When the patient jokingly touched my nose, I knew I had muddied the boundaries between us too much and it was too late to go back.

(Note: Except for the aforementioned sentence, all of the patient’s details and quotations have been altered.  Events from the interview and exam have been drawn from a conglomeration of patients to illustrate a general theme.)

It didn’t happen until the end of the interview, but it was not an entirely unsurprising turn of events.

“What can I do you for?” he had asked affably as I entered the room.  The nurse had mentioned that he was a talkative man in good spirits.  I needed someone in good spirits.  He was about to become my body to practice my physical exam skills on, and I wasn’t very good at the physical exam.  Done well, it should take 15 minutes.  Done by me, it would probably take several times that amount as I missed reflexes, shined my penlight in the eyes for an uncomfortably long time, and struggled to remember the order of tests and develop a natural rhythm.

Before entering the man’s room, I asked my tutor, a fourth-year medical student, how long she told patients the interview and physical exam would take.  “There’s no way I can say something that sounds close to an hour,” I told her, remembering the previous week when a patient told me 30 minutes was too long and I had to haggle my way up to 15.

“I just ask if I can ask him a few questions and do a few easy tests on them,” she said.  I laughed, realizing that avoiding the quantitative would probably be my best bet.  Even though this was a teaching hospital, the patients had no good reason to let second-year students near them.  Unlike the upperclassmen, we weren’t a part of their care.  We could be kicked out of the room at any time, if the patient became bored or tired.  Patients would derive no benefit from the exhaustive interview and physical exam other than the vague satisfaction of helping a fledgling physician-in-training become less fledgling.

So, to get the practice I desperately needed, I needed to make my patient want to help me become less fledgling.  In short, I needed to win my unwitting participant over.

My current 60-year-old patient definitely saw me as fledgling.  He grossly underestimated my age.  (I thanked him for the compliment but told him he was off by several years.)  Then I asked him if I could ask him a few questions about why he was in the hospital, and we were off.

It took about 20 minutes to talk about his current illness and the events leading up to it, his past medical history, his social history, and his family history.  I had done this dozens of times first year, so I felt at ease in making transitions and gathering relevant information.

At this point during first year, we would wrap things up and thank the patient for his time.  But I was just beginning.  I reached for my bag, which was heavy with my tools.  It was time to pull out the opthamoloscope and penlight (for eyes), otoscope (for ears, nose, and throat), tuning fork (for ears and nerves), and reflex hammer.

In addition to sticking devices in and near his orifices and banging away at his knees, ankles, and arms to elicit reflexes, I would have to push and pull at all parts of his body, checking his muscle strength, tone and bulk.  I would have to ask him to follow my finger as I traced an “H” in midair to test his visual fields, to tell me if my metal tuning fork felt cool on his extremities to test for peripheral neuropathy, to swallow as I gripped his throat in a chokehold and tried to feel for an enlarged thyroid, and to stay still as I traced along the bottom of his foot to check for motor disease.

I hoped he would still be in good spirits after I was done with him.

Thankfully, he was.  I wanted to make the experience less tedious in any way I could.  I relied on a sense of humor.  I also periodically tried to convey how much I needed him for practice and how grateful I was for his help. Unfortunately, what couldn’t be hidden with words was fledgling, fledgling, fledgling.

He looked at me warily as I approached his nose with my otoscope tip.  “Don’t worry,” I told him.  “You’re not the first person I’ve done this to.”  (He was the second, after all.)

He was happy to help, cheerfully telling me about his newest granddaughter as I poked around inside his nose and tried to see past mounds of nose hair.

I worked my way down his body, complimenting his reflexes and muscle tone.  I laughed at his jokes and bantered with him while I tried to remember each of the eleven cranial nerve tests.  I told him he was being the perfect patient.

I felt comfortable and I felt like I was learning.  I was even having a good time.

At the very end of the exam, I tested his cerebellar function.  Touch your nose and then touch my finger, I directed him, as I moved my finger.  I told him he was doing well as he hit his marks.  Then–probably out of boredom–he decided to touch my nose instead of my finger.

It was such a minor gesture, I doubt he even remembers doing it.  But my face flushed as I realized its significance. A literal boundary had finally been crossed.   Somehow, in the hour we had been together, I had let things decline so that this gesture seemed appropriate and natural for the patient.  How had this happened?

At this point, the exam was over.  He was still cheerful (though exhausted) and had genuinely seemed to enjoy the experience, so I took that as a good sign. I had gotten exactly what I wanted–information and practice in a way palatable to the patient–but I had sacrificed seriousness and stature to get there.  As time passed, the patient had grown increasingly at ease, to the point of informality.  Although I had reacted professionally, I wondered how I could better control the room so I wouldn’t have to be the one reacting.

I acknowledged what I couldn’t change: being young and female.  Then I ran over the 60 minutes in my mind.  Should I have smiled less?  Made fewer retorts to his banter?  Fumbled with the tools less (easier said than done)?  Feigned greater confidence?  Toned down the affability?  I saw the affability as compensation for the fumbling.  If I was going to be the incompetent medical student, then I’d rather be the pleasant incompetent one than the dour incompetent one.  But how to remain pleasant while still being taken seriously?  How to be taken seriously when I couldn’t even make out the eardrum?

