Grand Rounds

Why we do the things we do

Oh My! Have you had any unusual sexual contacts lately?

Have you had any unusual sexual activities lately?

 So, I found myself in the Emergency Room.   The orthopedic resident, a tall blond woman who rowed crew at the University of Wisconsin, smiled and confirmed the diagnosis. "It's really pretty common," she reassured me, and she recited a litany of professional athletes who had suffered similar ruptures of their Achilles tendons. Gabe Kapler for the Red Sox, Vinny Testaverde for the Dolphins, and so forth. All had to endure the downstream effect of evolutionary pressures so strong to be upright that we saw fit as we developed as a species to have a single tendon in between us and our capacity to walk. At least I was in good company. Gabe Kapler, Jewish and a hell of power hitter, was nick-named the "Hebrew Hammer". I could be the "Circumcised Suburbanite." At least it was alliterative.

I had the surgery, and to prevent any infection in the easily friable skin along the wound site, I was given a zillion gallons of antibiotics interoperatively.

Two days later I awoke with razor blades in my mouth, a nasty case of Oral Candida (a yeast infection) having found refuge and sustenance in my now bacteria-free oral cavity. I called my primary care doctor and explained, and he dutifully arranged an appointment.

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Before I saw him, however, I was greeted by an enthusiastic medical student, her white coat shining smooth as a hard-boiled egg, her stethoscope worn proudly, her eagerness palpable, her energy enviable.

My doctor explained to me that the student was on her primary care rotation and wondered if she might see me first. I teach medical students, and I, personally, feel that our students give some of the best, most thorough care in medicine. I was delighted.

Then the exam started.

Medicine is all about the history. Get the story, I tell my students. Confirm the story with your physical exam, answer unanswered questions by looking for signs. Don't lay hands on your patient before you talk. Talk first.

Nope. She started with my feet. All she had to do was ask "What brings you in today?" and my answer would have lead her to my mouth, to the white fibrous colonies hanging from my palate like oozing stalactites (or stalagmites - I can never keep that straight). She would see one of the best cases she had ever seen of thrush. Instead, she was carefully examining my toe-nails.

The clock ticked. "Take a deep breath," she said, her stethoscope in place, and I complied. She was getting closer now, moving north along my body, feeling for nodes along my neck and jaw.

"Can I take a look in your mouth?" she asked. (Finally!) She could have been asking whether I wanted to see the dessert menu, so enthusiastic was she at the nearing completion of her examination. However, there was still no attempt to take a history. Not a question. Only politely given instructions.

"Open wide," she politely instructed, and then her eyes grew wide at what she had discovered.

"Oh my," she exclaimed. "That looks like Oral Candida. Have you had any unusual sexual activities lately?"

Just like that. No hesitation, no explanation. She could have been informing me that today's dessert special was mango sorbet.

I couldn't help myself. I laughed. It hurt, the guffaw lifting my palate and stretching the inflamed skin that was angry at the invading yeast buds. Still, it was pretty funny.

She looked troubled. "Why are you laughing?" she asked. She knew I was a professor at the medical school, and I knew then I probably shouldn't have laughed.

"Well," I whispered, my throat raspy and raw, "My life really isn't that interesting."

"Huh?" she startled, standing still, her stethoscope clipped around her neck, oscillating like a pendulum with the audibly ticking clock on the wall.

"Typically we lead into these questions." I explained.

"What do you mean?" she asked.

And I felt bad. I am a medical educator, and here I had an indication of where things have gone very strangely in the education of today's doctors. So much primacy on the technology of diagnosis! So much emphasis on the collection of measurable data, on the discovery of fascinating symptoms, on genetic analyses and imaging that puts Star Trek to shame. And yet, the core, the centrality of why we practice medicine, is getting increasingly forgotten maybe because we have taken it for granted for so long that it is no longer granted as taken.

We should talk to our patients. My goodness, the fun is in the story, the finesse is in the listening, and the skill is in the application of the information within the context of the patient's world. It is a service profession. We are not surveyors. Any medical student ought to put Oral Candida together with immunosuppression, and it is appropriate to ask about sexually transmitted disease once that connection is made. How, when, and why you ask it - that is the art of being a doctor. Otherwise I might as well talk to a drop-down menu on a computer.

Oh wait. That's exactly what we increasingly do.

We medical educators have our work cut out for us...

 

 

Steven Schlozman, M.D., is an Associate Director of Medical Student Education in Psychiatry for Harvard Medical School.

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