probed every fingernail bed, meticulously [Inaudible 00:14:23] the cardiac contours, palpated the epitrochlear lymph nodes,” and she then ends by saying, “we feel that we are remised with our current patients that we are skimping on what is the [Inaudible 00:14:32]of the doctor patient connection.”

Dr. Ryan Gray: Must have been a neurologist with that bowtie.

Dr. Allison Gray: The bowtie comment, I know, right? Actually, it's not- I mean she's- oh I see you mean her attending at the time, yes. Because she's in internal medicine. But yeah, so- and I'll-

Dr. Ryan Gray: I don't know about guilt.

Dr. Allison Gray: I'll tell you Ryan, I can totally relate to that comment 100%.

Dr. Ryan Gray: Why?

Dr. Allison Gray: Because I've been there too. So I remember- not so much in medical school because again, you're- in medical school is a time- and I bet you you were told this too. They said to me and all the other medical students there and I've heard this multiple times. As a third year medical student, you have the most time available from among anybody else on the team, you have the most time available to spend with the patient.

Dr. Ryan Gray: Yeah.

Dr. Allison Gray: So at the time that's so exciting because I mean you are the go-to for that patient, you know the patient backwards, forwards. Anything about that patient needs to be done it's on you, so it's great. But it's a little bit sad if you think about it, right? So the attending, the fellow, the residents, they are removed a little bit. Anyway, so- but this whole quote is just again, it's talking about how during training you have all this beautiful time, this wonderful time to really learn and understand, and then fast forward and-

Dr. Ryan Gray: Well wait, you skipped over how you can relate to this comment.

Dr. Allison Gray: Well wait- I know, give me a second, I'm a little slow tonight I guess. Ryan's saying, “Pick up the pace!” So for me, I fondly remember those times bowtie or not, being taught by my attendings and then get into my residency, my internship, my residency where you are hurrying, you're hurrying all the time. I mean you barely have time to eat, you're trying desperately to get all of your work done, do all the things that need to be done for your patients, and you do sometimes find yourself- or at least I have, glossing over parts of the exam. You know I used to say- and this is, I'm being very- what's the word, authentic here, very honest. Sometimes we used to say in residency as long as you can hear a heart heat, a breath sound and a gurgle, you're all set.

Dr. Ryan Gray: Wow.

Dr. Allison Gray: Right? That's terrible though, but I'm just telling you as physicians, right? And in neurology I mean that's really- we're much more focused on the rest of the exam, our neurological exam. We're making sure that the patient is breathing, and their heart is beating and everything.

Dr. Ryan Gray: This is during your neurology, not during your internal medicine?

Dr. Allison Gray: No, no, no, no, that would have been horrible, yeah. No, I did do a much more thorough general physical exam in my intern year. But as a neurology resident, yes. I mean you just- you needed to make sure that they were alive, and their chest and their abdomen, but otherwise you were mainly concerned with their neuro exam. Anyway point being Ryan, I definitely have felt guilt from time to time, that yes I could have spent more time on the exam. But I felt the pressure to do all of the other things that I needed to get done. And some of them, by the way, were extremely important like going to have a family meeting with the patient down the hall who I was also taking care of. Or responding to a code. I mean things come up, it's not that we're saying, “Oh, it's all administrative stuff and we're always called away from the patient to do this stuff.” No I mean some of it's really, really important too. But I do- that does resonate with me, feeling that sort of guilt.

Dr. Ryan Gray: So I don't know if I've ever felt guilty, but I don't know, we'll see. So there's the physical exam and then there's the history. We're always told diagnosing a patient always starts with a good history and physical. A good history and physical will get you 90% of the way there.

90% Patient History – 10% Physical Exam

Dr. Allison Gray: Actually the way I was taught, is a history is 90% and the exam is 10%.

Dr. Ryan Gray: And together, 90% of the way there.

