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When the tail wags the dog: Clinical skills in the age of technology
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Salvatore Mangione, MD

“... with the rapid extension of laboratory tests of greater accuracy, there is a tendency for some clinicians and hence for some students in reaching a diagnosis to rely more on laboratory reports and less on the history of the illness, the examination and behavior of the patient and clinical judgment. While in many cases laboratory findings are invaluable for reaching correct conclusions, the student should never be allowed to forget that it takes a man, not a machine, to understand a man.”

—Raymond B. Allen, MD, PhD, 19461

From Hippocrates onward, accurate diagnosis has always been the prerequisite for prognosis and treatment. Physicians typically diagnosed through astute interviewing, deductive reasoning, and skillful use of observation and touch. Then, in the past 250 years they added 2 more tools to their diagnostic skill set: percussion and auscultation, the dual foundation of bedside assessment. Intriguingly, both these skills were first envisioned by multifaceted minds: percussion by Leopold Auenbrugger, an Austrian music-lover who even wrote librettos for operas; and stethoscopy by René Laennec, a Breton flutist, poet, and dancer—not exactly the kind of doctors we tend to produce today.

See related article

Still, the point of this preamble is not to say that eclecticism may help creativity (it does), but to remind ourselves that it has only been for a century or so that physicians have been able to rely on laboratory and radiologic studies. In fact, the now ubiquitous and almost obligatory imaging tests (computed tomography, magnetic resonance imaging, positron-emission tomography, and ultrasonography) have been available to practitioners for only threescore years or less. Yet tests have become so dominant in our culture that it is hard to imagine a time when physicians could count only on their wit and senses.

CLINICAL SKILLS ARE STILL RELEVANT

Ironically, many studies tell us that history and bedside examination can still deliver most diagnoses.2,3 In fact, clinical skills can solve even the most perplexing dilemmas. In an automated analysis of the clinicopathologic conference cases presented in the New England Journal of Medicine,4 history and physical examination still yielded a correct diagnosis in 64% of those very challenging patients.

Bedside examination may be especially important in the hospital. In a study of inpatients,5 physical examination detected crucial findings in one-fourth of the cases and prompted management changes in many others. As the authors concluded, sick patients need careful examination, the more skilled the better.

Unfortunately, errors in physical examination are common. In a recent review of 208 cases, 63% of oversights were due to failure to perform an examination, while 25% were either missed or misinterpreted findings.6 These errors interfered with diagnosis in three-fourths of the cases, and with treatment in half.

Which brings us to the interesting observation by Kondo et al,7 who in this issue of the Journal report how the lowly physical examination proved more helpful than expensive magnetic resonance imaging in evaluating a perplexing case of refractory shoulder pain.

This is not an isolated instance. To get back to Laennec, whose stethoscope just turned 200, auscultation too can help the 21st-century physician. For example, posturally induced crackles, a recently discovered phenomenon, are the third-best predictor of outcome following myocardial infarction, immediately after the number of diseased vessels and pulmonary capillary wedge pressure.8

The time-honored art of observation can also yield new and important clues. From the earlobe crease of Dr. Frank, to the elfin face of Dr. Williams, there are lots of diseases out there waiting for our name—if only we could see them. As William Osler put it, “The whole art of medicine is in observation.”9

 

 

TECHNOLOGY: MASTER OR SERVANT?

But how can residents truly “observe” when they have to spend 40% of their time looking at computer screens and only 12% looking at people?10 To quote Osler again, “To educate the eye to see, the ear to hear, and the finger to feel takes time.”9 Yet time in medicine is at a premium. In a large national survey, the average ambulatory care visit to a general practitioner lasted 16 minutes,11 which makes it difficult to use inexpensive but time-consuming maneuvers. Detection of posturally induced crackles, for example, may require as much as 9 minutes, and a thorough breast examination up to 10.12 On the other hand, ordering tests costs little time to the physician but a huge sum to patients and society. Paradoxically, “tests” may be quite profitable for the medical-industrial complex. Hence the erosion of clinical skills.

Overreliance on diagnostic technology is particularly concerning when the cost of medicine has skyrocketed. The United States now spends $3.2 trillion a year for healthcare, and much of this money goes into technology.

In fact, high-tech might hurt us even more than in the pocket. It is a sad fact of modern medicine that when unguided by clinical skills, technology can take us down a rabbit hole, wherein tests beget tests, and where at the end there is usually a surgeon, often a lawyer, and sometimes even an undertaker. The literature is full of such cases, to the point that the risk of unnecessary tests has spawned a charming new acronym: VOMIT (victims of modern imaging technology).13

I’m not suggesting that we discard appropriate laboratory and radiologic testing. To the contrary. Yet contributions like those of Kondo et al remind us that even in today’s medicine, the bedside remains not only the royal road to diagnosis, but also the best filter for a more judicious and cost-effective use of technology.

