The very first semester of medical school, my classmates and I were taught the full-body physical exam. It took the. whole. semester. Every couple of weeks, in small groups of 5 students and one faculty preceptor, we would approach a different organ system–cardiovascular, respiratory, gastrointestinal, and so on–first practicing on each other, and then several times with trained actor-patients called physical exam teaching associates. At the very end of those first four months of medical school, we were timed tested on the entire thing on a healthy actor, head-to-toe, and had to write up our findings in a “note” right after. Patient is well developed, well nourished, in no acute distress. Head is normocephalic, atraumatic. Pupils are equal in size and reactive to light bilaterally… And if it sounds overly rehearsed, it certainly was—I, along with most of my classmates, had literally memorized a normal physical exam note so that we could regurgitate it onto the computer screen after.
The second and third semesters, we had the opportunity to practice these painstakingly acquired exam skills in an outpatient setting through a “longitudinal clerkship” one afternoon a week, typically in various primary care offices across the city. But despite all of this training and practice, I really didn’t know what I was doing.
The reality is that the physical exam is something it takes years to perfect. As a first-year medical student, I was instructed on placing the stethoscope on the chest in “at least four different areas” to hear the heartbeat. And I mechanically did as I was told, not having the slightest clue what I was supposed to be listening for or why those four areas. As a second-year student, I learned that various pathologies produce murmurs, and the location on the chest where they are appreciated clues one in to what issue might be causing the sound. But even so, my naive ears heard only garble. Murmur or not, I honestly had no idea. Smile and nod, smile and nod.
Now as a third-year, just this past month, something changed—drastically. I was working in a pediatrics primary care clinic, doing dozens of exams a day, on kids both healthy and sick. One random day about a week into the experience, while examining a healthy baby, I was going through the motions of putting the stethoscope on the chest in the four areas for the cardiac exam, listening to the racing lub dub, lub dub of the infant’s heart. But suddenly I heard something else—lub whoosh dub, lub whoosh dub. Wait a second. Is this real? I repositioned the earpieces and closed my eyes. Lub whoosh dub, lub whoosh dub. Yes, this was real. I reported my findings to the attending, who verified the murmur upon repeating the exam.
Over the next few weeks, I picked up several additional heart sound irregularities. And it wasn’t just cardiac findings that I was noticing–other systems, too, seemed to have been affected by what felt like a miraculous shift. One day I noticed a scarred tympanic membrane while looking through an otoscope. Another day, a potentially damaged retina. How was this even possible? And were these exam skills going to disappear as quickly as they came?
A part of me felt that it was I who had changed, but a part of me oddly felt that it was the exam equipment that had changed. Maybe, I thought only half-jokingly, the stethoscope had been “off” all these years and had only just been turned “on.” The night after the rotation ended, I even dreamt I accidentally threw my magical stethoscope away and woke up the following morning truly scared for a moment until I saw it still there on my desk. Phew.
But, of course, the stethoscope and otoscope and ophthalmoscope were not any different now than they were on day 1 of this journey. Two and a half years of medical school had actually changed me. Being in the trenches of it, I hadn’t even noticed. But sure enough, every step of the way, I was learning something, gaining tiny increments of knowledge and skill that were initially imperceptible but eventually built up into something real.
When I was a first-year, an upperclassman had talked about how in medicine, you will be learning the same things over and over and over again, each time circling the topic, adding something new to your knowledge base. The physical exam is the perfect example of this phenomenon. We’ve been circling around it, over and over, building layer after tiny layer in our tracks. I didn’t understand the approach at the beginning. Why bother practicing the exam when I don’t even know what normal is? I used to think. Why can’t we just learn the exam when we actually know more about what we’re examining?
But now I’ve come to understand that even when the conscious mind hasn’t got it all figured out yet, the subconscious mind is still learning, synthesizing, waiting for the opportunity to use that knowledge at the right time, and in the right place. From first year to third year, I feel like I’ve come a long way, and even so, there are so many layers waiting to be placed, footsteps waiting to be retraced.
