29 January 2013

Our unheralded teachers

When listening with a stethoscope to a patient's heart, one sometimes hears a deviation from the typical "lub-dub" rhythm. Sometimes the "dub" is too loud, or the "lub" too soft. There might be a rubbing sound, or a harsh blowing sound. By interpreting subtle characteristics such as the location, pitch, and timing of these sounds, one can sometimes diagnose things like a diseased heart valve or congestive heart failure. It's very hard to do, and the surest ways to get good at diagnosing heart murmurs are to thoroughly understand the mechanisms of heart disease and to get lots of practice.

Our cardiology professors kindly arranged for me and my medical school classmates to examine patients with various audible heart abnormalities. We were divided into groups of eight and herded through a series of exam rooms. Three or four of us at a time would place our stethoscopes on each patient's chest, and as a group we tried to diagnose the heart abnormality. One patient had pulmonic valve stenosis, a rare murmur that most physicians will never encounter in their careers. Pulmonic valve stenosis is difficult to differentiate from its oft-encountered cousin, aortic valve stenosis, so finally hearing a patient with the rare pathology was quite useful. Some of the patients had severe disease, with classic physical findings that we've only read about in textbooks. One patient with severe aortic valve stenosis had pulsus tardus et parvus ("diminished and weak pulse"): the feeble pulse I felt in his wrist noticeably lagged behind his heartbeat. Examining these patients helped cement my clinical knowledge.

These patients, most of them elderly, were compensated for letting us examine them. I can't imagine that our examination was fun for them. The patients had to partially disrobe, and some of our stethoscopes probably were cold to the touch. I'd like to think that they came in for reasons besides the pittance they were paid.

Patients seem happy to help us learn, whether it's a couple who lets us examine their newborn or a psychiatric patient who lets us ask deeply personal questions about his life. When I tried drawing blood from one of my first patients, my first two "sticks" were unsuccessful and I informed her that I would get someone more experienced to perform the next attempt. She insisted that I keep trying until I succeeded, because she wanted to help me improve (I thanked her and found the more experienced student anyway).

Two volunteers had had their larynges (plural of "larynx") removed because of cancer caused by smoking. They could breathe only through a hole that had been surgically carved in their necks ("stoma"), and could speak only with the help of assistive devices (which made them sound like Stephen Hawking). They spent an hour with us, taking our questions and letting us try out some of their assisted-speaking equipment. They also taught us some useful clinical pearls: since their mouths are disconnected from their lungs, if they need to be resuscitated, we need to ventilate their necks.

I make sure to thank these patients, and I hope they understand how much they are able to teach us. They have my gratitude.