Don’t tell patients they look great, except in these cases

One of my colleagues sat on a wheeled clinic stool at the end of the examination table and told the patient, which was in this case an actor, “Everything looks great.” After, he swiveled around to face the instructor and the small group of onlooking medical students behind him. Our instructor also turned to us and said, “Very good job. But can anyone tell me what he did wrong?” He had done everything correct I thought, and the rest of the students must have felt the same way because they didn’t speak up either. I replayed the encounter in my head.

First, he introduced himself to the patient, which was, in this case, an actor, then he described the purpose of the exam. He next asked her to move her bottom down to the edge of the table, “until she felt his hand.” He asked her to “let her knees fall to the side” rather than inappropriately telling her to “spread her knees.” He performed the exam properly and was able to, remarkably, find the cervix on his first try. He had even introduced her skin to the temperature of the speculum and announced his touch on her leg before beginning the vaginal exam, two things the instructor identified as commonly overlooked by students. Despite going over his examination again in my head, I couldn’t figure out what he had done wrong.

To alleviate the awkward silence, the actor attempted to help us by hinting, “It isn’t anything he did. It’s something he said.” To which we each responded with a collective, “Ohhhhhh!” indicating we had known all along but weren’t confident enough to answer. Our instructor then reinforced the important learning point: Never say to the patient that anything “looks good” during a physical exam, instead tell the patient that whatever you are examining looks “normal” or “healthy.”

It is an important communication competence to have as a clinician, especially when performing examinations that involve sensitive body parts such as the genitals. And it makes sense. To have a stranger calling your private parts “good” can have an uncomfortable or dangerous sound to it, even if uttered out of naivety. But it can also be an imprecise or even confusing term to use in other less invasive parts of the physical exam. For example, “your heart sounds good” is much less reassuring than “your heart sounds healthy, I do not hear any murmurs or other abnormal sounds.” It is for both of these reasons that it is taught to medical students to avoid words like “good” or “great” and to instead use “healthy” or “normal” when discussing physical exam results.

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