Good Medicine - Residency II
Copyright© 2025 by Michael Loucks
Chapter 57: Direct Examination
November 8, 1990, McKinley, Ohio
"Doctor Michael Loucks?" the bailiff inquired.
"Yes."
"Come with me, please."
He escorted me to the courtroom and walked with me to the witness stand.
"I prefer to affirm," I said.
"Raise your right hand, please."
I did as he asked.
"Do you affirm that you will tell the truth, the whole truth, and nothing but the truth?"
"I do."
"Please be seated."
I sat down as instructed.
"Mr. Crowe, you may begin," Judge John Maxwell said.
"Good morning, Doctor," he said. "Would you state your full name and address for the record, please?"
"Doctor Michael Peter Loucks, 5683 Hayesville Road, Circleville, Ohio."
"What is your profession?"
"I'm a second-year Resident Physician specializing in trauma surgery, and an Associate Professor of Medicine at McKinley Medical School."
"How would you prefer me to address you?"
"As Doctor Mike, please. That is what I use professionally."
"Doctor Mike, where were you born?"
"Objection," Amanda Temple said, rising to her feet. "Relevance?"
"Mr. Crowe?" Judge Maxwell asked.
"Your Honor, in order to head off a litany of objections, may I address a general point?" Mr. Crowe asked.
"Yes, Mr. Crowe," the judge replied.
"Doctor Mike's background is foundational to a number of points which we will make both by eliciting testimony from him and from others, and the relevance will be obvious when we draw it all together. I would point out that Mr. Braun elicited significant background material from Doctor Liston."
"Your objection is overruled, Ms. Temple," Judge Maxwell declared. "Mr. Crowe has leeway to elicit background testimony from this witness. The witness will answer."
"Rutherford Regional Medical Center," I replied.
"When was that?"
"February 2, 1963."
"Where did you attend school?"
"Harding County," I replied. "From kindergarten to graduation."
"Where did you live during that time?"
"With my parents in West Monroe, which is southeast of Rutherford."
"What was your High School GPA?
"3.975," I replied.
"Did you take the ACT and SAT?"
"I did. I scored 1560 on the SAT and a 34 composite on the ACT."
"When did you decide you wanted to be a doctor?"
"When I was in fourth grade, there was an accident on the playground, and a girl in my class was badly cut on a piece of jagged metal. I took off my T-shirt and used it as a compress to slow her bleeding. According to the ambulance attendants and the emergency room doctor, I saved her from bleeding out."
"That single event?"
"Yes."
"Did you ever waver?"
"No."
"Did you hold any jobs during High School?"
"Yes. I worked at a hardware store stocking shelves, helping customers, and running the register from the time I turned sixteen."
"Where did you go to college?"
"William Howard Taft State University in McKinley."
"With your grades and test scores, you could have gone anywhere. Why there?"
"Because I felt that I could better serve our local community by staying in the area."
"Was that your primary consideration?"
"Yes, it was."
"How did you pay for college?"
"A mix of grants, scholarships, money I'd saved, money I earned while working, and a stipend because I served as RA."
"Where did you work?"
"At the Quick Mart here in McKinley and during Junior and Senior year, as Resident Advisor for my dorm.
"Did you graduate?"
"I did."
"When was that, and what degree did you receive?"
"I was awarded a Bachelor's in biochemistry with a dual minor in chemistry and biology in May 1985."
"What was your GPA?"
"4.0."
"Did you receive any awards for your academic performance?"
"I graduated summa cum laude and was named class valedictorian."
"Did you take the Medical College Acceptance Test, known as the MCAT?"
"I did, and scored in the 98th percentile."
"What does that mean?"
"That I scored in the top 2% of all prospective medical students in the country."
"Did anyone suggest a course of action after you received your scores?"
"Several people suggested I should apply to Yale, Stanford, Johns Hopkins, or Emory."
"Did you consider those options?"
"I strongly considered both Stanford and Emory."
"Where did you choose to go to medical school?"
"McKinley Medical School."
"Why was that?"
"Because that would allow me to complete my clinical rotations in the community where I intended to work."
"Did you apply elsewhere?"
"Yes. University of Cincinnati, Ohio State, Indiana University, and University of Pittsburgh."
