Thankful Again

My last post was exclusively about social stuff, and I think my work deserves a thanksgiving post as well.

A few weeks ago, one of the residents complained that some residents (not him) lack physical exam skills, and I should spend more time teaching exam skills. In general, Americans think of doctors in the developing world as having much better physical exam skills, because they have fewer imaging resources and lab tests to confirm their diagnosis. However, this has not been my experience, here or in Africa. I think it’s because you do still need a teacher skilled in physical exam to encourage and supervise your learning. My residents here are very good at some things - they can confirm ascites with a fluid wave or shifting dullness at the drop of a hat (thanks Hepatitis B!) - a skill I never practiced much in America because it requires 2 people, and also because American patients tend to look askance at you when you try to have one person press down firmly on the middle of their abdomen and have another tapping and feeling either side. And in America, if there is every any question, you just get an ultrasound (or look yourself with the portable.) But some of the more basic exam skills - good cardiovascular exam, neuro exam, etc are at or below the level I would expect from an American resident, probably because they don’t have good teaching for this. (They have a great GI teacher. They also have good cardio and neuro teachers, but I think they get less face-to-face time on the wards with them.) So I told the resident that was complaining that I believe learning good physical exam skills is mostly achieved by taking the time to do a thorough exam on many patients, even those you expect to have a normal exam, so you get in the habit of doing things well and efficiently, and so you get familiar enough with normal to recognize small abnormalities. Of course, this practice has to be paired with the willingness to ask a teacher when you’re not sure, and the availability of a teacher who can answer your question. I’ve been trying to do more exams on rounds, watch the residents do more exams, and focus more on physical findings in our discussion of assessment and plan since the complaint.

One of the things I have noticed residents here do not do (much like residents in America) is examine wounds. I have seen several patients with diabetes and possibly infected foot wounds who were presented to me and the residents could not describe the wound for me when asked. I have tried to model good behavior by unwrapping and looking at the wounds, but decided to do some formal teaching as well. So, last week I lectured on Diabetic Foot Wounds and created a hands-on lab where they used pig feet that I created wounds on to practice the probe-to-bone tests. (For my non medical readers, if you can feel bone at the bottom of a wound it changes your decisions about antibiotics significantly.) It turns out, pigs feet have pretty tough skin, too, so if anyone is tempted to repeat this exercise, I advise you to buy as scalpel or two before starting your wound-creation. I ended up using my matt knife extensively. The probe-to-bone demonstration was also harder that I thought it would be, because after visiting several medical supply stores I had to come to the conclusion that there are no sterile swabs in Laos. So we used Q tips soaked in Iodine as clean (but probably not sterile) probes. The residents all giggled when I brought out the pigs feet, but they did all practice, and hopefully learned something. And several cameras emerged from bags to take pictures, so I think they liked the exercise. Hopefully, it will change the way they approach (or don’t approach, currently) diabetic foot wounds and give them some confidence in their ability to examine and assess them.

I think in America if I had made residents practice exams on pigs feet, they would have felt like it was unrealistic and a waste of their time. So I’m thankful to be teaching here in Lao where any extra effort you expend in teaching is much appreciated by the residents.