Sunday, 24 May 2009


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.


Ink and Indigo said...

I don't think you're over-reacting at all - you were clearly in a position where you couldn't retaliate, and the patient took advantage of that situation to intimidate you. Inappropriate sexual comments and advances aren't tolerated in any workplaces, so why should you have had to put up with it? I'd definitely ask some other female doctors personally how they deal with such situations. Poor you - I can see why you are fuming.

Krafty Like A Fox said...

Ugh, what a creepy old prick. No, I don't think you're overreacting, and I agree with the above-ask other female doctors what they do in the same situation. I don't know what the sexual harassment legislation is in your area, but probably there is something on the books that allows you, politely but firmly, tell the guy to back the hell off.

Kate said...

Your mother is wrong. This behaviour was so inappropriate that it was bordering on harassment. The patient needs reporting (so that he never makes any woman in the same position feel uncomfortable again) and you need to discuss this with whoever is mentoring you. There must be professional guidelines for you to follow swiftly when these situations arise. I feel terrible for you, and its awful that you still feel you have cause to question the legitimacy of your own reactions here. Even if he was protecting his manliness in the manner of a seedy stock character in a 1970s sitcom, the fact remains that he inappropriately sexualised a medical situation, and made a woman that was assessing his condition - caring for him and his cancer - feel uncomfortable. You are right to be angry. It is completely unacceptable.

Katie M. said...

I have to agree with the other comments: I don't think you're overreacting at all. A situation like that would make me both angry and uncomfortable, not to mention undercut professionally. Other female doctors must face similar problems: are there any with whom you could discuss appropriate, professional responses? I'm sorry you had to deal with this -- it sounds very unpleasant. I hope the garter stitch is helping.

Emily said...

Well, here I am, a female doctor who has had similar situations. You are right that it's easier to deal with once qualified in that they need you too, you are not relying on patients' generosity to learn (though they are still teaching you lots); I think you're right to be angry. And it's fine to be ngry with someone even though he's in a horrible situation (cancer, hospital).

I think it is certainly something you can and should bring up with anyone you feel is mentoring you, formally or informally, and in this clinical situation or any other. You may find that you get support, you may not (I think working in hospitals is quite degrading to ones sensitivities and can result in a glossing over of these sorts of difficult situation). That may still mean that your comments starts to awaken others to this inappropriate behaviour.

I wonder whether he was taking out his anger about his situation on you two, rather than simpply being routinely slimey (not that that's ok).

Not sure that I am helping much in this, but as someone who has been working as a doc for quite a while (currently in Nottingham) I'd be very happy to communicate about it. Have you discussed this on or similar?

BTW, I do agree about the Eng. Lit./medicine comments you made (two approaches etc); hang onto that!

Enjoy your garter stitch. Something you can complete can be a wonderful therapy!

MeowGirl said...

i love what you've written about clerking. it's such a compassionate and gentle view of doctoring, and your obvious appreciation for the process is heartwarming to me.

ok, now i'm going to get really really long winded, as your encounter with this patient crosses the gender-in-society issues i constantly worry/ponder over...

i sympathize with your anger and frustration. i've felt the same sort of stymied, uncomfortable anger before in similar situations. i don't think it's an overreaction. i also think it's just fine for M and your mom to have different views on it. everyone has different ways of interacting with others, different expectations, different levels of sensitivity to inappropriate behaviors. over/under-reactions are labels on a slippery slope, since the crux of issues like this is allowing every person the right to define themselves.

it seems to me he did feel vulnerable, having two young and whole women closely examining his elderly and ill body, and acted out of it. even so, the intention behind the comments isn't necessarily clear, it could have been in irony to point out the powerless of the situation, as banter to mask/ease his discomfort (especially since he is of an older generation), or malicious intimidation to violate your mental space for having violated his physical one.

what is clear is you have right to communicate appropriate and inappropriate ways of interacting with you, regardless of what he intended, since it's not at all a case of medical information or advice. it's also important to realize the situation gives you more power to define the interaction than you think. if there hadn't been some power differential, he wouldn't have felt as vulnerable.

how to demand appropriate behavior though... like everyone else, i think it's a good idea to consult others, though not just other female doctors, but any mentors and colleagues you trust. it's not a "female" problem; it's a social one that requires social discussion. the profession benefits from discourse on how best to quell such behavior without antagonizing patients, be it a direct "i'd rather you not make comments like that mr. so-and-so" or sterner/lighter rejoinders.

finally, i want to say it's unfair to expect yourself to have known the "right" thing to say... you have to learn how to work with verbally abusive patients, uncooperative patients; why wouldn't you need training to deal with this behavior? discussion amongst your colleagues and teachers could help the program realize the need to include this as part of the curriculum, to help students learn how they wish to cope with such issues.

sorry to have gone on longer than i probably should have. can't seem to talk about this without doing so. :(

Elli said...

I don't know why this isn't part of career training for all females! I don't have any special insight, but I try to address situations like that politely and directly - definitely the first time it happens, so that I don't send mixed messages.

Older gents are definitely the worst offenders...also the most likely to try to reason with you and tell you why their behavior shouldn't be considered offensive. Grr.

Noo said...

Oh dear. I hope you don't have to encounter too many of that kind of patient.

Have you read "Direct Red"? It's a literary account of a female surgeon. Excellent reading. I don't know who else to recommend it to, but as a med. student, you might be interested in it. I liked it because the author can actually write.

EJ said...

I too reckon it was probably a case of the patient trying to protect himself from the mortality of his situation. It's tough that it would be unnecessarily harsh for you to tell him it'll never 'be his turn' because that's (for him) the unsavoury truth. People find themselves 'old' before they're really ready to accept it. I sometimes use self commentary like that to get myself through difficult encounters but that leaves an unpleasant taste in your mouth too. I agree how to deal with situations like that are part of the training even if you learn it through unstructured encounters. talk to some doctors you trust. if one brushes you off try another.Everyone experiences this at some stage but the position you're in makes it a more fine lined situation. I hope the good times will always outweigh the bad.

Jess said...

Wow, I love what you wrote about clerking. It's so frustrating to be in our position... I want to inform and discuss, and generally be useful in some way rather than just taking for my own education all of the time.

As for the man, I've had similar encounters, and it is uncomfortable indeed. I don't think there's much you can do other than just maintain a professional composure and try not to get flustered until you leave the room (unless of course he's really crossing the line!). Good luck!