What the Mind Knows the Eye Will See

I think that I can safely state that most clinicians have one or more patient experiences that they will never forget. They can be times when a theory or health condition comes sharply into focus in the real world of clinical practice or a near-miss situation that comes to mind every time we encounter a similar case presentation. I have had a number of such events, including one that involved a woman who had decided she was ready to start a family and was seeking advice on how to best prepare for that journey. It was relatively early in my career as a women’s health nurse practitioner. I had been in full-time practice for about 4 years exclusively caring for women across the life span. At that time, yearly women’s health visits were the standard of care and always included a bimanual examination and cervical cancer screening. People who were using hormonal contraception were required to follow up every 6 months, which also meant a bimanual examination. I typically had 21 appointments daily on my schedule with very few unkept visits. So, adding in the bimanual examinations that were performed for those who came for the evaluation and management of reproductive system symptoms, in 4 years I had probably performed about 20,000 bimanual examinations, plus or minus a few hundred. Because many of the people I examined were not experiencing any symptoms, most of the physical findings were what would be expected for healthy persons (ie, “within normal limits,” although I never used that term, instead routinely describing the physical findings that would be consistent with “normal” as I had been taught by my mentors in nursing and medicine). This practice was very helpful for comparing physical findings over a continuum of care and for consultation with more expert colleagues on cases of conditions that were unfamiliar to me. As you probably already guessed, one of those situations was the young woman who came in for a well-woman/ready to start a family visit who we discovered had a very advanced case of endometriosis. At the time, I only recognized that the uterus seemed “different” (ie, hard and immobile). This led me to consult with my more experienced colleagues and obtain an appropriate referral for this patient.