"Were you accepted?"
"To all five."
"Was there anything that caused you to consider any school other than McKinley Medical School?"
"Yes. Doctor Albert Barton, who was then at Indiana University, offered me a scholarship."
"Did McKinley Medical School offer you a scholarship?"
"No."
"And yet you chose to attend there?"
"Yes, as I said, because I wanted to train in the community I would serve."
"Doctor Mike, what is a Preceptorship?"
"It's the first introduction medical students have to clinical work. It begins during your first year and consists of four hours of observation each week, in eight-week modules, spanning all the major services."
"What was your first Preceptorship?"
"Emergency medicine — observing in the Emergency Department."
"That's the Emergency Room or ER in layman's terms, correct?"
"Yes."
"During your first observation in the Emergency Room, did you have occasion to see a patient who presented with ringing in her ears?"
"Objection," Ms. Temple said. "Relevance?"
"Mr. Crowe?" the judge asked.
"We are establishing Doctor Mike's credentials," Mr. Crowe said. "If Ms. Temple is willing to stipulate that Doctor Mike is a credible expert witness and accept his judgments as definitive, we can dispense with this line of questioning."
"Ms. Temple?"
"Withdrawn."
She had neatly avoided a trap Leland had set for her — had she accepted that stipulation, she would have to accept my affirmation that the patient did not suffer from malignant hyperthermia. Given that was the key question on which everything turned, there was no way she could accept that.
"The witness will answer," Judge Maxwell said.
"I did observe Doctor Loretta Gibbs evaluate a female patient with tinnitus."
"What was the diagnosis in that case?"
"A possible brain tumor, which was later confirmed."
"How did Doctor Gibbs come to that diagnosis?"
"By asking the patient, at my prompting, if she smelled anything funny. The patient reported smelling burning toast. That phantom smell, along with burning rubber, is an indication of a tumor or lesion on the brain."
"At your prompting?"
"Yes. I had read about it when I was researching possible treatments for my then-girlfriend, who had been diagnosed with schizophrenia."
"Just to be clear — on your very first observation shift, during your first week in medical school, you diagnosed a patient with a tumor?"
"A neurologist made the formal diagnosis, but yes, it was my question that led directly to the diagnosis."
"Do you have a nickname in the Emergency Department?"
"Yes. Some people call me 'Kid Whisperer'."
"Why is that?"
"They believe I have a gift for dealing with toddlers and pre-teens. They respond well to me, making diagnosis and treatment easier and more effective."
"When was that nickname given?"
"During my third year of medical school."
"So before you received your MD?"
"That's correct."
"When do medical students typically learn to fully read EKGs?"
"Most don't," I replied. "Only those who select a cardiology elective during their fourth year learn to read them beyond the basics."
"When did you learn to read EKGs?"
"During my preceptorship in cardiology during my second year of medical school."
"How did that come about?"
"I asked to be taught."
"When do medical students learn to do obstetrical exams?"
"Most don't. Generally speaking, only those who intend to become OB/GYNs are taught those procedures."
"When does that training typically occur?"
"During a Sub-Internship, which is what fourth-year clinical rotations are called. Even then, it's limited; most of that training occurs during Residency."
"Were you trained to perform those exams?"
"I was."
"When was that?"
"During my Clerkship, which occurs during the third year of medical school."
"How did that happen?"
"I asked," I replied. "It was approved because I demonstrated the necessary knowledge and abilities."
"Would you agree that you were advanced compared to most medical students?"
"Yes."
"What evidence would you give for that assessment?"
"I was trained in procedures and diagnoses earlier in my training than most other students, and during my fourth year of medical school, I was largely treated the way a Resident would be treated, albeit with the restrictions imposed by regulations on non-physicians."
"What were your scores on the Medical Licensing Exams?"
"For the first step, taken after the second year of medical school, I scored in the 99th percentile, that is, in the top 1%. For the second step, taken before the National Residency Match, I also scored in the 99th percentile."
"What were your grades for medical school?"
"They are only pass/fail, but with the possibility of honors notation."
"What was your class rank?"
"First."
"How was that determined in a 'pass/fail' environment?"
"By the honors notations, as well as the evaluations for my Preceptorships, Clerkships, and Sub-Internships."
