Clinical Seconds

Well, as predicted, my second clinical experience was SO much better than my first. For one thing, I was on time; actually, EARLY. I was working w/ a different preceptor this time, and she had asked us to meet at her office 8:45 to go over what we’d be doing, and discuss any issues we had. This made a big difference for me. Instead of feeling like we were just being thrown in, I felt like we had a plan. It also helped to go over the physical exam again and discuss which parts of it we were absolutely supposed to do, since all of it wasn’t necessary.

Armed with a Plan, I was able to actually take my patient’s histories while they were still dressed and we were sitting across from each other like equals. And when we finally did get to the physical exam part, I was much less nervous, and able to go through the exam pretty smoothly. Head, face, mouth, a quick eye exam, the lymph nodes of the head and neck, thyroid exam, lungs, heart, breast, abdomen, and then pelvic. I was much more thorough this time, and thankfully not shaking. I even got to talk to my patients about breast self-exams, and teach both of them how to do them. Believe it or not, they’d never had a health practitioner do a breast exam on them before. Sadly, I think a lot of it is cultural: these are poor, under-served, urban women, most of them african american or latina, most of them without health insurance…thorough annual physical exams are not something I think they’ve had a lot of. They were both so receptive to what I was showing them and telling them. In a way, being a student is a really good thing, because your case load is not so overwhelming that you’ve got to rush through all of your patients. I was able to spend about an hour with each patient, which is such a luxury. They both seemed so grateful for all the attention, and I was very pleased to be able to give it to them, and teach them about their bodies. That’s always one of the best parts of what I do.

The pelvics also went more smoothly. I still had a hard time finding the cervices of my patients, but was able to find them in the end; I think that’s just a practice thing (these are, after all, only the 5th and 6th cervices I’ve ever examined!) I was using small speculums this time, as opposed to mediums, and I think it really made a difference (although, on one of my patients, the speculum wasn’t quite long enough, and the posterior vaginal wall kept getting in the way). How do you know for sure which size to use? How do you judge it? Is there a way to tell, just by looking at the size of the woman? Or do nullips always get small speculums, and multips use mediums, and if she’s unusually large, then use a large? Anyone have any handy measuring system they’d care to pass on? Same thing with sizing a uterus. My preceptor kept asking me how large I thought it was, during the bimanual exam, and I would feel, and feel, and feel, and finally say something like: a large lemon, or an orange, or a small grapefruit. I’m still not sure exactly what an 8 week uterus feels like, versus a 12 week uterus, or a 14 week uterus. It’s so hard to tell! I guess nothing is going to fix that except practice, practice, practice. One can only hope that after I’ve examined 100…200…uteruses, I’ll start to get a better sense of it.

This time around I was also armed with tissues, and made sure my patients were given the tissues to clean themselves up with before the exam started, which, I think, made both of us feel better. I’m also pleased to report that I didn’t make either of my patient’s bleed this time, when I was collecting their specimens.

My preceptor’s comments were overall positive. Her one critique was that I’m very slow, and need to work harder at getting more efficient at my exams. Which is true. And again, I think that will just take practice, as well. I can’t wait for well-woman gynecology and antepartum next semester. Really, really looking forward to that!

Anyway, off to shower and hit the books, and then go to work tonight. Happy pre-Turkey Day, everyone!

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