“I did not appreciate”: learning the physical exam

At home in New Haven, I’m very comfortable taking patient histories; I enjoy helping people piece together the stories of their illnesses and thinking about the meaning of the language they choose. But here, where language barriers pose a serious issue with most patients, my mouth is largely sealed, my ears largely bound. I’ve learned some basic Luganda by now. I can ask, “Do you have fever? Cough? Pain? Weakness?” I can follow up affirmative responses with “How long?” and fumble my way through some simple questions about “better” and “worse.” I know many one-word commands for completing the exam (e.g., “take a deep breath, follow my finger, open your mouth” and most useful of all: “do this”). But by necessity with many patients I am limited to simple questions with binary yes-no answers and all of the nuances leached away. I learned how to ask the open-ended, “What is the problem?’ in my first week here but I rarely use that phrase because the flood of words that comes back is largely undecipherable to my untrained ear. And it is not just the visiting Americans who have problems; Ugandans speak more than 40 languages and Luganda is not the first language of many of the interns and post-graduates. Some of them, too, struggle with the fine distinctions of language.

Even when patients do speak English, the chronology of their illnesses can be frustratingly difficult to piece together. Almost inevitably, a patient will report that his symptoms started “some time back,” or that she has had fevers for “a long time.” I constantly rephrase, asking about last night? Last week? Last month? But in part because this is a final referral hospital--literally the end of the road for many patients who may have been fighting intractable symptoms in their homes and villages for months--I am often unable to pin down a good timeline of disease. Chief complaints can be similarly elusive, particularly in patients ravaged by AIDS. The question “Why did you come to the hospital now?” often brings blank stares, answers about money or family or transport, or, more than once, the sadly eloquent description that it is all simply “too much.”

I am unfamiliar with many of the most common diseases here and the way people incorporate them into disease narratives. One of my favorite moments on rounds on the GI service was when the Ugandan attending asked the patient why he had come to the hospital and he responded, in between vomiting episodes, “I have typhoid and malaria.” The attending laughed and told the team, “he’s probably right! Why does he need us?!” We learned on our first day on the wards that when a patient says he has “malaria,” he simply means he has a fever. Ugandans seem to think of malaria the way people in the U.S. think of the flu, or even the common cold. The disease is seen as largely inevitable, particularly in children, and is a common reason for missing school or work as well as a huge source of childhood morbidity and mortality. I had read plenty about the high prevalence of the disease in the region, but I had no sense of what the numbers meant until I started hearing house staff regularly describing colleagues “out sick with malaria,” or until our housekeeper, driver, and program coordinator all jumped to the assumption that my own subacute illness was malaria. (It wasn’t.) We visited a clinic that is following 601 healthy children under age 10, providing all of their medical care as part of a malaria study. Just in the 13 to 19 months since these children had been enrolled, 329 of them had had a total of 687 laboratory-proven episodes of Plamodium falciparum malaria. It is no wonder that fever equals malaria in Uganda until proven otherwise.

In trying to elicit histories, I have learned that a quick review of systems is crucially important. I had a ten-minute conversation with a patient who spoke very good English about her fevers and her abdominal pain and her headache. She initially denied other complaints and it was only on the review of systems that I found out that she had had a seizure the previous day and in a classic “oh by the way,” now could not walk or move her legs. I’ve also learned to avoid negative sentence constructions in my interviews; more times than I can remember, I made the mistake of saying, “so, you don’t have fever?“ The answer, inevitably, was: “yes,” and the dance of trying to understand each other began again.

For many patients, though, language barriers are the least of their worries. Most acutely ill patients are simply too sick to provide any history, and there is no computer or paper filing system to look up patient records. Some patients carry school notebooks with jotted treatment information or cards from ARV or TB clinics, others come bearing chest X-rays, or hand-written laboratory slips, or pills in small plastic bags or carefully folded envelopes. Many come with nothing at all. I saw one man in casualty (emergency) who was too ill to answer any questions. The only clue we had to his condition was a neatly typed bill from a private hospital in his pants pocket, which noted the patient was being transferred to Mulago for “treatment of ARF [acute renal failure] and financial reasons.” That was the full extent of transferred clinical information. The patient had apparently been unable to pay his bill, a bill that had grown to nearly US$100 over eight days in the private hospital and that meticulously spelled out the costs of the laboratory tests he’d gotten (including a charge for an HIV test), the drugs he’d received, and even the number of individual gloves and syringes used for his care. None of this clinical data had come with the patient, however, so we had no way of knowing his clinical course or even something as fundamental as his creatinine level or HIV status. The harried intern shook her head angrily at this lack of information and I started combing the bill, looking for clues. This patient had received insulin, but apparently only once. Did he have diabetes? Oh, but look, he had also received glucose the same day. And could this abbreviation be bicarb? Maybe the insulin had been used to help lower a critically high potassium instead? There was no way to know for sure, and no further testing available unless the family could pay for repeat blood work at Mulago.

