How can I help you?

I'm going to try to express what bugs me so much about our clinical preceptorships. It's not just visiting a new hospital every semester and getting taught by another new doctor whom you'll only meet three times. I like the patient visits a lot, and I like hearing people's stories and practicing physical exam and seeing how the whole hospital/clinic/ER works, but...still. I hesitate. Here's what happened this morning:

She was pretty stoic about her condition. After years of working as a health worker herself, she was hospitalized by sudden and severe back issues that left her in a wheelchair for life. In addition, she is obese and diabetic. She has fungal infections in the folds of her skin, which had opened the pathway for bacterial infection. She has had several severe cellulitis infections (skin infections that turn red, make you swell up, and spread rapidly). Luckily, her partner seems to be supportive but there are, as she pointed out, limits.

She agreed to speak with me, told me her health history, and then gave me her story. She knew all of her medications, trade name and generic, with dosages and also what they do -- which I think is an unmatched feat (among the patients I've seen). But as she spoke to me, I got this overwhelming sense of -- what are you going to do? Like she was testing me, and wanted me to 'practice' on her, but also that she was fed up.

So what did I do? Given that we didn't have to do the whole exam for our last two patient visits, and that my preceptor was waiting, I opted to do a focused H&P (meaning the problem at hand, any relevant history -- which is often extensive, and then pick one system to examine). With her, obviously, it was skin. I wanted to do the neuro exam, too, which is much more extensive and involves cranial nerves, motor, sensory, and mental status -- but I had a feeling she had had it. I asked if her feet hurt, and she said yes, but I could touch them. And I was thinking -- why am I here? To practice? I can't help you -- I don't have the knowledge. I can do a neuro exam, but you don't need one. You need to go home. I got this overwhelming sense of shame, making someone go through the paces -- and there was no interest from her about what they were teaching us, etc, which you often get if you examine healthcare workers. So I think she was humoring me, and I did the basics and ran -- well, not quite, but spent almost as much time on her labs (40 minutes) as with her (70 minutes).

Wimpy? Dumb? Good idea? Bad idea? I mean, obviously, I can't and won't when I'm on the wards -- but on the wards, I'll have a function that goes beyond putting people out for the sake of my own learning.

She said to me, "This is not how I envisioned living at 5X years old. It's not much fun having to show your boobies to everyone (common site of fungal infections). I don't want to visit the hospital again for another 7 years." My preceptor seemed to think that much of it stemmed from carrying extra weight -- probably around 100 lbs. But the fundamental question I wanted to ask this brave, somewhat fed-up, and talented historian was, "I'm not even on the wards yet. So how can I help you?"

And the painful answer is, I can't. I can just learn from you in order to help someone else. And none of my professors have given me a truly good justification for why one patient (who has 'volunteered,' but often is simply doing it as a favor to their doctor) should go through an hour or two of crap for me.

I mean, some patients really enjoy teaching. They enjoy interacting with a medical student, they like telling their stories, they don't mind someone spending an extra hour with them. But inevitably, as a student, you are called upon to examine and interview people who don't really get much out of it. And unlike when you're on the wards or when you're a physician, you can't say, "I know this is annoying/embarrassing/painful, but I'm really trying to help you." Because you're not trying to help them! You're just trying to get to the point where you could.