During one of my breaks from medical school in Cuba, I rotated at a US hospital. I was rounding with a third year Family Medicine resident who had a patient with a pleural effusion that needed draining.
The resident had not done a thoracentesis before and the attending asked him to locate where he thought we should insert the needle into the patient. He was not comfortable with this and went to get the Ultrasound. While we waited with the patient, I percussed the patient’s back and could hear where the sound went from light to dull, indicating the upper level of fluid filling his lungs. When the resident brought the Ultrasound, he confirmed that my exam was correct.
I was trained at the Latin American School of Medicine in Havana, Cuba. One the things I value most about my training was the focus on the physical exam. In today’s fast paced world of medicine where we spend less and less time at the bedside, there is still value in what you can find by talking to and examining the patient. Abraham Verghese writes about these experiences in his article “Treat the patient, not the CT scan” [New York Times in 2011]. As another physician trained in low resource settings, he describes more than just the diagnosis that can come from an excellent physical exam. He reminds us of the ritual in connecting with the patient in those moments when we are not in front of a computer screen.
In Cuba, where resources are scarce and there is not a CT or MRI at every hospital, we spent a lot of time “laying hands” on the patient. We spent the first 6 months of our clinical training on internal medicine, focusing on the physical exam. Each day we would walk through the wards with our professor and we would examine patient after patient going through our senses. What is the first thing you see when you walk in the room? What can you pick up during the physical exam?
Then we would discuss what tests we could order to confirm what we thought was going on. While Cuba lacked resources, they did not lack for evidence. Every professor would engage us with “what is the best test for this disease in the US? And what is the best test in a low resource setting? Using their local remote, mountainous region as an example “How would you diagnose this disease in the Sierra Madre?”
This has changed my practice here in the United States. In the busy, county clinic where I work, I still make a point to step away from the computer to listen to and examine my patients. Sometimes I don’t expect to find anything that will change my plan, but many times I do. Recently, I saw a patient with end stage liver disease who did not have a doctor. He was very defensive and angry about the difficulty he was having in getting care. After listening to him and doing an exam, he said “that is the first time a doctor examined me”. I knew that doing the exam established trust for him. He asked if I could be his doctor. In another patient, I pursued an extensive work up in a very sweet, healthy older patient because of a worrisome abdominal exam. After many tests, it was found that she had metastatic ovarian cancer. Moments like these make me reflect fondly on my excellent teachers and mentors in Cuba. It reminds me too that certain aspects of medicine, really, humanity are truly universal; that across oceans and borders, patients and doctors, like everyone else, connect through communication and touch.