Nervous Excitement

The evanescent Cambridge summer was giving way to the sights and sounds of early autumn. College students made their annual return pilgrimage to the city in hordes and filled the old streets with an air of renewed youthfulness. The whisper of the Charles River's lazy current sprang to life with the hum of the precise, choreographed strokes of dozens of crew shells gliding along its length. Amidst this backdrop, a dozen newly minted second-year medical and dental students—fresh off their last foreseeable extended summer vacation—entered the hospital to embark on their yearlong quest to acquire and hone the most sacred of clinical skills: the physical examination.

I met them on their first afternoon in the hospital and admired their freshly laundered white coats donned with new purpose. The collection of stains on my own coat reminded me of the highlights from the previous year on the clinical wards. The black streaks from hastily pocketed pens that were carelessly shoved into my white coat were juxtaposed with the fading light brown spots where drops of a too-quickly-grabbed morning caffeine fix had spilled as I ran from room to room to preround before 6 am. The cleansing powers of bleach had proved no match for these persistent marks. I had made it through the prior year—my third year of medical school—with these indelible reminders of life on the clinical wards now etched onto my emblazoned coat. I greeted the new second years with confidence as I introduced myself as a fourth-year medical student; my white coat's blotches speaking volumes more than any resume could have done about my clinical experience.

The afternoon began with an introduction from the attending physician who would serve as their course director on their evolving journey. Unboundedly energetic and with a motherly affection for her pupils, her joy and enthusiasm for the practice of internal medicine cast a wondrous air over the afternoon. Within moments, she foretold, the students would make the pivotal transition whereby the sights, sounds, and contours of the human body would cease to be elements of a wholly foreign language and re-present themselves as a new lingua franca for deciphering the diagnostic dilemmas of medicine. The excitement in the room was, indeed, palpable.

I was assigned a small group of the students to guide on to the wards for a hospital tour and to begin their first clinical examinations. The 5 eager-eyed students quickly followed me up the stairs, jostling to be the first to elicit a patellar reflex, auscultate a fourth heart sound, or correctly identify a seborrheic keratosis. Their trust in me and their joy at performing the most fundamental rite of medicine added a spring to my own step, and I strode confidently down the hall, reaching the door of our first patient's room, ready to begin.

Our first diagnostic exercise—a cranial nerve examination—was timed to correlate with the neurology pathophysiology curriculum being covered in the students' lectures and tutorials. Grabbing the door handle and turning around to face the eager crew behind me, I paused just before knocking, appreciating a new expression permeating the group. The excitement on their faces had given way to a subtle but detectable nervous collective countenance. Hints of sweat beading across the brow of a student's forehead quickly reinforced my suspicions. I released the handle and redirected the students toward the central nursing station where we could regroup before proceeding.

“So,” I asked nonchalantly, not wanting to add to the mild anxiety I sensed, “who wants to take the lead on examining our first patient?” The furtive, askance gazes told me there probably wouldn't be any volunteers in the immediate future. The collective senses of low self-confidence and high self-doubt in clinical examination skills resonated from the silent students as they looked around.

Being a fan of preparedness and much less so of surprise, I decided it would be good to review the normal cranial nerve examination before we entered the patient's room. Our precourse sessions with experienced clinician educators had primed us for such situations, wherein students might be apprehensive about beginning their physical examination practice. Although the students were adept at taking a medical history with a year's worth of experience by this time, crossing the threshold from conversational interaction with a patient to tactile manipulation of their body apparently represented a progression that would require more guidance and support.

Suddenly finding myself empathizing with a stand-up comedian forced to improvise in front of a tough crowd, I thought back to the effective and inspiring teachers who had walked me through the stages of my medical education for the best way to instill confidence in these students. Several brilliant researchers and gifted lecturers from my first 2 years of medical school quickly came to mind, but their instructional tactics didn't seem quite appropriate for this clinical setting. I realized then that the best teachers I had had for learning physical examination skills were, in fact, the patients who had provided me with support, encouragement, and feedback on my techniques, allaying my fears of total incompetence and ineptitude.

Spying an empty conference room near the nursing station, I walked in, sat down, and beckoned the students over. “Okay, here we go: I'm your first patient of the day. I'm a 20-something-year-old gentleman with a headache. You've taken a brilliant, thorough history and have decided you need to do a cranial nerve examination. I'm all yours!” Unsure if my over-the-top portrayal would be appreciated or ridiculed (in retrospect, the feigned photophobia when staring up at the overhead lights may have been a bit much), I waited for the students to react.

The theatrics paid off. Chuckles of laughter filled the room. A student cautiously stepped forward and reached into her coat pocket, retrieving a small vial. “Good afternoon, I'm sorry you're having a headache. May I examine you now?” After securing my assent, she instructed me to smell a small vial of coffee grounds produced from the bag she was carrying alongside her, ever the diligently prepared second-year medical student. We were off to an excellent start.

In subjecting myself to several quick yet complete cranial nerve examinations that afternoon in the small conference room, I had confirmation of my active gag reflex 5 times over and was reassured in quintuplicate that my hearing was, in fact, intact. The students were all more than competent in their skills already, and I reassured them of such multiple times over, constructively critiquing their techniques. As we walked down the hall and entered the patient's room to begin our first examination, I looked back once again at the students, who now showed that same vivacity and enthusiasm they had carried earlier. Out of the corner of my eye, I glimpsed a faint brown streak on the bottom hem of the short white coat of the student who had first examined me; the coffee grounds had spilled when she had tried to put them back in her bag. I smiled silently, proud to have both contributed to dashing the pristine blankness of her white coat and to have launched the students on their journey of the physical examination, guided thereafter by the greatest of teachers: their patients.