Looking but not seeing

Posted: October 30, 2014 in Uncategorized

Every time I am at the DeSales Free Clinic with students, I am reminded of how much our homeless have to teach us about the best way to practice medicine. It is truly a classroom like no other. I had 4 excellent students with me last week and so this is not a knock on their clinical skills. After all, they are still in school to learn and grow as providers. The truth is, that growth never stops (or if it does, you are doing something wrong)- but I digress.

Last week’s Clinic session was a prime example of the difference between looking and seeing.

A patient who had previously been seen by the Street Medicine hospital consult service team was discharged to the Rescue Mission and came to the Clinic last week. The students diligently went in to see him only to come back out 2 minutes later. The patient, they said, only wanted two things- 1300mg of Advil and to know when the orthopedic doctor would be here. They told me he refused to answer their questions and would not allow for an exam. What they were able to gather from a review of his last two visits, were diligently written in the subjective portion. At the top of the physical exam was written “Patient Declined” ( a small personal victory as I despise writing that the ‘patient refused’).

I took the chart, gathered my student team and went into see the patient. What I saw through my clinician eyes was a tremendous amount of information. Students in general, love to examine the patients. There are always losing points in their practical exams for skipping right over the ‘inspection’ part and diving right in to something requiring their expensive fancy-pants medical equipment. I talked with the patient and figured out his needs and how to build some rapport. He, of course, still wanted nothing to the with the ‘exam’.  I was thinking “Too late buddy, I have already completed a detailed exam without ever even touching you.” In our education area (I use the term loosely, it is essentially the 15 feet between the exam rooms and the bathroom), I asked the students what the physical exam was. They told me there wasn’t one. Interestingly, what they had seen through their eyes was confirmation that the patient wouldn’t answer any real questions and wouldn’t allow for an exam.  I walked them through the objective section of the note- we could assess the skin on his face and hands, his hair pattern and distribution, he dentition (or lack thereof), facial symmetry, eye tracking.  He had tardive dyskinesia- a side effect of too many old time psych meds that results in involuntary unnatural facial movements, fasciculation and, in his case, repeated lip smacking.I assessed his gait as he walked from the waiting room to the exam table And, I was just getting started. We talked about his psych exam and what we could deduce from our conversation. His affect, his thought process and content, his view on the future, his view about the past, his insight into his current situation.

It was an illuminating experience. Suddenly, we had a lot to say about his physical exam.

The next patient that was seen (by the same lucky pair of students) was a very soft spoken young man. He had recently had some instability in his mental health and was trying to get back on track. I saw the patient with the students after they had assessed him. Their assessments were technically spot on. However, as I talked to him, he seemed sad and lonely, disconnected to the world around him but yearning to belong. He told me he was from Tennessee and he didn’t know where anything was up here. I noted on his intake form that he had missed many meals in the last week. We talked about soup kitchens and food banks and where he could find certain things. Suddenly, I saw what I had been looking at for 20 minutes.

He was cold. And he was scared.

He had no socks on. He had on two t shirts and two ill fitting zip-up light weight hooded sweatshirts. He had a beat up backpack that was ripped at one seam.  I asked him if he was wearing everything that he owned. He was.  He was fearful because all the guys in the shelter were reminiscing about last winter and how brutally cold it was. Here is a guy from Tennessee who has no coat, no hat, no gloves, no socks and no lay of the land. No knowledge of what places will let you loiter for hours on end to avoid the cold. The students suddenly saw too and I do believe their eyes are now opened.  Small victories. Small victories.


“The common eye sees only the outside of things, and judges by that, but the seeing eye pierces through and reads the heart and the soul, finding there capacities which the outside didn’t indicate or promise, and which the other kind couldn’t detect.”

MARK TWAIN, Joan of Arc

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