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Jo Marie Reilly

As I teach first- and second-year medical students to take patient histories and to perform physical examinations, I always feel humbled and privileged--energized by their compassion, enthusiasm and facile, curious minds.


Occasionally, I feel particularly challenged--especially when I'm teaching a student who, though bright, is struggling to acquire some of medicine's basic skills. As we journey up the learning curve together, my responsibilities can conflict: as a teacher, I want to nurture an aspiring student physician, yet as a physician, I must ensure that patients receive appropriate care.

Now, sitting quietly in the corner of the room and watching a young medical student interview a county hospital psychiatric patient, I begin to feel this tension.

"What brought you into the hospital?" the student queries nervously.

Small and reserved, she's quite a contrast to her patient--a burly, imposing middle-aged man, his body splattered with tattoos of birds of prey and firearms. He folds his arms tightly across his chest, and a large cross sparkles on his neck chain.

"It's when I tried to commit suicide on the bridge," he responds agitatedly.

There is a long, awkward pause. "So...what medication did you say you take?" she asks.

"I take respiridol. It's for my voices," he replies flatly.

The student clenches and unclenches her hands.

"What about drug allergies?" she asks. "Do you have any drug allergies?"

"No." He stares at her blankly.

"Alternative medical therapies?"

"No!"

She fidgets with her papers, looking through her history-and-physical book for the next question to ask this obviously disturbed man. Her eyes dart around the room's harsh, white walls, devoid of any mirrors and pictures. The stark surroundings make the interview even more intimidating.

As a seasoned clinician, I feel frustrated by the fumbling interaction unfolding before me. But as a teacher, I feel compassion for the student's discomfort with this emotionally fragile man and hope that she can find a way to connect with him. I continue observing silently.

The student locates a phrase on her mental-status sheet that seems to give her comfort.

"Your mood," she blurts. "How would you describe your mood?"

"Angry!" he shouts, picking furiously at some invisible specks of dust on his hospital gown and flicking them off with his fingers.

"Oh." She glances nervously past the bed curtain to the guard watching curiously from his doorway post.

Okay, I think. It's time for an attending-physician rescue. I stand up and walk to the bedside.

"Mr. Adams, " I say, "tell me about the bridge. You must have felt pretty desperate to want to end your life."

He looks at me, relaxing a bit. "Yeah, I jumped from that bridge, but that fisherman pulled me out. Damn well near froze in that water."

Thinking that I've jump-started the interview, I nod to the student, who's been frantically scribbling down our conversation.

"I haven't asked you yet about your past surgical history," she stammers.

He simply looks at her.

"That's quite a story," I interject. "What made you so anxious that you wanted to jump from the bridge?"

"It was those voices again. When those voices come, it's all over."

The student looks at me; I raise my eyebrows encouragingly.

"How about immunizations? Did you receive your childhood immunizations?" she asks.

"Immunizations?" He looks at her strangely and begins to tap his foot against the bed. "What are immunizations?"

"Well Mr. Adams," I say, "I actually think it'd be important to know more about those voices. Tell us about them. What do they tell you to do?"

"They tell me I'm worthless. They tell me to hurt myself." Looking distressed and ashamed, he gazes at the wall.

I pause, giving the student another opening.

"Let's see," she says, looking at her notes. "Did you ever do any military service?"

I look over at her again, trying to conceal my exasperation. Does she just not get it or what? Time to bring this painful interview to a close.

"Mr. Adams, you've been so kind to talk with us this morning. Your voices sound like they are very scary, and they cause you to do some unsafe things. How are your voices now?"

"They've quieted down since I got back on my medications," he says. "They're not telling me to kill myself anymore."

I nod. "I'm so glad that you're feeling safer now. We'll make sure the social worker gives you enough medicine so that when you leave the hospital you can keep your voices down. Can we do anything else for you today?"

"I just want to rest now. I'm pretty tired from all this talking," he answers, closing his eyes.

Out in the hallway, I turn to the medical student.

"How do you think it went?" I ask.

She glances at her notes, looking distracted. "I think it went pretty well," she says. "I got almost everything--but I did forget to ask him if he had a family history of diabetes."

I sigh inwardly. How can I give her feedback that is constructive and tactful? How much of her stumbling is due to her youthful inexperience and to the intimidating environment? With more maturity and less nervousness on her part, will her communication skills blossom?

The inevitable doubts set in. What is my role and responsibility as her teacher? How can I help her "get it"? What if, despite my best efforts, and those of my colleagues, she still cannot adequately listen and respond to patients? I dread the thought.