"Were you named valedictorian for your class?"
"I was."
"I'm sorry to raise this point, but did you suffer a personal loss during medical school?"
"I did," I replied. "My wife died the same day she gave birth to my daughter."
I saw a visible reaction amongst all the female jurors and from one male juror.
"When did that occur?"
"At the beginning of my third year."
"You raised your daughter as a single father, and you completed your third and fourth years of medical school, earning perfect marks?"
"I did."
"One last question from me, Doctor Mike. Are you considered the best young physician at Moore Memorial Hospital?"
"That has been stated by a number of senior staff members."
"Thank you, Doctor. Your Honor, I'll turn the remaining direct examination over to my colleague, Miss Halland."
"Doctor, do you need a break?" Judge Maxwell asked.
"No, Your Honor; I'm fine to continue."
"Ms. Halland?"
"Thank you, Your Honor. Doctor Mike, what is the National Residency Match?"
"It's the method by which medical school graduates are assigned to teaching hospitals."
"How does that work?"
"Each student applies to as many hospitals as they feel necessary, and the hospitals invite some number of those applicants for interviews. Once the interviews are completed, the students make a list of preferred hospitals, and hospitals make a list of their preferred students. A computer analyzes all of the lists and comes up with the best Match for each student, such that it is not possible for the student to have had a better Match, given all available students and hospitals."
"Do hospitals invite students to apply?"
"On occasion, though that's not the norm."
"Were you invited to apply?"
"Yes, by Stanford and the University of Chicago."
"Did you apply to those programs?"
"No, because as I said when Mr. Crowe asked, I wanted to train in the community I intended to serve."
"Would you have been better off accepting one of those invitations?"
"It depends on how you mean that. Could I have made more money? Sure. Been hired by a prestigious hospital? Absolutely. But neither of those things was important to me."
"Where did you Match?"
"Dorothea Rhodes Lummis Moore Memorial Hospital in McKinley, commonly known as Moore Memorial."
"For which specialty?"
"Trauma surgery."
"Was that an established program?"
"No, it was new."
"How did that come about?"
"I designed the program, with assistance from a doctor who had implemented a similar program at two other hospitals."
"You designed your own Residency?"
"Yes."
"Did you receive any additional training besides medical school?"
"Yes. I was certified as a paramedic and rode along with the Fire Department for a week."
"Do you have any other certifications?"
"Yes. I'm a certified Flight Surgeon."
"What's that?" Ms. Halland asked.
"A physician who is qualified to escort patients, typically in critical condition, via air transport."
"Is that a common certification?"
"No."
"When is that usually achieved?"
"Around the third year of Residency."
"When did you receive the certification?"
"During my first year of Residency."
"What is your role as a Resident in trauma surgery?"
"I work in the Emergency Department and perform life-saving procedures on critically injured patients, as well as evaluate patients who present who might need surgery, and treat other patients who present."
"What surgical procedures do you perform?"
"Cricothyrotomies, central lines, chest tubes, pericardiocenteses, and escharotomies."
"Could you briefly explain those in layman's terms?"
"A cricothyrotomy is what a layman would call a tracheotomy — surgically inserting a breathing tube into a patient's neck. A central line is a large-bore IV inserted into a large vein to provide rapid blood transfusion. A pericardiocentesis is a procedure that involves using a hypodermic needle to remove fluid which has built up in the sac around the heart. An escharotomy is a surgical procedure performed on burn victims to prevent swelling from cutting off blood flow."
"What else does your training cover?"
"General surgery."
"What is that?"
"A general surgeon is a surgeon who performs routine procedures, usually abdominal or soft-tissue surgery."
"Could you give some examples?"
"Appendectomies, which I believe is self-explanatory; cholecystectomies, which means removing a gall bladder; bowel resections, which are procedures to remove part of the large or small intestine; and laparotomies, which are used to find and control internal bleeding. Those are the four most common, at least at Moore Memorial."
"Have you performed any of those surgeries?"
"I've performed several appendectomies and assisted with other surgeries."
"Is it typical for someone at your level to perform surgery, or even assist?"
"There is no 'typical' given it's a new program. If you compare it to typical surgical training, I'm performing procedures which are usually reserved for surgeons in their third or fourth year."