Dr. Allison Gray: I don't know about that math. I'm bad at math but that's pretty bad. Anyway, yeah that is what we were taught. And I'll tell you my mentors, my teachers in residency, it's 100% how I was trained. The history is the hallmark, is the key to figuring out what is going on with the patient. So my take on this piece that she wrote, I do think there's a way to sort of continue to embrace the physical exam and its importance if you hold true to that fact that yes, we have CTU, we have MRI, we have x-ray, we have a million different- we have FMRI, we have a million different things to offer nowadays in terms of testing. But at the end of the day, if you talk to physicians who have been doing this for many more years than Ryan and me, if you really hold true to 90% is your history and 10% is your exam, then really I think you will at least hopefully prevent yourself from just shooting in the dark and ordering a million tests.

Dr. Ryan Gray: Alright so I know we have it later on here, but we're going to talk about neurology a little bit because you guys are the kings of- and queens of the physical exam. The neurology exam is something that you guys hold sacred and you think everybody else just doesn't know what they're doing. That's a different podcast.

Dr. Allison Gray: Okay.

Dr. Ryan Gray: But there was just a big article with one of your mentors from Brigham and Women's Hospital. And it talked about at the bedside- is it Dr. Ropper?

Dr. Allison Gray: Dr. Allan Ropper who's one of the most amazing mentors and just an incredible neurologist.

Dr. Ryan Gray: So Dr. Ropper talked about how he could pretty much pinpoint where a lesion was in a brain, where an infarct happened, where a-

Dr. Allison Gray: Infarct meaning stroke.

Dr. Ryan Gray: Yes. Where something happened to the brain from something. And from a physical exam.

Dr. Allison Gray: Absolutely.

Dr. Ryan Gray: So why doesn't it end there?

Dr. Allison Gray: Well I'll tell you something, for many neurologists it does, it does. And that- see that's the difference.

Dr. Ryan Gray: Wait, hold on. I was going to say meaning as soon as he pinpointed that exam, he said, “Okay let's order an MRI and-”

Dr. Allison Gray: Actually he doesn't, that's the thing. So training there where I did at Brigham and Mass General, it's not the case. And actually I'll tell you the honest truth Ryan, in practice- in private practice, I have seen way more test ordering than I ever did in residency. In residency there were times when we encountered a very challenging case where it was very, very hard to figure out what was going on and there were times that for these very complicated, challenging cases, there were many tests ordered. But as a rule, yes I ordered less tests as a resident than I do now.

Dr. Ryan Gray: Okay.

Localizing the Problem

Dr. Allison Gray: And the way I was trained, I really, really try to hold very fast to that you really do- I mean so what are we talking about? The beauty of the neurologic exam, and part of why I love my job, is that we do something that other branches of medicine and surgery don't; we localize. Neurosurgery does this too, but not as good as we do. Not as well as we do. No that's not true to my neurosurgical colleagues, I'm just kidding. But anyway the point is that as Ryan said, somebody comes in with neurologic symptoms and the first order of business is figuring out where the problem is. Not what the problem is, but where. So with the skills that we learn in the neurologic exam we're able to figure out based on somebody having slurred speech or weakness on one side of the body, where the problem is originating in the brain or the spinal cord or elsewhere in the nervous system. The peripheral nerves, the muscles, the neuromuscular junction. So it's a beautiful thing, and it's a lot longer than the rest of the physical exam, there are a lot of parts to it. Just in brief there's a mental status exam, cranial nerves, motor exam, sensory exam, reflexes; it's a long exam which is why I always used to joke with people there's no such thing as a short neurology consult. But it's a great thing because you get to the end of it and you have a very good sense after you've taken a really good history and done this exam, not only where but also what could be going on with this patient. So what I actually literally tell my patients in the office, and I've said this many times, is- because sometimes they'll say, ‘Well aren't you going to get an MRI, or I'd like to-‘ and I say, “Well look, in my mind a good neurologist is someone who takes everything based on what you're telling me and then your exam. What you're doing on exam is the key for me to figuring out what's going on with you.

