An important part of our medical education is patients. We are often told that the best way to learn medicine is to talk to patients, examine them to find any physical clues to broaden or narrow the picture we have built up from talking to them, and then go away to read up on everything we have learnt from that encounter. As medical students, we are expected to ‘clerk’ patients on a daily basis, to spend our days in between timetabled teaching sessions talking to patients, looking at their hands and inside their mouths, tapping their tummies and listening to their chests and generally trying to build up our knowledge of patients and diseases from the foundations of the individuals who happen to end up on the wards in our teaching hospitals.
‘Clerking’ a patient involves taking a full ‘history’ and examining them. Taking a history means asking questions about how and why they came into hospital, what led up to that, any other medical issues they might have, medicines they take and any allergies they have, their social and family background, and also doing a ‘systems review’, running through a checklist of questions to pick up any other symptoms or past events that might have been missed in the rest of the history. Examining a patient means looking at, feeling and listening to various parts of the body to pick up any diagnostic clues and to build up a better picture of their overall health. For students in my year, this means making a general assessment of the patient’s appearance, and examining the cardiovascular and respiratory systems (heart, major blood vessels, lungs, signs of oxygenation or carbon dioxide retention), the abdomen (including the digestive system, liver, spleen, kidneys, and bladder), and central nervous system, which involves asking the patient to perform lots of odd tasks like baring their teeth and tightening the neck muscles like a scary monster.
Clerking patients is an extraordinary privilege. You can ask patients about anything from headaches to their bowel habits, and most of the time they will tell you happily. Because you’re wearing an ID and a stethoscope (not a white coat; they’re considered infection vectors in this country!) people will tell you things they wouldn’t tell close friends. You might talk about what happened when they were giving birth, or learn that their daughter’s husband hits her and they’re not allowed to see the grandchildren, or that their brother was killed by a landmine.
I went into medicine because I am interested in people above anything. People are often surprised that my first degree was in Eng. Lit., but to me, they’re just different approaches to the same questions: about who people are, and how they got to be like that. Clerking a patient can be fascinating, gratifying, and inspiring. To begin taking histories from the most boring-looking patients can be to embark on stories that are complicated and challenging, uplifting and often humbling, and the relationships you can build from spending that time with a patient, and keeping an eye on them for the rest of their hospital stay, are rewarding beyond words.
There are times when it doesn’t go so well, of course. The patients with cancer who feel accused when you ask how much they smoke or drink alcohol, no matter how hard you assure them (truthfully) that these are routine questions you ask absolutely everyone. The patients from the local prison who will happily tell you about their past drug use, but absolutely clam up and become verbally abusive when you try to establish their social background or any illnesses that might run in the family. The professional patients who’ve been in and out of hospital so many times they know the format off by heart, and tell you you’re useless when you start asking questions they think aren’t relevant. All this before you’ve even got to the examination and started poking and prodding while asking them to take big breaths in out through their mouth.
A few days ago I went with a friend to clerk an elderly man who’d been in hospital for a few days. He was fairly happy to talk to us, although he became annoyed a couple of times during the history when we tried to clarify things, or he felt he’d already answered our questions. When we’d examined his chest and abdomen and were about to begin our neurological exam he seemed to be getting annoyed and M suggested we could stop if he was tired. His response was, ‘Look, I’m half naked, lying here being touched by two beautiful young girls. What more could I want?’. Neither of us said anything. M carried on with examining the cranial nerves, and I watched her doing it, looking at her red pen and waving finger instead of his cheerful face. When we finished, we thanked him, and as we were gathering up our notepads and stacking the plastic chairs he cackled and asked ‘When’s my turn?’.
I don’t really know what I should have done in that situation. I wanted to tell him he was behaving inappropriately. I wanted his cancer to disappear immediately so that somebody would realise it was a mistake his being in hospital and throw him out so I’d never have to see him again. I wanted not to be a student, to have some kind of role in his care so that I’d have at least some authority to tell him that his behaviour was not acceptable.
As medical students, we rely on the generosity of patients to give us their time and let us into their secrets. We are not allowed to give patients information, to tell them anything about their condition, advise them in things as basic as how to seek support for stopping smoking, or talk to them about the operation they about to have in any kind of informative way, although we are taught all of these. This is a recurring theme in my medical student support group. We find ourselves in a strange position as medical students: one with authority but no power, with responsibilities but few rights. We walk and talk like doctors, but if you try and catch us, you’ll find we are just shadows, flitting onward after the qualified doctor who actually can give you reassurance or answer your questions.
So instead, I am angry. I am pissed off with the patient for overstepping the mark. I am furious with myself for not saying anything, for not being sure what I should or could say. I’m annoyed with M for not thinking that this was beyond the pale. Above all, I am outraged with a society which allows a man in hospital for treatment and care to think that it’s acceptable to sexualise an encounter with two young women trying to improve their clinical knowledge and further their education.
GMC guidelines for students state that they ‘are expected to maintain a professional boundary between themselves and their patients … They must not use their professional position to cause distress or to exploit patients’ but there are no guidelines for when the situation is reversed. Guidelines don’t necessarily help anything, but I wonder if it’s time there were.
In the meantime, I am trying to get on with my day, and, in the spaces in between, to think of what I could do next time I'm in a similar situation, and how I could be better.
Incidentally, my mother thinks I am overreacting, and that this was 'harmless joking' from a man 'trying to regain some manliness' in a difficult situation in hospital. If you do too, let me know.