At such challenging moments, I think of my professional vows--the Hippocratic Oath's admonition, "Do no harm." As a teacher, I am called upon to do no harm to this hopeful, aspiring student physician. As a clinician, I must ensure that no harm be done to the patients she serves.

I must dig deeply for courage, patience and wisdom.

And so continues this tug-of-war.


About the author:

Jo Marie Reilly is Associate Professor of Family Medicine at the Keck School of Medicine of the University of Southern California (USC), where she is Director of the Professionalism and the Practice of Medicine course and Assistant Director of the Introduction to Clinical Medicine course. She is also a member of Pulse's Editorial Board. "Writing helps me connect with the power of humor, joy and compassion in the work that I do, and in doing so helps me balance my professional life, patient care and personal life, which includes spending time with my family."

Story editor:

Diane Guernsey

Comments   

# Siddhi Mittal 2019-11-19 23:50
This was a very interesting read! As a PA student, I hear stories from other students about how their day went in clinic while on their rotations. However, it was insightful to read the preceptor's perspective in this anecdote. I like how Dr. Reilly is cognizant about her different roles in this scenario, as a clinician and as an educator, and how she realizes that she must balance the two in order to give both the patient and the student justice for their purpose of being there.
Reading about how the student was so adamant on getting the patient's medical history instead of focusing on the patient's serious complaints was unsettling. However I could understand why she may have acted the way she did. Sometimes when we are stuck or uncomfortable, we try to follow the "script" we are taught in school in the hopes of doing something right. We are taught to systematically obtain all the information for charting, that sometimes we may forget that this person in front of us is not a chart or just some patient; this is a human being seeking help and guidance. We are taught how to obtain medical histories and diagnose illnesses, but we must also know the importance of interpersonal skills and communication with the patient. This article was helpful to understand that when we are on rotations, we must practice both our medical skills and our communication skills.
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# Joshua Grimes 2019-11-19 23:39
As an aspiring physician assistant student I can understand the nervousness that caused the youthful medical student's thoughts to be clouded, which the physician understood. However I was concerned at the fact that when the physician tried to interject and steer her in the right direction with questioning she failed to identify this on multiple occasions. As a student we are taught to gather a good history and to hit all of the information required, but we must also understand that in some situations, this one specifically, getting immunizations and other medical information is not as vital. Sometimes it is more important to talk about the patients thoughts thus establishing and demonstrating to the patient that we are invested and that we care about them as a patient. Although this encounter may have been difficult for the student it is important to all other students to be aware of this so they can be prepared for a situation like this in the future.
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# Nicholas Anderjack 2019-11-19 21:09
This article was very helpful for illustrating a new perception that often occurs in medicine that often is not discussed or evaluated. Most of the time, we believe patients are in the hospital to get better and are usually accepting of their situation, remaining calm. But sometimes situations like this can occur and there is a certain approach one must take to give the patient the care and comfort for the patient regardless of their current mood. Compassion and reassurance that a patient is still a human and is being treated by someone who has humanity for people will treat the whole person and not just the disease. Having a connection with a patient will help to keep the patient engaged and understand that someone is listening to them and is willing to help.
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# Nick Cunningham 2019-11-19 20:10
I really enjoyed reading this article. It perfectly illustrates how we, as care providers, can get so caught up in a systematic approach to obtaining information, that we fail to realize the reason we entered the health field in the first place; the patient's well-being. We must understand that patient's cannot connect to someone who doesn't care for them as a whole. We need to first connect with the patient, show empathy, and true understanding, and then dig for whatever information may be necessary for providing the patient with the best care possible. As a student, this article was very relatable and definitely information to learn from.
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# Emily Graziano 2019-11-19 18:46
I thoroughly enjoyed reading this article about this patient-student interaction, and I think it’s a great way to get into the behavioral medicine mindset. Although there were clearly some red flags as to how the student was interacting with the patient, it was also very relatable. Every patient needs approached in a different way, especially in the mental health field. It is definitely a challenge to be able to always be compassionate and listen to the patient, while trying to collect all the vital information for the sake of the patient’s health. I’m excited to learn more about how to talk to and treat patients with mental illness so that I can provide the best care possible.
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# Rebecca Mikules 2019-11-19 18:35
This article offers a great perspective. Often we are taught all of the information that we need to gather and the facts, but it is hard to teach an individual how to be personable and relate to the patient. Knowing how to appropriately engage with a patient is difficult. There is no way to teach how to react to any number of scenarios that will happen. Time and experience is important in learning how to relate to patients and show empathy while also demonstrating confidence. Medicine is an art and although we often expect situations to be black and white, they almost never are. Teaching and learning are both difficult to balance. You want to let students learn and gain experience. Yet it is important to ensure the patients safety.