Dr. Ryan Gray: So you think it's- is it the patients that are driving a lot of tests, because they just want to see and-?

Putting Out Fires & Avoiding Lawsuits

Dr. Allison Gray: No, I think it's something else. And this is another point that she also talks about. What are we also doing in medicine these days which is a major problem in the United States, and the other parts of the world too, we are rushing around, putting out fires, avoiding lawsuits, right? So even if you are really, really skilled and you are in there and you've gotten a beautiful history, you have a really good sense of what the problem is, you've done a great exam, you've confirmed where you think the problem is if you're a neurologist. I mean you can also feel a mass in the belly, and I'm not just saying neurologists are the only people that can figure out where a problem in the body is. But- and then you figure out what the problem is. So even if you've done all of that, then you worry, ‘Well what if I missed something?'

Dr. Ryan Gray: What if I missed something and it comes back to haunt me with a lawsuit?

Dr. Allison Gray: Mm hmm.

Dr. Ryan Gray: Yeah.

Dr. Allison Gray: And what do they tell you in medical school? In medical school they tell you you're going to get sued. It's that whole look to your right, look to your left, you're going to get sued. It's just a matter of when.

Dr. Ryan Gray: Yeah. I don't know. That's why I like the military. You can get sued in the military too.

Dr. Allison Gray: But that's not to scare everybody out there. We're just saying- again, we're sharing our personal experiences and things that we've learned along the way. But I think part of what Dr. Ofri is talking about here is that in rushing to put out these fires and ordering all of these tests, and spending all this time on the computer, we're really- our physical exam skills are going by the wayside.

Dr. Ryan Gray: And the fact that- I really don't like this excuse to ‘make ends meet,' we're seeing a lot more patients, the primary care physician is. So they're cramming 20-25 patients in a day with fifteen minute, twenty minute exams. And so there really isn't enough time. And so typically this annual exam turns into, ‘How are you doing? What's going on? Have you gained any weight? Do you have any new problems? Let me check your blood pressure, let me check your weight, and anything you want me to look at today?' And that's kind of what it turns into.

Dr. Allison Gray: Yeah, no and I've seen recently- I've had some patients who've been established with a new primary care, and so I've seen what they've done and they've reported back to me. And sometimes they don't have time for an exam, they spend the whole time for this first encounter, which maybe is forty minutes because it's the first time you've ever met the patient. And there's no time for the exam. And I've seen it listed in the record, ‘No time for the exam today, we'll do it next visit.'

Dr. Ryan Gray: That's not good either.

Dr. Allison Gray: No but I guess at least it's honest, right? So you don't have that guilt of, ‘Well I kind of listened to the heart, and-‘

Dr. Ryan Gray: But an exam is, ‘Patient is in no apparent distress, looks well.'

Dr. Allison Gray: That's true I mean you could-

Dr. Ryan Gray: Vitals.

Dr. Allison Gray: So some of it could have been documented. There is some that you can always say, that is true.

Dr. Ryan Gray: I did that on one chart when I was a medical student.

Dr. Allison Gray: What?

Dr. Ryan Gray: Exam not completed. It was during an orthopedic rotation.

Dr. Allison Gray: What? Your exams in that are like two minutes. Your notes are like two seconds.

Dr. Ryan Gray: But it was a follow-up exam that just really didn't- I forget what it was for, it didn't need an exam.

Dr. Allison Gray: So did you forget?

Dr. Ryan Gray: No, I put exam not done.

Dr. Allison Gray: Oh. Because you really didn't need to.

Dr. Ryan Gray: I didn't need to. And yeah, I got-

Dr. Allison Gray: You got reamed out?

Dr. Ryan Gray: Yeah, so if you're listening- for you listening, do not ever put ‘exam not done.'

Dr. Allison Gray: Yeah and my pet peeve is never put ‘not able to do.' You're always able to do something. So, yeah.

