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Teaching and Learning Moments

A Skin Exam Shares a History, a Physical, and a Story

Yanovsky, Rebecca L.

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doi: 10.1097/ACM.0000000000002809
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Throughout our medical education, we are taught to trust our patients and to listen to them. Entire courses are dedicated to eliciting their story, establishing rapport, and obtaining an accurate history. Despite this thorough instruction, little prepares us for the cognitive dissonance felt when a patient’s verbal account differs from the clues we have been trained to pick up on the physical exam.

By the time I admitted my last patient in my third-year obstetrics–gynecology clerkship, I felt confident soliciting an obstetrical history and proposing an admission plan for patients who were ready to deliver. Most of the patients were known to attending physicians in the hospital, and their care benefited from the context and longevity of their physician–patient relationship. When Jane was wheeled in, her situation differed. Having received no prenatal care, she was a young woman whose story immediately raised the eyebrows of the experienced labor and delivery nurses at our small community hospital.

As I made my way to her room, I tried to block out the hushed whispers flying among the care team: “She says she didn’t know she was pregnant until last week.” “She doesn’t look so good.” “She just showed up to the emergency room.”

I entered the room reminding myself of the lessons I had learned throughout my third-year clerkships. I committed myself to offering the best care I could in the moment, starting with a thorough history and physical exam.

Jane was about my age. I instantly noticed that her affect was completely flat. Her story was patchy. Despite her protruding belly, she swore she hadn’t known she was pregnant until the prior week. She had given birth one year ago and had gotten on suboxone through a community program after her son’s birth. No, she was not currently using opioids.

As I completed her physical exam, I noticed the track marks up and down her arms, but my eyes lingered on a few fresh scars. Unprompted, she repeated her statement: She was clean. I could not ignore the story her skin told me, but I also could not ignore her words and the implications I heard behind them: Don’t judge me. Don’t dismiss me. Take care of me and my child.

When I took her hand, I saw the first flicker of emotion cross her face: surprise. Listening to her subtext, I assured her that I understood and that every decision we made would be to keep her and her baby as safe as possible. I paused, as we seemed to communicate without words, before confirming we could send a urine sample, call special care to be present for the delivery, and take the requisite precautions. I used words to make everything seem routine and emphasized our priority of safety for her and her baby. She nodded. I tried to spare her pride. I hope it worked.

Though the room seemed busy as the practiced care team shifted into autopilot, I couldn’t help but feel the absences—a partner, a parent, a sibling, a friend. If I was to provide compassionate care as well as health care, Jane needed me to be more than a student. For the next few hours, I occupied as many additional roles as I could, holding her arm as the withdrawal tremors started, whispering words of encouragement as her discomfort increased, wiping away sweat as her body rose to its simultaneous challenges, and eventually celebrating the birth of her beautiful baby girl with tears, laughter, and relief.

As physicians, we need to use every element in our toolbox, including the history and physical exam, to provide the best care to our patients. When a patient’s story does not match up with the physical exam, we must accept the dissonance and take everything into account or else risk throwing away something our patient is trying to tell us. To provide the best possible care, we must listen with our ears, our eyes, and our hearts.

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