Monday, July 17, 2006

The Doctor is Out

Yes folks. Last chance to touch the screen for healing for a week or so as I'm off to the sunny Aegean on hols for a week on Wednesday. Feel free to use this space to chat amongst yourselves whilst I'm gone. But before I go I have an observation and a question.

First the observation. Going on holiday can be a challenge. Mr Angry posted today about the profusion of "Doctors" with PhDs but not medical degrees. To be proper about it they have earned an academic title that dates back to antiquity and just refers to their learned wisdom. Thye have earned it and deserve to enjoy the benefits of their title. But I feel I must warn them that claiming it as an honourific comes at a price.

Before we had kids I could travel incognito as a "civil servant". Sounds just boring enough to kill all conversation and allow the repost "and what do you do?", deftly changing the subject avoiding any comeback. The thing is, even before I qualified any slip re my secret identity was an invite to the most excruciatingly embarrasing ordeal. Don't believe me...

Xmas
1980 (ish)
Dr J (then undergrad' J) takes a job behind a bar somewhere in the Wild West Country over the hol's.

All is well for the first week. Then the Landlord's cousin (an hardened drinker) discovers from the Landlord the secret identity of the fledgling Doc. Cue the public display of the worldst most awful and awe inspiring hernia scar to the very loud if somewhat slurred accompaniment "Whaddaya fink a' that then Doc?" as he yanks his trews down to his ankles and pulls his not so tidy whities to one side. For the next two weeks yours truly was bombarded with questions about hysterectomies, gallstones, cystitis... you name it, I got it, often to similarly inappropriate visual displays. It was a relief to get back to Med School, so since then, on hols and in social settings with strangers you'll find mild mannered cub reporter (well civil servant in this case) Clark Kent standing in for Dr J.

Now we have kids I'm generally outed within the first couple of days, and again the discussion of subjects far better left to the privacy of the confessional resumes. Now don't feel that I'm complaining. I love what I do, and am generally more than happy to offer an opinion on just about anything, but it is nice to be off duty once in a while. Also it staggers me that on hearing that one little six letter word many people seem to shed all inhibitions to talk about and indeed on occasions to display bits of themselves they would never normally bring in to a polite conversation.

Which brings me to my question.

From time to time I am called upon to examine lady patients chests. Often, this can be safely limited to a brief application of a stethoscope to the back with clothing simply untucked and lifted. This I feel quite ok to handle in surgery as part of the normal routine, but sometimes, as today, a full examination in a state of undress is required. In accordance with current practice I no longer do these exams unaccompanied and so patient and I will move into the treatment room and sister will stand in as a chaperone throughout the exam. But, with a disrobed female patient laid on the couch, during the chest examination, where is it safe to look?

Over close inspection of the breasts sounds pretty obviously intrusive. Eye contact seems an equally obvious no no. Closed eyes is open to all sorts of misinterpretation (though I will often do this when trying to listen to chest sounds as I find it helps me to concentrate better -- whatever the age of gender of the patient before you go all funny).

So ladies, help me out here. What's a poor boy Doc to do?

Happy Holidays (well for me anyway). See you all next week.

Play nicely.

20 comments:

Anonymous said...

What about focusing on the wall with a look on your face that says "shhh, I'm concentrating"?

Z said...

If you're examining her chest, isn't that where you have to be looking? It doesn't matter too much though, she will be anxious not to catch your eye so she will stare at the wall.

Have a wonderful holiday.

greavsie said...

Could you examine by reaching round from behind?

Mr Angry said...

So you can't mutter under your breath, "Hmmmm.....boooooobeeeeees...."

Doctor Jest said...

Anon-- Only if you are prepared to take a chance on putting the stethoscope somewhere you shouldn't....

Z-- thank you for those kind words. I'm hoping that when the three new lady docs start with us in the Autumn I won't be challenged to do this so often. Awkward for both parties then these examinations it seems...

Greavsie-- only domestically ;-)

Mr A-- not unless I'm turning into Homer Simpson and just failed to notice ;-)

Ally said...

Damn! For years I've been consoling myself during these kind of exams that the Doc has seen it all before and is in now way embarassed, therefore I don't need to be either ... :)

jaunty rakes said...

I'm with Ally, I have to believe that to you I am just a body with breasts and a vagina. Look where ever you need to look. Just dont look embarassed.

And the other thing, a friend of mine who was a zoo keeper and I who was a windsurfing instructor spent long hours working out occupations for ourselves that didn't involve long arguements on the ethics of zoos or bar-room enactments of the not quite perfected carve jibe. What is the perfect "no one wants anymore information" career?

Geena said...

I'm with Ally...darn it you chaps are supposed to be automatons in that examining room...thats what I've always told myself and now you've exploded the myth...oh dear...well I am looking for a gynae and you have just persuaded me to find a female doctor.

So just keep your face blank when doing those exams and pretend its a rubber duck. Or something. Please.

Ew. I almost wish you hadn't written this.

Chairwoman of the bored said...

I always thought the doctor was as embarrassed as I, and now dammit, you confirmed it.

