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Date Posted: Saturday, February 09, 2013, 02:15: pm
REPOST FROM THE PEDIATRIC STORIES SECTION
Date Posted: 14:10:26 12/31/10 Fri
Subject: A Lesson in Temperament
During my first year of medical school, I had the opportunity to shadow a Family Practice physician in my home town. Each weekday from 9 AM until 5 PM I would follow the doctor as she saw patients in her office. The physician I was working with was a 42 year old female physician who had graduated from the medical school I am attending. I saw the whole range of patients and ailments during that summer. All patients were informed by the nurse that the doctor had a medical student accompanying the physician and the patients were asked if it was alright for me to be present during their visit. About 2/3 of the patients said it was OK for me to sit in and the other 1/3 said no. Most of the patients were not told nor did they ask the gender of the medical student. I realized that regardless of how professional I act, I am still a just a regular person who experiences the same reactions and emotions as everyone else.
One patient seen towards the end of summer was an 8th grade girl who was here for her high school freshman pre-participation physical. Besides playing sports she hoped to make the freshmen cheerleader squad as she had done in 7th and 8th grades at the Christian school she attended. When I entered the exam room with the doctor I observed a stunningly beautiful teenage girl sitting on the exam table in a gown. The girl had a remarkably symmetrical face; one that meets some bizarre algorithm that when solved, is the formula for beauty. She was 14 years old, 5’9” tall, 115 pounds, light brown hair, and blue eyes. After the doctor introduced herself and me to the girl, I stood on the opposite side of the exam table from the doctor. The doctor asked the girl the standard questions for a 14 year old …” are you sexually active yet? Do you understand the risks of getting pregnant? Etc.”. The girl said that she is a Christian and won’t be having sex until after she is married.
The doctor began the exam checking ears, eyes, nasal passages and throat. The doctor asked if it would be alright if I could perform the same exam steps after she did and the girl said sure. After the ENT exam the doctor checked thyroid, and lymph nodes and then posterior breath sounds. I followed with the same steps noting no abnormalities. The doctor then had the girl untie her gown and lower it to listen to heart sounds at the aortic, plutonic, tricuspid, and mitral locations and the palpated for PMI near the mitral location. The girl had removed her bra before putting on the gown so both breasts were exposed during this exam. For a 14 year old girl I thought that she was toward the higher end of the Tanner scale as her breast had clearly delineated areolas and nipples that were semi erect even though her breasts were a bit small, 32A perhaps. I listened to the heart sounds and found nothing remarkable until the mitral site when I though I heard a slight echo after each valve closing. I didn’t want to linger listening too long so went on to feel for PMI. To properly feel PMI one places their hand palm down under the left breast and feels for the point where the heart beat is strongest. This is normally done with the patient sitting and when the patient is a woman with large breasts (>36C) one usually asks the woman to lift her breast so that one can feel for PMI. This was not necessary with this girl though as I could cup her breast and raise it with the same hand I was feeling with. I was a bit embarrassed and being only 22 years old at the time, I was somewhat aroused.
After feeling for PMI the doctor resumed her examination having the girl lie back on the exam table. The doctor again listened to the girl’s heart sounds in the supine position and then proceeded to the abdominal exam. I observed the doctor first osculate the abdomen listening for bowel sounds and then begin light palpation of the abdomen in the LRQ working clockwise to the LLQ and repeating the sequence with deeper palpation. The liver was located and palpated on expiration. The doctor had the girl roll slightly to her left side to palpate the right kidney and then to the right for the left kidney. I was then allowed to perform the same abdomen exam. I listened to the heart sounds again and proceeded to osculate the abdomen for bowel sounds. I had begun light palpation of the LRQ when the doctor stopped me and told me that I was palpating to high up on the abdomen. She moved the girl’s gown lower to expose the entire abdomen to the supra-pubic midline and showed me that I should begin palpation just above the supra-public midline. My first observation was that again, for a 14 year old girl she was very well developed with pubic hair easily visible just below the supra-pubic midline. The doctor preferred to have patients undress completely for physical exams so this girl had also removed her panties before putting on a gown. I resumed light palpation of the LRQ of the abdomen working clockwise and then repeated with deeper palpation and proceeded with the liver and kidney exams finding nothing remarkable before stepping back to allow the doctor to resume her examination.
The doctor next did a quick visual inspection of the girl’s legs from mid thigh down checking pulses on each ankle. The doctor said that genital, rectal and gyno exams were not indicated for a girl of this age and would not be performed. She did want to do a scoliosis exam however since this screening exam is indicated for a 14 year old female patient. The doctor asked the girl to hop off of the table and to stand facing away from us. The girl began to pull her gown back on but the doctor told her to just hop off the table and leave the gown lying on the table. The girl hesitated and then said “but I’ll be completely naked then”. This struck me as an abrupt change in level of modesty because until this point the girl had shown no problem with exposure. I just assumed that the doctor would just let the girl put the gown on since all that was really required for a scoliosis exam was visualization of the entire spine area of the back. The doctor said to the girl “this will only take a minute and we need to see your entire back so just hop off the table and leave your gown behind. The girl slowly got off the table holding the gown up in front of her and slowly walked around the table to where the doctor had told her to stand. As she passed by the doctor, the doctor grabbed hold of the gown the girl was still holding up in front of her and pulled it out of her hands quite violently. That surprised the hell out of me and the girl as well. It was clear that this doctor had no tolerance for someone not complying with her instructions. The girl continued over to where she was told to stand. The doctor told the girl to stand up straight, had her bend forward and touch her toes, lean back, and then side to side. The doctor then gave me an explanation of what I should look for when checking for early signs of scoliosis. She demonstrated using the girl as a model, that I would observe a curvature of the spine at specific vertebrae having me locate and point to the vertebrae on the girl. She also said I should check by putting my hands on the patient’s hips and having them bend forward and then backward. Then she told me to show her. I walked up behind the girl and told her that I was going to put my hands on her hips and have her bend as far forward as she could. I observed that this girl had some of the most well defined tan lines that I have ever seen. Her skin on her thighs and lower back was a golden brown and the skin on her butt was very pinkish white with a line of demarcation line it was drawn with a fine pencil. I felt bad for the girl after seeing how the doctor treated her by tearing the gown out of her hands. The doctor’s instruction on scoliosis exam using the naked girl before me now was not for my benefit. She hadn’t giving me any instruction for any other part of the exam. This scoliosis exam demonstration was to punish this young girl for not following her instructions. I was being used by this doctor as a tool to punish this girl. With my hands already on her hips and the girl bending forward her butt pressed firmly against my groin area, I felt my self getting hard. The doctor told the girl to keep bent forward for a minute because she wanted to show me something else to check for. The doctor showed me the L4 and C5 vertebrae should protrude slightly on a patient with no scoliosis when bent in this position. The doctor took her time locating the vertebrae to show me. All the while this is happening, I have a full on erection pressed against this poor 14 year old girls naked butt while she in bent over in front of me with only the fabric of my trousers between her skin and my foreskin.
When the doctor was done with the demonstration I let go of the girls hips and said “OK you can get dressed now”. The doctor looked at me and said something like “when did you take over my practice”. I just responded that I just thought we were done. I finished the 2 weeks of my summer working with that doctor but won’t ever go near her again. That experience taught me plenty about how a doctor should be and how not to be. For all the good a doctor can do to help people, throwing a hissy fit because a patient hesitates too long following instructions can do more harm to that patient over the course of her lifetime than the healing rendered could ever heal. After that experience I vowed to myself to never lose my temper with a patient.
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