Dr. Ryan Gray: Anyway.

Dr. Allison Gray: Anyway, that's another podcast. So what's the sort of- what's the silver lining? What's the good news in all this? So part of it is that there are physicians out there who are trying to- they're pushing to bring back the importance of the exam in the eyes of us as a medical community, and the insurers, and all of this. And that's so important. I mean part of what we do as physicians, we are the only ones out there who are trained in doing this sort of comprehensive physical exam and then using our diagnostic skills to order the appropriate tests, and et cetera. And we have a lot of practitioners who are also skilled in the exam, and nurse practitioners, and physicians' assistants. But we can't as physicians, in my mind and in a lot of people's mind, we cannot let all of the other pressures allow us to- these skills that we've honed and worked so hard on in medical school, to disintegrate in our fingers.

Dr. Ryan Gray: I think a lot of it too can come down to- I don't want to say complacency, but I've probably felt 1,000 or more abdomens. Do you know how many times I've felt an enlarged spleen?

Dr. Allison Gray: I know, but so Ryan that's another point that she makes at some point in this article. I mean so you might say, okay well you've taken a great history, why do you even need the exam? If it's 90%- if you're at 90% why do you need that additional 10%? That's exactly the point. You could feel 1,000 abdomens but at some point in there you are going to feel an abnormality, you're going to feel an enlarged liver or an enlarged spleen. And if you don't do it, then that whole point about you're rushing around trying to put out fires, you're going to miss the thing you could have picked up with just your fingers, with just your hands on the exam.

Dr. Ryan Gray: Yeah.

Non-Romantic Intimacy

Dr. Allison Gray: So who cares about odd? It's finishing the job. So and Dr. Ofri has an interesting sort- as you put ‘touchy feely' point to all this which it's really neat what she talks about. She takes a different spin on this in a way. She talks about how yes, there's so much intimacy with the computer nowadays if you will, you're constantly in front of the computer, eyes are almost spent more on the computer than on the patient. And so when you put that down and you actually go over to the exam table and you examine the patient, it's what she calls a sort of ‘non-romantic intimacy.' And she talks about how that's the time when patients open up about their concerns, and she calls it sort of a refuge from the intrusions of technology. She's a really beautiful writer, it's a really good piece.

Dr. Ryan Gray: Maybe we'll have to get her on.

Dr. Allison Gray: I think we should, we should ask her. But anyhow I thought that that was really interesting too. And it's true, I don't know Ryan, tell us about your experience, and mine it is true that when you're taking that time with just you and the patient to do the exam, that's the focus and many times people do I think let their guard down more and feel like they can tell you things during the exam that maybe they felt a little bit more uncomfortable about when it was you and the computer and the patient.

Dr. Ryan Gray: Yeah, I don't know if I have any specific examples, but I could buy it.

Dr. Allison Gray: Well so that's the piece and I think it raises a number of really- of difficult points, things that we're dealing with as a profession that we wish we weren't. But I think that there again are- there are some takeaways here that you as a premed and as a medical student can really hold onto. And I'm telling you, I mean I really do try to continue the way that I was trained, to really start from the history and the physical and everything else follows. And we fight every day to these pressures that are around us, but I think we need to keep up the fight.

Dr. Ryan Gray: Yeah, I like it. It's important and again I hope that you listening take this information, take this knowledge, take our experience and the piece that Dr. Ofri wrote about and just keep that with you as you go on your path, and when you see physicians auscultating lungs or heart through a sweatshirt, just think to yourself, ‘You know what? That's not going to be me.'

Dr. Allison Gray: Yeah, you always say take the good, leave the bad. And don't get disillusioned. It's just like you were saying at the beginning that there are a lot of students out there who've been told not to go into medicine. Well Ryan and I tell you every week that- or when I'm on, but he tells you every week that we would do it all over again. And there are challenges that we face like there are in every profession, and we just need to keep holding true to things that matter so much to us as physicians. The reason that we worked truly hard when we were premeds to get here where we are today, and why you should keep working so hard to get there for yourself too. It's all worth it despite all the silliness that is sort of on the edges that there's so much wonderfulness- is that a word?

