Heart Sounds
http://www.100md.com
《新英格兰医药杂志》
The second-year students are learning about the cardiac exam today. They file into a large classroom, where they will first learn about heart murmurs — their location, quality, and meaning. Then, as part of their session, they will have the opportunity to work in small groups examining several patients who have good examples of "classic" murmurs. As they listen to each patient, they will be guided by a fellow in cardiology. They are excited to be able to listen to real patients' hearts instead of just each others'.
Over the years, I have watched my students examine these patients, many of whom are my own, who have so kindly offered their hearts for an afternoon of student education. When the students are introduced to their first patient, they are unfailingly polite, concerned about the patient's comfort, grateful for the opportunity to listen to a real heart. Then they settle into the process of performing the exam: observing the chest wall, feeling for the apical impulse, trying to understand its character and what it might tell them about the heart they are about to hear. Finally, using their stethoscopes, they listen to the sounds beneath. They are awkward and nervous as they listen, brows furrowed in concentration. Suddenly, their faces light up: they have recognized the mitral regurgitation that, until that moment, had been a mere description in a textbook, a manufactured sound on a simulator. Over and over again throughout the course of the afternoon, they will greet patients and then eagerly bend over their hearts, listening intently.
A few years ago, after one of these sessions, I had an office visit with one of my patients who had graciously volunteered to let my students examine her. I thanked her again for her time. She said, "Kate, tell me, how bad is my heart?" This woman is in her 70s now, but I have known her since I was an intern. She has had severe mitral regurgitation for years and, remarkably, has never been symptomatic. I follow her with periodic echocardiograms and discuss the possibility of a valve replacement in the future — an option she has vehemently resisted.
"Why do you ask?" I said.
"Well, when one of the students had listened to my heart, she turned to the cardiac fellow and asked, `How can she live if her heart is that bad?'"
There it was. The moment when, in her enthusiasm and intense interest in the problem before her, the student forgot there was a patient. How easy it was for this to happen — and how potentially devastating for the patient. I reassured my patient about her health, talked with her about how I would use the event as a teaching opportunity, and thanked her for telling me.
So today, before I send my students to meet their patients and listen to their hearts, I tell them this story. There is an audible gasp when I repeat the student's question, "How can she live if her heart is that bad?" I know that most of them are horrified — how could anyone say such a thing? They're certain they would never do that. But of course they could do it, and they almost certainly will someday.
"The student who said this was not a bad person, was not insensitive or uncaring," I say. "She did what I myself have done and what every one of you will do as you go on in your training. The process of learning about the problem was so engrossing that she simply forgot the patient was lying there listening. Perhaps, also, as a student, she had not yet learned how powerful her words could be. This is a wonderful example of the dilemma that will face all of you as you go on in your training. As you acquire more medical knowledge and responsibility, you will focus more and more on the problem and forget the patient attached to it. As you strive to take a good history, get the facts straight, perform a good physical exam, and put it all together into a comprehensive clinical picture, you will find that with all the anxiety involved in wanting to do it right, the patient becomes further and further away. Use this story to remember that there is always a patient and that you have not finished your work until you have taken care of the patient, not just the problem."
One of the benefits of teaching, I have found, is that it requires reflection on these sorts of issues — and, inevitably, on my own practice. How many times have I been so intent on solving a clinical puzzle that I have forgotten that the patient may be worried or anxious? How many times has impatience crept into my voice when I've called a woman to tell her that she needs additional mammographic views because of what is, in all likelihood, a benign "vague density" and she has a hundred questions about what it means? For me, this is just another task to do; I am not worried. For the patient, I have just raised the terrifying possibility of breast cancer. It requires a conscious act to shift my mindset to that of my patient — to grasp her vulnerability, confusion, and need.
While I am busy treating the bodies of my patients, I try to remember to treat the patients as well — to touch them in small ways as well as large. It is critically important to treat the hypertension, the diabetes, or the heart disease skillfully, but when I remember to treat the patient as well, I experience the essence of being a physician. Caring for my patient as a person provides a comforting connection for both of us — the doctor and the patient facing the fears and managing the problems together. I know this alliance is at the heart of our calling, of why we went to medical school all those years ago.