That filter starts with history-taking (“Listen to the patient” said Osler, “he is telling you the diagnosis.”),9 and continues with the physical examination. In fact, the history typically guides the physical examination. Hence, when the patient’s symptoms point away from a particular organ, the examination of that organ may be reduced to a minimum. For instance, in neurologic patients whose history made certain findings unlikely, a Canadian group was able to cut in half the number of core items of their neurologic examination.14

Yet when the history flags a system, the clinician needs to go deeper into the examination. It’s very much what we do with laboratory tests, moving from screening tests to more advanced inquiries as we tailor our diagnostic studies to the patient’s presentation. For that we need validated maneuvers. Recent efforts in this direction have turned the art of physical examination into a science.15

Lastly, patients expect to be examined, and in fact they resent when this doesn’t happen.16 Lewis Thomas called touching our “real professional secret” and “the oldest and most effective art of doctors.”17 It may even have therapeutic value.

TEACHING BEDSIDE DIAGNOSIS

So, if bedside diagnosis is important, what can we do to rekindle it? Probably anything but continue in the old ways. Studies have consistently shown that auscultation does not improve with years of training, and that in fact attending physicians may be no more proficient than third-year medical students.18 Other areas of the examination have shown similarly depressing trends,19 thus suggesting that the traditional apprenticeship mode of learning from both faculty and senior trainees may not be helpful. In fact, it may be akin to Bruegel the Elder’s painting of the blind leading the blind, and all ending up in a ditch.

Advanced physical diagnosis courses have thus been advocated, and indeed implemented at many institutions, but usually as electives. Faculty development programs have also been recommended. Still, these interventions may not suffice.

Cutting the cord to technology by serving in a developing country

My hunch is that the rekindling of physical diagnosis may require extreme measures, like putting ourselves in a zero-tech, zero-tests environment. Years ago, I had that kind of cold-turkey experience when I spent a month in a remote Nepali clinic with neither electricity nor running water—and, of course, no cell phone and no Internet. In fact, my only tools were a translator, a stethoscope, and my brain and senses. It was both terrifying and instructive, very much like the time my uncle tried to teach me how to swim by suddenly throwing me into the Mediterranean.

Maybe we should offer that kind of “immersion” to our students. A senior rotation in a technology-depleted country might do a lot of good for a young medical mind. For one, it could remind students that physicians are not only the “natural attorneys of the poor,” as Virchow famously put it,20 but also the ultimate citizens of the world. To quote Dr. Osler again, “Distinctions of race, nationality, color, and creed are unknown within the portals of the temple of Æsculapius.”21 Such an experience might also foster empathy and tolerance for ambiguity, 2 other traits whose absence we lament in today’s medicine. More importantly, if preceded by an advanced physical diagnosis course, a rotation in a developing country could work miracles for honing bedside skills, especially if the students are accompanied by a faculty member who can be both inspiring and gifted in the art and science of bedside diagnosis.

Ultimately, this experience could remind our young that the art of medicine is much harder to acquire than the science, and that medicine is indeed a calling and not a trade. Osler said it too, and these are indeed provocative thoughts, but short of provocations and out-of-the-box ideas, the tail will continue to wag the dog. And in the end it will cost us more than money. It will cost us the art of medicine.

