The Touch (Finesse Factors)

I should be finishing my final write-up on my last posting for first cycle of 5^th year; instead I am choosing the thanatos path and procrastinate instead. My End of Posting Clinical is next Tuesday, my End of Cycle theory exam follows Wednesday to Friday’ all three postings (Surgery, Orthopaedic & ObGyn). And I am not at all aroused to study, not a flick of action potential in my pleasure centre. It deemed unpleasant, so it’s only survival to fled away unpleasant stimuli (read: pain). My body perception has far exceeds me in this specialty; back pain is here, my sugar and calorie cravings are maniac. Next, do anticipate apthous ulcers and toothache.

I am inspired to write this entry upon reading opinion of writers in The Differential blog by Medscape. I really enjoy their writings, it broadened my horizon but I rarely got a pleasure to indulge on them. I mostly lost in the interweb (read: Facebook) stumbling into some random link and chain of clicking and ‘open in new tab’ that finally rendered me lost. Don’t even get me started on YouTube where you often share common notion of “How the hell did I got here” or “I am at that weird part of YouTube again.”

The clinical year is where we first experience patient encounter; their story and the feel upon touching illness-burdened body; them people except for ObGyn of course. I still remember words of one of ObGyn HOD, whether in HRPZII or HTAR, I couldn't really distinguish; thought it must be the common adage of ObGynist “Pregnancy is not an illness, stop calling your client as patient,” it came with a footnote, “Unless that pregnant lady presenting with medical condition of course.”

Well my first exposure to clinical skills came from one important figure in the name of Prof. Yasmin. How can I ever forget her? There are plentiful individual involved in the teaching of my (our) journey throughout medical school, particularly and specifically in ‘special’ situation our Uni chose [sic] to remain dwelt in. There are countless people to send ‘Thank You’ cards upon graduation later next year. Yes I plan to do that, to have it specially made and send them  out to as many contributing people as possible as an act of gratitude. So that there will be blessings in whatever knowledge you acquired from them. In sha Allah.

Prof Yasmin was the one that ignite the fire in me to be a real doctor. During our Clinical Method (instead of Clinical Medicine) class, she taught us about history and physical examination. She taught us about differential diagnoses for which she gave us assignment to list differential diagnoses in every system. I principally copied, pasted and edited an entire legit book of ‘A Pocket Manual of Differential Diagnosis’ and submit the thickest assignment (compare to the rest). FYI, the softcopy that I had was in .chm format, therefore I had to re-edit them in MS Word. My assignment later photocopied by others and I was honored as un-authorized re-authoring author of Ddx book.

I purchased my stethoscope during my prior clinical attachment in HKL in 2008. That was the first time I actually put it to use, on a dummy. With emphasis on respiratory, cardiovascular and abdomen examination, we had our practical examination, still on a dummy. I heard my senior group got real people a.k.a fellow students as model. Nevertheless we were taught to examine systematically and that was unforgettable and really helpful during BMS practical later on. Except for ObGyn examination that I had to learn from YouTube, Ten Teachers and Oxford Handbook, my surgery posting back then was quite a smooth sail. Plus, no big expectation = low stress.

Our first BMS practical posting was in Specialized Centre, a tertiary;  Institut Perubatan Respiratory, and this is where our clinical skills were honed and reshaped. Thanks to Datin Aziah for her motherly and excellent way of teaching, we actually got it, and our first patient encounter was sort of try and error. We were encouraged to examine patient solo except for those required chaperon.  Hell, I even go such extent by went into extensively drug resistant tuberculosis (XDR-TB) quarantine room. He was a drug abuser and frequent defaulter. He should be jailed for a crime of defaulting treatment and threatening public health safety walking with XDR-TB.

We were lucky to have been posted there as our first posting. We gain confident and that is indeed diamond if not gold.

The skills and art of physical examination is later re-adjusted in an attempt to reach elusive finesse. Some lecturers want you to include this and omit that. Some prefer adhering into specific textbook skill. Some questioned the conventional in the name of relevant. Exposure to international lecturers really open our eyes on various technique of physical examination and how it was taught in different countries.

Some example questionable techniques are:

• Why would you want to retract bilateral eyelids to check for jaundice and pallor, patient will not get icteric and pallor in single eye? So checking one is enough to tell that both are.
• The relevance of whispering pectorilaquy and aegophony when tactile vocal fremitus is enough. You are going to do x-ray anyway.

Bookwise, gravid uterus requires Pinard, but bullshit, it is quite challenging enough to listen to fetal heart rate with stethoscope, let alone Pinard. My hat goes off to those nurses that confidently locate anterior shoulder and listen with that museum-grade auscultation device in a face of handheld sonicaid and stethoscope. Pinard should be gazette as antique together with iron lung, Kielland’s rotational forceps and fleam bleeder. It should be banned, redacted in every medical book, updated to non-relevant on account of causing embarrassment an unnecessary need to lie during clinical exam. “Fetal heart heard at 130 beat per minute” my foot.

Then again, Medicine is Art.

Throughout my long winding journey in medical school and event prior to that, I have lots of people to thank and it can be traced way back to my parent, as my mother is my first official and unofficial teacher. There is no such thing of time-wasting study. I appreciate my STPM years though I once taught it was wasteful and unnecessary.

How amazing our journey of knowledge has been.