Column 8:
The Foot Bone’s Connected to the Talocrural Joint

PMI, I think. Point of maximum impulse. Located just below the pectoral. Feel with two fingers. Right between the ribs. PMI, point of maximum impulse, just left of pectoral, two fingers, between ribs…

I’m sitting in a chair in the hall. My foot taps madly against the carpeted floor. In my lap, I cradle a binder full of notes. Soon—too soon—I will take a Test. I haven’t taken a rote memorization test in, oh, ten years. Writers don’t memorize things, they write things down. And when actors get stuck on a line, they make things up. We’re improvisational artists, after all. But this is a test test. Right and wrong answers. All or nothing.

The door opens and Sally steps out. “Oh,” she says, surprised to see me. “Are you testing today?”

“Yeah,” I say.

“Are you ready?”

I smile meekly. “No?”

Sally laughs. It should be weird, sitting alone in a corridor and striking up conversation with a fiery redhead dressed only in a hospital gown and socks. But we have grown used to these sights. We don’t even notice. Even when we wear “bloody” bandages or carry Kleenexes full of “rust-colored mucus.” They no longer register. No one even bothers to tell the usual jokes (How’s your head? Har, har).

“I have to get a soda,” Sally whispers as she tiptoes away. “Good luck!”

There’s no reason to whisper, but we’re so accustomed to being discreet, especially when people are testing. And this is the big test: THE NORMAL PHYSICAL EXAM.

Overall, we standardized patients have it pretty easy. It takes a little time to learn our characters, but nobody expects us to be perfect. They want us to dress and talk and behave like our characters, but everyone knows it’s a simulation. The students commit to their roles (as students), and when the simulation is over, we give feedback and walk away. We dust our hands. Another job well done.

But the Normal Physical Exam is a different story. In this case, we have no “character.” We are basically healthy patients. But we also happen to know how to run a normal physical exam. We train in all kinds of physical tests—we take blood pressure, feel for pulses, listen to lungs, check for edema, test reflexes, everything.

Last year, I took this exam with only a few days of preparation. It wasn’t easy. My grandfather had just died, I was bushwhacking through grad school classes, my mom was having job issues, my dad was in China, and my brother had recently been hit by a car. Not the best circumstances to take your first Big Test in a decade. But I muddled through. On the way to Hilton Head for Grandpa’s funeral, I studied methods and procedures. I learned how to feel for swollen lymph nodes and to properly measure a human liver.

And then, sleep-deprived and agitated, I beasted that exam. The proctor was astonished. “Most med students don’t learn it that fast,” she marveled.

I was a rock star.

But this year I’ve procrastinated. Yes, the circumstances are better, but I still haggle with classes and work and side projects and washing dishes and paying the electric bill. For the past few weeks, I’ve found any excuse not to study. I’m an expert at this, I thought. I can take a damn blood pressure test. And it’s not like anybody’s dying. This time.

And now I’m here—minutes away from testing the knowledge I almost have. I’ve lost so much in twelve months. What is the “tragus” part of the ear, and do I pull it or press it? Where do I feel for a pulse in the foot? What’s the third test for finger-strength? Do I still adjust the ophthalmoscope with my thumb, or did the procedure change?

The office door opens again and Hattie leans into the hall. When she smiles, her nose crinkles and her glasses push upward. “Are you ready?” she says.

I sigh, because I’m tired of this question. No, I’m not ready. Even if I did have time to prepare, I wouldn’t have used it wisely. I’m getting old, Hattie. I can’t memorize crap like I used to, not that I was ever good at it. How come we have to be so skilled at this anyway? Oh, right—this is the one opportunity we have to give advice. The one time we can say, “Hey, you’re doing it wrong, let me show you.” In this one, singular instance, we know medicine just as well as the med students, and sometimes even better. I know, I get it. And I want to do a mind-blowing job. I want to knock your socks off, Hattie. Because I love this job. But there’s just too much going on right now. Never mind Mr. Hodges or Mr. Thompkins or Detective Walker. I, Robert Isenberg, am stretched too goddamn thin. So no, I’m not ready. But I’ll do anything to make it up to you. Even fail the first time around.

“Ready as I’ll ever be,” I say.

I step into the examination room, and there is Clarence, wearing a hospital gown and sitting on a bed. His hands are folded in his lap. He nods to me, Hattie sits down in the corner, and I close the door. I squirt anti-bacterial gel into my hands and rub them hard enough to rip the skip off my palms.