As I look out at the earnest, eager students in front of me with their shiny stethoscopes around their necks, I think about the hearts they will hear and the hearts they will touch — including their own.(Katharine Treadway, M.D.)
Over the years, I have watched my students examine these patients, many of whom are my own, who have so kindly offered their hearts for an afternoon of student education. When the students are introduced to their first patient, they are unfailingly polite, concerned about the patient's comfort, grateful for the opportunity to listen to a real heart. Then they settle into the process of performing the exam: observing the chest wall, feeling for the apical impulse, trying to understand its character and what it might tell them about the heart they are about to hear. Finally, using their stethoscopes, they listen to the sounds beneath. They are awkward and nervous as they listen, brows furrowed in concentration. Suddenly, their faces light up: they have recognized the mitral regurgitation that, until that moment, had been a mere description in a textbook, a manufactured sound on a simulator. Over and over again throughout the course of the afternoon, they will greet patients and then eagerly bend over their hearts, listening intently.
A few years ago, after one of these sessions, I had an office visit with one of my patients who had graciously volunteered to let my students examine her. I thanked her again for her time. She said, "Kate, tell me, how bad is my heart?" This woman is in her 70s now, but I have known her since I was an intern. She has had severe mitral regurgitation for years and, remarkably, has never been symptomatic. I follow her with periodic echocardiograms and discuss the possibility of a valve replacement in the future — an option she has vehemently resisted.
"Why do you ask?" I said.
"Well, when one of the students had listened to my heart, she turned to the cardiac fellow and asked, `How can she live if her heart is that bad?'"
There it was. The moment when, in her enthusiasm and intense interest in the problem before her, the student forgot there was a patient. How easy it was for this to happen — and how potentially devastating for the patient. I reassured my patient about her health, talked with her about how I would use the event as a teaching opportunity, and thanked her for telling me.
So today, before I send my students to meet their patients and listen to their hearts, I tell them this story. There is an audible gasp when I repeat the student's question, "How can she live if her heart is that bad?" I know that most of them are horrified — how could anyone say such a thing? They're certain they would never do that. But of course they could do it, and they almost certainly will someday.
"The student who said this was not a bad person, was not insensitive or uncaring," I say. "She did what I myself have done and what every one of you will do as you go on in your training. The process of learning about the problem was so engrossing that she simply forgot the patient was lying there listening. Perhaps, also, as a student, she had not yet learned how powerful her words could be. This is a wonderful example of the dilemma that will face all of you as you go on in your training. As you acquire more medical knowledge and responsibility, you will focus more and more on the problem and forget the patient attached to it. As you strive to take a good history, get the facts straight, perform a good physical exam, and put it all together into a comprehensive clinical picture, you will find that with all the anxiety involved in wanting to do it right, the patient becomes further and further away. Use this story to remember that there is always a patient and that you have not finished your work until you have taken care of the patient, not just the problem."
One of the benefits of teaching, I have found, is that it requires reflection on these sorts of issues — and, inevitably, on my own practice. How many times have I been so intent on solving a clinical puzzle that I have forgotten that the patient may be worried or anxious? How many times has impatience crept into my voice when I've called a woman to tell her that she needs additional mammographic views because of what is, in all likelihood, a benign "vague density" and she has a hundred questions about what it means? For me, this is just another task to do; I am not worried. For the patient, I have just raised the terrifying possibility of breast cancer. It requires a conscious act to shift my mindset to that of my patient — to grasp her vulnerability, confusion, and need.
While I am busy treating the bodies of my patients, I try to remember to treat the patients as well — to touch them in small ways as well as large. It is critically important to treat the hypertension, the diabetes, or the heart disease skillfully, but when I remember to treat the patient as well, I experience the essence of being a physician. Caring for my patient as a person provides a comforting connection for both of us — the doctor and the patient facing the fears and managing the problems together. I know this alliance is at the heart of our calling, of why we went to medical school all those years ago.
As I look out at the earnest, eager students in front of me with their shiny stethoscopes around their necks, I think about the hearts they will hear and the hearts they will touch — including their own.(Katharine Treadway, M.D.)