I concluded that until I stopped fumbling, authority would be difficult to garner.  And to stop fumbling meant repetition of the tedious on patients with patience.  I wondered who else would decide to touch my nose along the way and how I could stave off the advances while I gained proficiency.

When I applied to medical school, I wrote in my personal statement that I had a knack for being able to quickly gauge my audience and relate to it.  No one could argue that I hadn’t been able to relate to this patient.  But it was precisely this easy familiarity that had blurred the boundaries.

In that room, I made a friend.  Friends touch each other’s noses.  But patients don’t.

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8 Responses to Fledgling

  1. David Kroll says:

    Perhaps he did it because you were young and female and, yes, he likely wouldn’t have if you were one of your male classmates. But something about this interaction tells me that this conglomerate patient had also been used to second-year medical students and was just good-natured.

    I’m not a physician but I live with one, also female. I think that you’ll find many more patients becoming friends with you – in a well-meaning and non-condescending manner. You may even find that the quality of care you provide requires that you sometimes let the boundaries grow fuzzy.

    I love these stories. Keep them coming when you have a chance to do so.

  2. Elle Gee says:

    I’m struck by your statement “authority would be difficult to garner.” Not really sure what right you have to possess authority – as in ” the power or right to give orders, make decisions, and enforce obedience.” I, for one, do not believe any physician has the right to have authority over her patients. For sure, engendering professional relationships with your patients is necessary, mutual trust, mutual respect most definitely – authority – not so much.

    Having “the power to influence others, esp. because of one’s commanding manner or one’s recognized knowledge about something” (another definition of “authority”) may be closer to what you’re striving to attain – but by your own admission – you’re in the process of acquiring such knowledge. Authority is not yours yet – and really shouldn’t be. A professional boundary is all you have a right to expect. Trial and error will help you find it. It seems to me that what you experienced is part of the process. You’re right to question what it was that you can do differently to establish and maintain that professional boundary. But, in my opinion, “authority” is not the way forward.

  3. Shara Yurkiewicz says:

    I suppose the definition I was thinking of was “being an accepted source of information or advice.” I certainly can’t imagine wanting to force anyone to do anything by a brute power play. The ultimate goal is to help inform and influence a patient’s decision, by building a foundation of both expertise and trust. This is what I hope to gain through training.

  4. Nate Favini says:

    Hi Shara- I just stumbled across your blog and saw this piece. A nice reflection. Every physician develops different boundaries as they grow- if this experience felt like it crossed a boundary to you, then that is good to reflect on. But too few physicians (especially in settings where the patient-doctor relationship is so transient) allow themselves to become close to their patients- at times a friendship does develop and that’s not always bad. I’d encourage you to keep thinking critically about your professional boundaries as you continue in your training. As your stature grows and if patients regard you as a distant expert, you may think fondly of the days when they felt more comfortable with you. I bet you’ll decide to incorporate the humor and personal touch that helped this patient relate to you, while maintaining boundaries that make you comfortable. It’s wonderful that you’re reflecting on it now. Best of luck! -Nate

  5. I believe I should say Congratulations! At such a young age you have engaged and touched a heart. The gesture of touching your nose represents your inate ability to make a patient feel so comfortable and be so at ease with you. This is something that many in the medical profession never achieve. Do not ever lose this or believe for one second that it is unprofessuional!

    The barrier that you so desperately believe you need to achieve will be the barrier that will turn you into “just another Doctor.” Let that barrier go and you become “that special Doctor.” Patients expect excellent knowledge and treatment from you, that is a given. Very few patients will ever comment that the physical exam was the best one they ever had. What they do not expect is to find out that you actually care about them as a person in addition to a patient, and that you are also a real person just like them, willing to share some of your life with them.

    As you get older and see more patients you will begin to realize that it is not the treatment or great diagnoses you give that matters in your life. I am sure that will be excellent, superb, as good as it gets, normal. That is what you have been trained to do and what you have to do. But rather it is all about the relationships that you develop with your patients, the freindships, the moments you laugh together and the moments you put down your stehoscope and hug and cry together. Your comfort level allowing them in to your life just as they are allowing you to do.

    Don’t be “just another Doctor.” I can already tell you want a whole lot more than that. You can be “that special Doctor.”
    So tear down that barrier and always remember, it’s not the care that matters, it’s the caring.
    You go girl!

  6. Shara Yurkiewicz says:

    Thanks so much. These comments are helpful as well as kind.

  7. clairesmum says:

    I’m a nurse so I have a different perspective. This gentleman felt comfortable enough to do something a bit playful at the end of the session. He sounds like a friendly person who was not in any acute distress, so he was willing to be patient with you as you struggled to do the physical exam. It was clear to him (and to you, although it was undoubtedly not spoken of directly during your examination of him) that you are new to the process, and you were not, in fact, an active member of his treatment team. So, it makes sense to me that he did not perceive you as an ‘authority figure.’ There is no indication in your post that you will have any ongoing relationship with him, so don’t fret about it too much.

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