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Teaching and Learning Moments

Blind Spots

Yang, Alan Z. MSc1

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doi: 10.1097/ACM.0000000000004631
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The patient was on the phone with someone when we arrived, so we waited outside his door. “I was told he’s kind of grumpy today,” my preceptor whispered at me with an expression that said yikes.

When we eventually stepped inside the room, I saw a man with graying hair clipped short, just thicker than a buzzcut. His face was wizened and overrun with thin fissures, like hilltop rocks exposed to the wind. His skin sagged a bit, and his chin melted into his neck like wax.

From taking his history, I learned a lot about M. “Have you ever smoked?” I asked him, going down my mental checklist methodically.

“Yes,” he replied.

“And how much do you drink?”

“A lot.”

It turned out that a lot meant a liter of vodka a day. His chart said he had been admitted to the hospital because of a withdrawal seizure, but he also suffered from uncontrolled vomiting and diarrhea. He had a long history of digestive problems, beginning with a duodenal ulcer at age 16 and a perforated esophagus later in life. He told me about trouble breathing, a pain in his chest, and places on his arm where had scratched himself until he bled. He did not mention the 2 heart valves that had been replaced or the stab wound on his belly. “You guys must be tired of me,” he groaned.

The patient was not grumpy. He was hurting.

I learned a lot from what I observed about M that day as I practiced my history taking and physical exam skills, but I learned even more from what I had failed to see.

“What happened to your legs?” my preceptor asked more than halfway through my interview.

“Well, this one was frostbite….” he started to say. I looked down, and to my shock, I saw the stubs he had for legs making 2 little hills in his blanket. I had gotten through most of the interview without even realizing that my patient did not have legs!

In hindsight, the clues were there the whole time—the folded-up wheelchair in the corner of the room, the syncopated way he rolled over to fumble around for his soda—things I saw but did not see.

The fact that he was missing his legs mattered. M could not afford a motorized wheelchair or prosthetics, so he struggled to get in and out of his apartment, which stood at the top of a hill. Hardly anyone visited him there, and he would often drink when he felt lonely.

I had been so focused on not forgetting any parts of the standard interview or physical exam that I failed to really observe my patient. As soon as I entered the room, I started rattling off a rehearsed script instead of paying full attention to my patient and his surroundings.

My inexperience was part of the problem. I was a first-year medical student, and M was my very first patient. Like a new driver focused on the road ahead instead of his mirrors and blind spots, I was so focused on not missing any interview questions or messing up any exam maneuvers that, ironically, I had made a glaring omission.

Our patients should not be our blind spots. Although the history and physical will become second nature over time, I know I will be picking up other responsibilities during my clinical training that will compete for my attention. My encounter with M will always remind me not to dwell entirely inside my own head, consumed so completely by checklists or tasks that I do not see the patient in front of me. Because even with the most thorough routines, I may not catch important clues—be it some subtle discomfort or altered affect—without keen observation, clues that may drastically change a patient’s story and care.

Like other skills, observation can be trained. My instructors have polished my history taking, teaching me to ask if there was something else—not anything else—the patient wanted to talk about. Can observation be coached with the same intention?

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