Two students arrive on the ward, as per the arrangement that has slipped my mind. I see them loitering by the nurses station. They are eager to see and hear signs – that’s all I wanted when I was at their stage. Unprepared, I scan the names on the white boards at the end of each bed bay. There! An elderly patient with florid aortic stenosis, a slow rising pulse, oedema in the lungs and in the skin… but she is frail, she is ‘end stage’. Some days she is bright and talkative, some days she is withdrawn. Today she is in between. Her clinical signs are classic, and it would be a shame if the students did not have the opportunity to examine her.
I remember similar encounters from my own training – the first murmur, the first example of bronchial breathing; they stuck in my mind, and advanced my knowledge. So, I am decided… I will ask the patient for permission to be examined by the students. Before doing so I flick through the notes to catch up on any developments. I see the coloured A4 sheet used by the palliative care team. They have been asked to see her for symptom control, and to help arrange her discharge. They came this morning, just two hours ago. And prior to that entry is a short note from the registrar saying that she has spoken to the patient and her middle aged son to explain that there is now nothing more that can be done to optimise her breathing or oedema. She has progressed from ‘end stage’ to ‘end of life’. It is not obvious to the passing observer. She is the same woman.
The students are looking at me in expectation. Should I ask her? It will not benefit her. It will probably tire her. It will not be in her best interests. But neither is it positively harmful. And the signs… so precious, educationally. No, I’ll leave it. It’s not fair. I approach the students and explain that in the absence of any other obvious patients we will tour the acute medical unit and find something there. Then I glance back to the patient and watch her. She is sitting out, and looking out across the ward. I reconsider. I approach.
“Mrs ______,” I say (gabble actually), “I wondered… if you wouldn’t mind… please say No if you are too tired… if two students came to ask you some questions and examine your heart?”
She looks around slowly. I think she heard and understood. But I have to ask again. She nods, which I interpret as consent. I beckon the students over, and watch as they perform the examination. I then demonstrate the signs, before getting them to examine again, until they are satisfied that they have heard and absorbed the features of the disease. We leave. It has taken twenty-five minutes, with feedback given along the way. The patient sits passively. It has tired her, as I thought it would. The look in the eyes of the students is priceless. Descriptive words on a page in a book have evolved into physical, memorable reality.
They thank the patient and they thank me. Their morning was well spent. My morning was well spent. Her morning was devoted to the education of two students who had nothing to do with her, and the convenience of a doctor, an educator, who offered nothing in the way of medical care. But that’s what happens in hospital. When there are students, or doctors studying for exams, the question will always be asked. Sometimes it feels uncomfortable, and the path of least resistance appears attractive (‘Sorry guys, I don’t want to trouble her today…’). However that path does not lead to the best educational experience – the palpable liver, full of metastases, nystagmus secondary to a disabling cerebellar stroke, the petechial rash due to acute leukaemia.
Patients can say No of course, but in my experience they rarely do. The thing that is asked of them sits outside the usual therapeutic transaction. Consent, when asked, relates not to an intervention, but to what amounts to a ‘favour’ – their time, their inconvenience, in exchange for knowing that they have contributed to a general good. Often the reply is not so much a ‘Yes, of course…’ but a ‘Well they’ve got to learn haven’t they!’ That phrase contains an imperative – an expectation. I have very rarely heard a patient say ‘No, no thanks, not today,’ although I have read as much in their look of pained exasperation, or the unfocussed gaze that betrays distraction, by unresolved concerns – questions, prognosis, a scan result, disability, mortality. It is easier when you know the patient, but sometimes a colleague will have tipped you off about a valuable examination before a teaching session. Then you must introduce yourself, explain the purpose of your visit and ask permission all in one go – the fast track. It feels intrusive. It is intrusive. But it is necessary.
See also ‘Signs’
New booklet, click picture to explore…