Here, where many patients cannot even scrape together funds for a single complete blood count or chest Xray and more sophisticated imaging and lab studies are generally out of the question, we appreciate any tangible pieces of lab or imaging data even more. Most often, though, we have incomplete patient histories and outdated lab data, if any at all. We therefore turn to the physical exam, simply because it is all that is available. Patients don’t have to pay for it, it needs very little in the way of supplies, and often, it’s the only solid clue to the patient’s pathology. Even thermometers and blood pressure cuffs and the data they provide are luxuries on the wards. We listen for crackles in the lungs, murmurs in the heart, and bowel sounds in the abdomen not just as a cursory first step before CT or echo but sometimes to make treatment decisions. I’ve seen patients get blood transfusions without ever getting a CBC, simply based on pallor in their conjunctiva, on their palms, and under their tongues, perhaps coupled with tachycardia or flow murmurs. Enlarged, palpable lymph nodes provide an opportunity for aspiration (performed by the intern and therefore free for the patient) and a possible tuberculosis diagnosis.

When describing physical exam findings in the U.S., doctors sometimes use an unusual turn of phrase. Rather than saying “The patient did not have any enlarged lymph nodes,” the examiner may shift the burden of proof and report, “I did not appreciate any enlarged lymph nodes.” That phrasing has always struck me as a bit odd, but the sentiment is fundamentally true: in the U.S., we rarely appreciate or value physical exam findings. Instead, we appreciate pieces of data that give us more solid answers: the histopathology report on the ultrasound-guided biopsy; the positive antibody test; the hour-by-hour blood test; the clear visualization of a mass on MRI. We can do amazing things using technology but our physical exam skills have largely atrophied.

The doctors who practice here at Mulago know that their highly tuned physical examination skills are a strength we generally do not share and they are willing to teach. We had five wonderful afternoon sessions with one of the most senior Ugandan residents, spending two to three hours each time talking through just one aspect of the physical exam and then demonstrating techniques on patients with significant clinical findings. The time-honored medical student tradition of beating yourself up over things you don’t know is as prevalent in Kampala as it is in New Haven; it just takes a different form here because the physical exam takes center stage. I’ve been most upset with myself here when I’ve completely misinterpreted physical findings. I totally missed a spleen on a child that was so enlarged that it filled the whole left side of her abdomen and I never got underneath the edge. I misinterpreted the world’s most dramatically positive Babinski reflex as voluntary patient withdrawal (it was so dramatic that I didn’t trust it!). I may not be very good at it yet, but I have learned to take the physical exam more seriously. On call in casualty this week, one of my favorite interns sent me to examine a patient for her, and I see that she trusts my exam skills by now, even though I don’t fully trust them myself. I am hyper-aware, willing myself to listen better, palpate more deeply, since I know that she will take my word for what I find and there likely will not be follow-up studies. There is not time to ask her, “can you check this?” for every possible finding, and I worry that I am missing important clues in my inexperience.

Last week, while informally presenting a patient to a Ugandan attending as part of an extended case discussion, I finished the history and started describing what I’d found on physical exam, as we do in the U.S. The doctor stopped me and pulled me closer to the bedside. “Here,” she said, “you have to demonstrate anything you find. Show me what you did.” I fumbled my way through the neuro exam, describing muscle bulk and tone, attempting to demonstrate reflexes and grade strength, willing the reflexes to behave as I thought they had earlier in the day. She and the others around the bed watched me closely, then collectively imposed the same strict systematic attention I’d seen the Ugandan medical students demonstrate in their clinical exams. “First,” she said, “describe any fasiculations. Next, demonstrate this...” I followed her directions and she continued correcting my technique, saying “I usually hold the leg like this for checking reflexes” or “don’t forget to assess that,” and so on. In a year of presenting patients on the wards at Yale, I have never gotten that kind of instruction from anyone, never even really had anyone watch me do a physical exam. Being in Uganda, blind to laboratory and imaging data, deaf to patient histories, and therefore dependent on physical exam skills I rarely use at home, I’ve realized how much I’ve been missing and how much I still have to learn.