Friday, February 21, 2014

On Touching a Woman's Breast

Before anything else, this was because of an academic requirement for a subject that encompasses 4 specialties. It was a breast examination for Clinical Evaluation. Essentially, for our 2nd year, we have a synthesis subject that has doctor-professors from four specialties: Pediatrics, Medicine, Neurology and Surgery. One requirement is a graded 2-on-1 patient encounter. You have a partner but you are graded individually. So you can divide the history-taking and physical examination. However, the discussion and the clinical impression is done individually. Also, the patient rapport and professionalism are noted.

Anyway, a day prior to the encounter, my mind froze because studying for 4 specialties is really too much. You will only know minutes before the said encounter what specialty you'll be under in. So in essence, if you didn't study well enough months before for Pediatrics, Neurology, Medicine and Surgery; you are screwed.

Personally, my least favorite specialty is Neurology. Not only because of its difficulty, during the 1st semester half of our class failed one block exam of Neurology I, but because of the sheer technicality of doing a neurological examination. This in addition to doing the routine physical examination that falls under Medicine.

On that day, I was hoping to at least fall under Pediatrics or Medicine. I got Pediatrics for the non-graded 2-on-1 encounter and I wouldn't mind repeating that. Well, sure doing a physical examination on a squealing, non-cooperative toddler is challenging but I'd take a chance on that rather than doing an intricate neurological examination. I'd even hope for Medicine, which I loathe, because of its encompassing nature. Medicine or Internal Medicine is basically the jack-of-all trades in the medical profession. Browsing through their textbook which is "Harrison's Principles of Internal Medicine" tells you a lot about their specialty. Oh, it consists of two volumes. So it is the only specialty that has 2 big books as its main reference material; all the other specialty has only one.

Imagine my surprise when I landed in Surgery. In the out-patient setting, surgical patients are those who have a)masses, b)blockages in the gastro-intestinal system (so think gallstones, diverticula and the like), c)hernias and d)hemorrhoids. In essence, structural problems that cannot be corrected by medication or lifestyle modification; these have to be taken out by a surgeon. So you asses whether these patients are eligible for surgery and of course, if they have any other medical condition. Having diabetes mellitus, for instance, instantly qualifies said patient as a risky patient because diabetes mellitus affects every part of the body. It slows down healing, affects the cardiovascular status of a patient and increases the chances of complications post-operation but I digress.

So, no we weren't required to do a surgical operation. We just had to interview the patient and physically examine her. My partner and I had a prior agreement. If the patient is male and has an abdominal or genital complaint; I'd do the required physical examination and if the patient is female and has a breast complaint, she'd be the one to examine the breast.

Our patient was female and went for a follow-up check-up on her breast and ankle. For the breast, she noted a mass on the inner quadrant right breast and on ultrasound, the mass measured only 0.3 cm. And for the ankle, the patient tripped causing her slight pain yet both range of motion of the joint was intact. As another digression, "both range of motion" in this sense means ACTIVE range of motion, the patient is moving the joint on her own, and PASSIVE range of motion, the examiner is moving the joint itself.

Anyway, we elicited the history and asked the right questions (for the breast: was there pain before menses, when did she first notice the mass, the rate of increase in size of the mass and was there discharge. And for the ankle: how was it injured, can she still climb the stairs and walk around and intensity of the pain on a scale of 1-10).

And following our prior agreement, my partner did the breast exam. And then the unexpected happened; the preceptor called me to do a breast examination. In my head, "oh shit" and "okAAAy, I'm going to touch a female breast!". I have never done it before the encounter; I only read the technique in "Bates' Guide to Physical Examination and History Taking". I was bit nervous because I'm a male and the patient is female and for women, the breasts are one of the private parts. So I swallowed my nervousness and proceeded to do the breast exam asking first permission from the patient. Thankfully, it was not an issue for her that I was male.

So I inspected one breast at a time, the other breast was covered. I looked at the nipple and the areola. And palpated the uncovered breast in an orderly manner; thinking inside "this is one of the sacred places for a woman and am I doing this right?!". And finally, I touched the areas near the armpits. But outside, still composed and relaxed.

And when the feedback came, well the preceptor commented I could have participated more on the history-taking. My partner did most of the talking and I did most of the writing. What can I say, one of my weaknesses is human interaction. Not that I didn't say anything, I asked some key questions that were missed but for the most part, my partner was the one asking. One of the pitfalls of being a BS Biology graduate; I would rather stand back and analyze the data.

Finally, commenting on my technique, the preceptor commended me for doing a good job and making the breast examination comfortable for the patient. She noted it was done in a professional manner (part of doing it properly is not uncovering both breasts but rather, only uncovering the breast to be examined). And I was thinking, "whew reading Bates' paid off!" and "wow, it wasn't noticeable that it was my first time doing it".

Well, I guess touching a woman's breast taught me that you can really never be fully prepared. It helps that you read ahead of time and study but ultimately, it is how you react to the unexpected that will be final judge of competence in the medical profession. Imagine what would have been the reaction of the patient had I loudly exclaimed, "Oh shit, I'm touching a woman's breast!!!". That sure would have earned me a very low grade and not to mention a very loud slap from the patient herself.  

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