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# Zachery Marker 2019-11-19 16:58
This article is a great example of the fact that medicine is not all about memorizing facts and mindlessly reproducing information. There is an art to it. As with all art, it takes time to perfect. The only problem is that failure may lead to someone getting injured or harmed. It is certainly a lot of pressure for both the students and professors to endure. Hopefully with time, all medical students will make the important realization that connecting to the patient and understanding their thoughts and feelings is just as important as reproducing facts.
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# Emily Anderson 2019-11-19 15:12
This article is a great way to dive into the behavioral health model because it depicts the struggle that every medical professional student experiences. As a current Physician Assistant student , I can relate to this article because it can be quite the balancing act of trying to get enough history from the patient while still trying to relate to the patient and form a connection with them. Sometimes we get so caught up with hitting all the patient history questions that we forget to read the patient's body language and pay attention to what they are actually telling us in order to adjust the patient interview accordingly. We must remember to slow down, listen to the patient and make it a priority to connect with the patient.
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# Lindsay Scala 2019-11-19 14:41
There is a large amount of pressure on students to obtain the entire medical history of their patient in order to give a good presentation to their preceptor. Asking the right questions and obtaining a pertinent history can sometimes be so important to a student that a connection and compassion for the patient may fall second. This article is a good reminder that it is important to listen to your patients and take time to slow down. In this situation, the patient seemed to appreciate when the attending physician stopped asking so many history related questions and spent more time connecting with them. I think this article teaches a good lesson for all healthcare providers.
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# Hayley Cottle 2019-11-19 12:16
The article “Tug-of-War” by Jo Marie Reilly appeared to me as a common occurrence among unseasoned medical providers. Putting myself into the shoes of the young medical student, I know I would have responded the same way she did, unsure of how to react properly to the patient’s response or ask the appropriate questions. The author’s depiction of how she handled the situation puts into context how not everything is by the “history-and-ph ysical book”, but rather, based on the patient and what their chief complaint and symptoms are. Additionally, I felt that this particular interaction displays how addressing behavioral health complaints is slightly overlooked in learning how to take a proper history and physical. Most of the time, histories and physicals are centered on a disease that can be measured with a stethoscope or assessed with a range of motion test, when rather we forget to assess the proper mental status or divulge further into a complaint from a patient that is a “red flag” for behavioral health. However, providers struggle daily with teaching students how to care for a patient and providing for the patient themselves. When a hurdle comes in the way of this balance, such as watching a student struggle to provide the proper care to a patient, it becomes conflicting to the provider on how to provide the proper “care” to each. Overall, the article adequately elaborated on the challenges young medical students take in addressing behavioral health histories and how providers must find ways to address these issues accordingly.
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# Tori Kilcoin 2019-11-19 11:32
When put into unfamiliar situations with patient, it is sometimes hard to get the ball rolling. As students we are taught to get information in a structured and formal way, but we sometimes forget that we need to break away from the format to get the information we need. Granted, it is important to make sure we gather all the information like past medical history and allergies, but sometimes in the moment we need to put those thing on the back burner and focus on connecting with our patients and helping with the issue they face. The patient is our number one priority and we cannot neglect giving them the proper care and compassion need at that time just because we do not know how to go about the situation.
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# Victoria Mayo 2019-11-19 08:54
I think this article was a great way to enter into Behavioral Medicine. Although most students are aware it is important to make a personal connection with their patient, it sometimes becomes difficult when there is so much pressure to gather all the "important information". This article is a good reminder to slow down, take your time, and focus on the patient's problem at hand as well as their personal feelings. Building a personal relationship with the patient will allow them to trust you more and in the end tell you more about their story so you can give them better care.
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# Kaitlyn Kline 2019-11-18 19:00
In medicine, especially as a student, it can be challenging at times to connect with patients on a personal level. I love how this article highlights the fact that patients are real people facing real struggles. As PA students and future providers, it can be so easy to focus on the medical illnesses and making sure we gather all of the pertinent parts of the patient’s history, but in the end it is just as important to talk with patient and hear them out. From this encounter, I can foresee that taking time to get personal with the patient will allow us to not only better understand them, but also to provide better medical care that they rightfully deserve.
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