Mexico Medical Student |

This post has been a draft for weeks, but I thought I’d finally get it out there. A few weeks ago, I finally had my certification exam. This exam is a 2 hour exam with a real patient which includes a hand-written write-up (in Spanish, of course) on the spot without reference materials or other aids. Think USMLE Step 2 CS, but on a far more basic level. The main point is to simply show that you are ready to start your clinical years and transition to the hospital setting. In other words, you’re not a danger to yourself or others; it’s not about whether you can diagnose small cell lung cancer with your palpation, percussion and auscultation skills.

There are two variables at play here: 1) our school never uses standardized patients, so the overseeing doctor at your clinic (randomly assigned) decides based on who comes in who is a good candidate for the exam, and 2) the variation in overseeing physicians at various clinics to which they send us and what they are looking for. We have a sheet of things we’re “supposed” to say and do, but it’s not only ridiculous (as you’ll see in a moment), but it is far and away different from what we’d been taught up to that point in many cases. For example, it’s totally understandable and relevant to ask during the clinical history if they live with any pets, but a rundown of the pets’ vaccinations, chronic diseases, and pet family history (”Did your dog’s mother suffer from hip dysplasia?”) OK, so I exaggerate, but that’s how it feels.

So you know exactly what I mean, here are some of the more, um, “questionable” questions:

GI:
Have you seen worms or other parasites in your stool?
Does your anus itch?

“Gee doc, I came in because of a sore throat, but now that you mention it…yeah, I did notice a bunch of worms running around, and wouldn’t you know it–they itch! I wasn’t going to mention it because I didn’t think it was important, but…HOW DID YOU KNOW?! You’re a genius, doc…A GENIUS!”

Neuro:
1) Do you learn quickly or are you slow? [I promise this is a word-for-word translation]
2) Do you hallucinate or hear voices/noises that don’t exist?

#1: I guess if you got somebody who actually replied, “Yeah, I’m kinda slow..*drool*,” that’d be enough data in and of itself. Note that there is no option for, “Well, I think I learn average/normal/like everyone else.” It’s the Corvette or the “short bus”–you choose.

#2: Now this is one that I couldn’t help but think, “What if the patient thinks they’re real?” The patient could have daily conversations with Abraham Lincoln and not hesitate in answering the question, “No, of course not–do I look crazy?”

OK, you get the drift. It’s so unlike a “real” patient encounter where time and substance can’t be set aside in the name of academic thoroughness, but I understand that at SOME point they have to make sure we understand the value of a complete history to get not only the details of the primary problem but hidden clues and details that would not be known if not asked. Of course, we understood this our first year, too, but they never stop trying to imprint this every chance they get.

So, in a hat tip to Punchberry who wrote a hilarious post about being clueless trying to figure out patients’ problems, I have to say during my certification exam, I had a major “duh” moment as well. My patient was a mid-20s, obese man with a history of significant hypertension but no diabetes. Chief complaint was epigastric pain and a headache, which were unrelated, but it was an overall “uncomplicated” case, for which I was grateful. When it came time to do the physical exam, I started with the abdomen. I was prepping the drape along his pants when I noticed what looked exactly like a C-section scar. “OK, this is obviously a male,” I told myself (you can never be too sure :P), but what kind of surgery would leave a scar there? From the umbilicus, it went about 8-9cm downwards. Ventral hernia? Unlikely, especially at this (pelvic) level–perhaps if it was above the umbilicus. Bladder surgery? Perhaps.

He denied surgeries on the history, so I asked again, “Are you sure you haven’t had any surgeries?”
“Yes, I haven’t had any.” he replied.
“Then how did you get this scar?” I asked, pointing.
He looked at the scar, then me, furrowed his brow, and said banally, “That’s from my pants. They’re a bit tight.”

It’s one thing to be embarrassed. It’s another when you’re embarrassed because you made a patient potentially feel embarrassed. It’s quite yet another when you’ve accomplished the latter while being supervised, look up, and see the proctoring doctor scribble in a clipboard with an disapproving look on his face.

In spite of the gaff, I actually scored quite well. I’m now certifiable certified!!