Dr. Ryan Gray: Sure. But that all goes back to something that we've talked about before and that's back in Session 45, that you can listen to at www.MedicalSchoolHQ.net/45, is why are you doing this in the first place? And again that's- we already talked about it a little bit and I know we'll talk about it in the future some more. But you have to be going into this with the right reasons in mind, knowing that once you get your MD, once you finish your residency, that's not the end. It's still an uphill battle.

Dr. Allison Gray: And we fight it every day. Part of how I fight on a daily basis is that I will not type a note as I'm sitting with a patient. I've had colleagues, some people in my office literally say to me, “Allison, why don't you just type while they're talking? You'd get out sooner, you'd have less notes to finish up.” I won't do it because part of how I maintain that doctor patient relationship, and I have so many patients that I think about that I really care about and I know their faces so well because I spend time sitting with them. What do I have in front of me? I have a piece of paper, a pad and a pen, and that's how I take a history. It's not that I type it into the computer and I make a sideways glance every now and then to them. So there are ways that we can continue to try and hold true to what we really want to be doing as physicians. But I agree with you, yes we need to stay- I think it's important to be informed about the challenges that we face when we get to the end of our premed path and our medical school path, and residency and beyond.

Final Thoughts

Dr. Ryan Gray: So what are your thoughts on this? What are your thoughts on kind of staying true to who you are and keeping with some of the skills that you've learned, that you will learn in medical school? Let us know, go to www.MedicalSchoolHQ.net/98 which is the special show notes page for this specific podcast. You can find links to the article that we talked about in the New York Times, we'll have a link to that there and links if we talked about anything else like the other podcasts that we talked about. We'll have links to all of that and you can leave us a comment and let us know and wish Allison a happy birthday there too.

Dr. Allison Gray: Gee, thanks.

Dr. Ryan Gray: So we're up to 208 five star ratings in iTunes in the US store, which is amazing. We had three more come in since last week. I want to thank TSwicer- I said I was going to make you read these, but that's alright. TSwicer who says, “Amazing podcast, the best podcast I have found to help the nontraditional premed student prepare for medical school.” Thank you.

Nate Loudon says, “Excellent, this podcast has been one of the most helpful resources I have yet encountered on my journey.”

And Chinosanz says, “Very entertaining and informative.” Listen to this, “I have heard almost every session in a matter of days. Definitely worth listening to.”

Dr. Allison Gray: You know there's a new term for that, there's got to be. You talk about binge TV watching, so it's like binge podcast listening.

Dr. Ryan Gray: Yeah, I'm sorry that you listened to us for-

Dr. Allison Gray: I'm sorry you listened to Ryan.

Dr. Ryan Gray: Yeah, that's a lot. I'm glad you listened.

Dr. Allison Gray: Hopefully you've enjoyed us moreso now than when we first started.

Dr. Ryan Gray: Yeah. So if you haven't yet gone to www.MedicalSchoolHQ.net/iTunes to leave us a rating and review, let me tell you that they greatly impact how much iTunes thinks of us. And I can see it every time somebody leaves us a rating and review, our kind of ranking in iTunes increases. So take a minute, go to www.MedicalSchoolHQ.net/iTunes.

If you have any questions for us, we'd love to hear them. Go to www.MedicalSchoolHQ.net/question and you can ask us there, we'll have links to email addresses and options to send us an audio clip like last week's podcast with- or audio question and answer.

If you want to say happy birthday again to Allison, go to Twitter. Allison_MSHQ. I hope you enjoyed this week's podcast, and got a ton of great value out of it. As always I hope you join us next time here at the Medical School Headquarters.

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