"Why is that?"
"It's due to a combination of the new program allowing some variation in traditional training and my skills and abilities."
"Did you have an occasion to deliver a baby in the Emergency Department?"
I smiled, "I did, and hope to never have to do that again!"
Several jurors laughed, as did quite a few members of the public.
"What was the outcome?"
"A healthy baby boy and a healthy mother."
"What happened that caused you to deliver a baby?"
"The OB/GYN service was overloaded. As it turns out, babies do not care one whit about physician or nursing staffing levels or available labor and delivery beds."
More laughter.
"Doctor Mike, do you teach?"
"I do, both at the hospital and at the medical school."
"Tell me about the hospital, please."
"As a Resident, I am responsible for training medical students in the same way I was trained by Residents when I was a medical student. I supervise them in exams and in performing the limited types of procedures authorized to be performed by medical students before they receive their MD."
"And the medical school?"
"I teach a seminar class on the practice of medicine, which is often referred to as 'How to be a Doctor 101' and contrary to rumors, does not involve degrading students' handwriting abilities."
Laughter from the jury.
"Is it typical for a Resident in their second year to be named Associate Professor of Medicine?"
"No. That usually does not happen until a physician becomes an Attending — that is, licensed to work without direct supervision."
"You don't have to be licensed to teach?"
"Surprisingly, no. The State of Ohio does not require it. All that is necessary is sufficient knowledge and an ability to teach."
"Would you say, overall, that you are far advanced compared to most physicians your age?"
"I would."
"Doctor Mike, now that we've established your expertise, I direct your attention to the events of April 19th of this year. What was your assignment that day?"
"I was assigned to the Emergency Department."
"Did you have an occasion to see a patient named Kenneth Webber that morning?"
"I did."
"Please describe how you first encountered Mr. Webber."
"At 0618, that is 6:18am, Nurse Ellie Green informed me and my student, Mary Anderson, that a patient had presented with bounceback abdominal pain."
"What is 'bounceback abdominal pain'?"
"In medical lingo, 'bounceback' means a patient who was seen very recently and returns with the same complaint or symptoms."
"How do you handle a situation such as that?"
"If possible, the same physician will see the patient; if not, a second physician will examine the patient, then review the chart notes from the original physician."
"Why would you not review the chart first?"
"As I instructed my medical student that day, reading the chart notes would risk pre-forming an opinion. I believe it's better to conduct a full exam first, then review the chart."
"That's not standard?"
"No. The typical approach is to review the chart first."
"How did you then proceed?"
"Miss Anderson and I went into the exam room where Nurse Kellie Martin was with the patient. She provided the patient's vitals and presenting complaint."
"What were his vital signs?"
"I need to consult my notebook," I said.
"Go ahead."
I read my notes aloud, "Ken Webber, thirty-six. Pulse 72; BP 120/70; PO₂ 99%; temp 38.1°C."
"Could you give that in Fahrenheit, please?"
"100.6°F."
"What is 'PO₂'?"
"The percentage of oxygen saturation in your blood. Anything above 90% is acceptable; above 95% is preferable; 100% is almost never seen."
"What did you do?"
"I introduced myself, and then my student, and my student began the H&P."
"What is that?"
"It stands for History and Physical, and it means asking the patient about their medical history and their complaint, then performing a standard physical exam."
"What did Miss Anderson do?"
"She began by asking why the patient presented. Despite the fact that the triage nurse had asked him, and it had been reported by the nurse assisting us, we always ask, as patients can and do change what they say."
"What did Mr. Webber say?"
"That the pain in his gut had become worse, and the doctor who had seen him the previous evening had instructed him to come back."
"What time was he seen the previous evening?"
I consulted the notebook, "He came to the triage desk at 21:49, that is, 9:49pm, and was seen at 22:02, that is, 10:02pm."
"Who saw him?"
"Doctor Paul Lincoln."
"Returning to your interaction, what happened next?"
"My student completed the H&P under my direct supervision, and the patient reported increased pain upon palpation, and even more when lying on his left side."
"What is palpation?"
"Using your fingers and palm to place pressure on various parts of the body to detect internal symptoms such as swelling, rigidity, and other conditions not visible to the treating physician."
"Why did your student conduct the examination?"
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