“Hello, Mr. Smith?” I say. “My name is Robert Isenberg. I’m a standardized patient here at the medical school, and I’ve been asked to perform a physical exam on you. Is that all right?”

“Quite all right,” Clarence says. His smile says, Take a breath, kid. Everything’ll be fine.

I can always rely on politeness. I am almost absurdly conscientious about intrusion and personal space. Before each step, I explain exactly what I’m about to do: “Mr. Smith, I’m going to take a look inside your nostrils. But before I do, I’m going to need you to keep absolutely still. If the tip of the speculum hits your septum, it can really hurt, believe me.”

“Thanks for the warning,” Clarence says.

Courtesy isn’t the problem. It’s remembering all the damned steps. I switch off the lights and examine the back of Clarence’s eyes, watching as his pupils turn red. I tug the rim of his ear. I tell him to say “ah.” When I unfasten the back of his gown, I use the stethoscope to listen to six places on his lungs, not the usual four. I feel his chest expansion. I tap on his spine and kidneys.

We’re making progress.

“Could you lie back for me?”

“Of course,” Clarence says.

When Clarence turns his head, I observe his jugular veins—I even point to them, so that Hattie can mark my “observation” on her checklist. I feel the pulse in his neck, listen to his heart in four places, feel for his PMI. I listen to his stomach in all four quadrants, depress his stomach, tap his side with two fingers and measure his liver.

Almost there…

I form rings with my fingers and say, “Can you break the rings?” I tell him to squeeze my fingers as hard as he can. I tap his tendons with the tiny rubber hammer, and his legs jolt each time.

“Could you stand up for me, please?”

Clarence walks across the room, flat-footed, then on tippy-toes, then on his heels. Finally, I tell him to stand still, feet together. “Now close your eyes,” I say.

This is always a peaceful way to finish the exam. After poking and prodding and tapping and shining lights in his eye, the examiner (me) tells the patient (Clarence) to just stand still, close his eyes, and not say a word. I hold my arms around him. “Just in case you lose your balance,” I say. “I’ll catch you.”

For a few seconds, we just stand there, facing each other, and nothing is said. It’s statuesque and strangely elegant, this silent pose. Then Clarence opens his eyes to see me smiling. He smiles, too.

“Thank you, Mr. Smith,” I say.

We shake hands. Clarence sits down on the bed. I tell Clarence everything looks fine, the doctor will be in shortly, thanks for his time. And I walk all the way to the door before pausing and turning to Hattie.

“Okay, how’d I do?” I say. Now that I can breath, I feel myself trembling.

“How’d he do?” Hattie says to Clarence.

“Great, as far as I can tell,” Clarence says. He pushes fingers through his thinning gray hair. “Great interpersonal skills. Great explanations. I felt very comfortable.”

I gaze at Hattie. She looks up from her clipboard and grimaces. “Well, what you did, you did very well,” she says. “Do you know what you forgot?”

“No,” I say.

“Can you guess?”

“No. I can’t even guess. I have no idea.”

“You didn’t check the nerves in his face.”

Fuck! Motherfucker! Goddamn it! Of course! How the hell could I forget? So goddamn easy! Like second nature! What was I thinking? Was I even thinking at all? Stupid, time-wasting son of a bitch! Fuck! Fuck! Fuck!

“Wow,” I say, nodding. “Yep. Definitely forgot that.”

And what a thing to miss—the easiest test in the physiology playbook. All I had to do was touch his face with my fingers, and then trace them outward. Like drawing whiskers on his cheeks, chin and forehead. Then I’d say, “Do these feel the same on both sides?” And he would say, “Yes.” That’s it. That’s all I had to do. And I blew it. I blew the entire goddamn test, because I forgot to draw whiskers.

“I can’t believe it,” I mumble.

“It’s okay,” Hattie says.

“No, it’s not. I just wasted an entire afternoon. I wasted your entire afternoon.”

“It’s okay, Rob. You’re almost there.”

“Yeah, but I’m not there,” I huff. “I shouldn’t have even signed up for this.”

“Don’t say that,” Hattie says.

“It’s okay,” I say, backing toward the door. “Next Friday. It’s the only time I have. I’ll get it next Friday. Will you be there?”

“Me? Yes, I’ll be here.”

“Okay. I’m gonna get this.” I grab my messenger bag and sling it roughly around my shoulder. “Just give me a week.”

And I charge out the door.