Nutty said...

Just so long as you don't do what one doctor did and undo my bra without asking. I was lost for words.

Shinga said...

Tricky - because you don't want to look too unfocused or un-noticing in case someone doubts your mental state.

Look at the relevant parts during the examination (if you're going through it, it may as well be comprehensive and reliable) and thereafter or in-between, somewhere around the chin or nose will suffice if neither you nor the patient can cope will eye contact. It's no good looking lower as many women would not welcome a gaze at the tum, the hips or the thighs...Looking at the ankles would just make you seem demented.

Regards - Shinga

Anonymous said...

Some patients are also uncomfortable with female doctors as well. i guess just keep the conversation or history taking going as you examine and naturally the thought of where to look won't ever occur at the first place. or as i examine, i even taught them the way to do self breast examination. and when i talk and examine at the same time, my eyes don't really focus anywhere.

Anonymous said...

I agree with the first commenter. Look at the wall with a faraway gaze that says "I'm blocking out all visual input to better concentrate on the subtle information I'm getting from my fingertips." Try to cultivate a look of boredom, too, as if you do this boring task every day, ho hum. If you can, I do think it's a great idea to keep going with a non-reproductive-system-related and non-anxiety-provoking history. "Any foot pain?", that kind of thing.

storkdoc said...

I am a male GYN so I do these all the time. I only disrobe the side that is being examined (Except when the symmetry of the breasts needs to be checked). I look at it while I am examining it as part of the exam requires a description of the skin and the areola and nipple. I also engage in easy conversation with by patient.

If she states that she is embarressed or nervous I let her know that as long as one of us is not nervous or embarressed, we will do fine.

And pretty much all breast and vaginas look the same.

Anonymous said...

The only time I have had a breast examination was on my own request as I thought I could feel a lump. But the doctor was a bit embarrassed about suggesting the examination - he said 'it's probably nothing but do you want me to check your breasts?' which meant I had to say 'yes please' which made me feel like a weirdo. I wasn't at all embarrassed about the examination itself, they are only boobs - but I was embarrassed by his reluctance. So there you are - be confident is what I say.

Doctor Jest said...

I knew I was opening a can of worms with this one. What a lot of helpful advice, thank you all. This is a bit of a portmanteau reply so please excuse me if I don't reply post by post.

I probably didn't express myself quite clearly enough in the original post. Under most circumstances I am quite happy to perform breast exams and continue a professional discussion, usualy along the lines of a more detailed history of the problem presented as we go.

I will always ask before performing any aspect of the examination and would NEVER take steps to "unwrap" a patient myself. If they are having difficulty I will offer assistance for outer garments, but for more intimate examinatins that is one of the fast disappearing functions that should be carried out by a nurse.

The specifics of the case I referred to were a woman in her late teens presenting with a chest pain that the A&E docs had terrified her about when she had presented to them the night before. They had done "Hospital Doctor" things to her like X ray and EKG without actually bothering to listen to what she was telling them, then booted her out, undiagnosed and still in pain, telling her there was nothing the matter!

I had a pretty clear idea what her diagnosis was from the history, but needed to do the physical to confirm diagnosis and for her ultimate reassurance. Normally I wouldn't have turned a hair, but two things complicated the exam. First, when asked to disrobe she expressed considerable embarrasment at having tan lines, having just returned from holiday, and second she was personally acquainted with the only availabe nurse to stand in as chaperone, so the whole exam became much more awkward than would normally be the case.

I do find it interesting that this set of circumstances made things so much more difficult, but am reassured that my own technique seems to chime in with the advice already offered. My aim was not to avoid personal embarrasment since as some of you have pointed out, in umpteen years there's not much that I haven't seen or been called on to do professionally. I was looking for a sure fire way to avoid such embarrasment for the "victims" of such examinations.

Sounds like I just need to keep waffling on as I usually do. So no problem there then....

Oh, and the diagnosis was costochondritis for those that were worrying. Medically trivial, but very painful.

Anonymous said...

Now then, I thought of this piece of yours when I was reading over a patient's notes today - a PRHO had been pre-clerking said patient and his writing was nothing out of the ordinary - nice and clear and confidently written - and then he had to carry out a breast exam. There followed a very shaky drawing of a pair of boobs and the writing went to pot after that. I DID wonder if it was his first breast exam, poor duck, but didn't ask to save him embarrassment.

Kim said...

I say look right at 'em.

That's what is being examined.

The key is to keep as much of the patient robed as possible.

There is no way to avoid the embarassment totally, but a matter-of-fact attitude and covering as much as you can while exposing enough for a good exam is the best you can do.

(Spoken as a female, and not as a nurse! LOL!)

Delboy's Daughter said...

All breasts and vaginas look the same ?????????
!!!!!!!

Doctor Jest said...

DD-- Heh, you see what I did there? Sorry couldn't resist the easy pun. But you're right. No they don't. But then again from an anatomists point of view they sort of do. In other words however they vary in external appearance they are still all made up of the same components, so I get what Storkdoc was saying. However, at an aesthetic level.....