References
  1. Allen RB. Medical Education and the Changing Order: Studies of the New York Academy of Medicine, Committee on Medicine and the Changing Order. New York, NY: Commonwealth Fund, 1946.
  2. Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med 1992; 156:163–165.
  3. Roshan M, Rao AP. A study on relative contributions of the history, physical examination and investigations in making medical diagnosis. J Assoc Physicians India 2000; 48:771–775.
  4. Wagner MM, Bankowitz RA, McNeil M, Challinor SM, Janosky JE, Miller RA. The diagnostic importance of the history and physical examination as determined by the use of a medical decision support system. Proc Am Med Inform Assoc 1989: 139–144.
  5. Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet 2003; 362:1100–1105.
  6. Verghese A, Charlton B, Kassirer JP, Ramsey M, Ioannidis JPA. Inadequacies of physical examination as a cause of medical errors and adverse events: a collection of vignettes. Am J Med 2015; 128:1322–1324.e3.
  7. Kondo T, Ohira Y, Uehara T, Noda K, Ikusaka M. An unexpected cause of shoulder pain. Cleve Clin J Med 2017; 84:276–277.
  8. Deguchi F, Hirakawa S, Gotoh K, Yagi Y, Ohshima S. Prognostic significance of posturally induced crackles. Long-term follow-up of patients after recovery from acute myocardial infarction. Chest 1993; 103:1457–1462.
  9. Silverman ME, Murrary TJ, Bryan CS, eds. The Quotable Osler. Philadelphia, PA: Am Coll of Physicians; 2008.
  10. Block L, Habicht R, Wu AW, et al. In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? J Gen Intern Med 2013; 28:1042–1047.
  11. Blumenthal D, Causino N, Chang YC, et al. The duration of ambulatory visits to physicians. J Fam Pract 1999; 48:264–271.
  12. Barton MB, Harris R, Fletcher SW. The rational clinical examination. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA 1999; 282:1270–1280.
  13. Hayward R. VOMIT (victims of modern imaging technology)—an acronym for our times. BMJ 2003; 326:1273.
  14. Moore FG, Chalk C. The essential neurologic examination: what should medical students be taught? Neurology 2009; 72:2020–2023.
  15. Simel DL, Rennie D. The rational clinical examination: evidence-based clinical diagnosis. JAMA & Archives Journals. New York, NY: McGraw-Hill Education/Medical; 2009.
  16. Kravitz RL, Callahan EJ. Patients’ perceptions of omitted examinations and tests: a qualitative analysis. J Gen Intern Med 2000; 15:38–45.
  17. Thomas L. The Youngest Science: Notes of a Medicine Watcher. New York, NY: Viking Press, 1983.
  18. Vukanovic-Criley JM, Criley S, Warde CM, et al. Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: a multicenter study. Arch Intern Med 2006; 166:610–616.
  19. Paauw DS, Wenrich MD, Curtis JR, Carline JD, Ramsey PG. Ability of primary care physicians to recognize physical findings associated with HIV infection. JAMA 1995; 274:1380–1382.
  20. Brown TM, Fee E. Rudolf Carl Virchow: medical scientist, social reformer, role model. Am J Public Health 2006; 96:2104–2105.
  21. Osler W. British medicine in Greater Britain. The Medical News 1897; 71:293–298.
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Salvatore Mangione, MD
Associate Professor of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA

Address: Salvatore Mangione, MD, Sidney Kimmel Medical College of Thomas Jefferson University, Hamilton Building, 1001 Locust Street, Suite 309c, Philadelphia, PA 19107; Salvatore.Mangione@Jefferson.edu

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Cleveland Clinic Journal of Medicine - 84(4)
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Cleveland Clinic Journal of Medicine
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278-280
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clinical skills, technology, Hippocrates, Raymond Allen, Sir William Osler, Laennec, Auenbrugger, physical examination, auscultation, diagnosis, Salvatore Mangione
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Associate Professor of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA

Address: Salvatore Mangione, MD, Sidney Kimmel Medical College of Thomas Jefferson University, Hamilton Building, 1001 Locust Street, Suite 309c, Philadelphia, PA 19107; Salvatore.Mangione@Jefferson.edu

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Associate Professor of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA

Address: Salvatore Mangione, MD, Sidney Kimmel Medical College of Thomas Jefferson University, Hamilton Building, 1001 Locust Street, Suite 309c, Philadelphia, PA 19107; Salvatore.Mangione@Jefferson.edu

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Related Articles
Blending classic clinical skills with new technology
The stethoscope as metaphor

“... with the rapid extension of laboratory tests of greater accuracy, there is a tendency for some clinicians and hence for some students in reaching a diagnosis to rely more on laboratory reports and less on the history of the illness, the examination and behavior of the patient and clinical judgment. While in many cases laboratory findings are invaluable for reaching correct conclusions, the student should never be allowed to forget that it takes a man, not a machine, to understand a man.”

—Raymond B. Allen, MD, PhD, 19461

From Hippocrates onward, accurate diagnosis has always been the prerequisite for prognosis and treatment. Physicians typically diagnosed through astute interviewing, deductive reasoning, and skillful use of observation and touch. Then, in the past 250 years they added 2 more tools to their diagnostic skill set: percussion and auscultation, the dual foundation of bedside assessment. Intriguingly, both these skills were first envisioned by multifaceted minds: percussion by Leopold Auenbrugger, an Austrian music-lover who even wrote librettos for operas; and stethoscopy by René Laennec, a Breton flutist, poet, and dancer—not exactly the kind of doctors we tend to produce today.

See related article

Still, the point of this preamble is not to say that eclecticism may help creativity (it does), but to remind ourselves that it has only been for a century or so that physicians have been able to rely on laboratory and radiologic studies. In fact, the now ubiquitous and almost obligatory imaging tests (computed tomography, magnetic resonance imaging, positron-emission tomography, and ultrasonography) have been available to practitioners for only threescore years or less. Yet tests have become so dominant in our culture that it is hard to imagine a time when physicians could count only on their wit and senses.

CLINICAL SKILLS ARE STILL RELEVANT

Ironically, many studies tell us that history and bedside examination can still deliver most diagnoses.2,3 In fact, clinical skills can solve even the most perplexing dilemmas. In an automated analysis of the clinicopathologic conference cases presented in the New England Journal of Medicine,4 history and physical examination still yielded a correct diagnosis in 64% of those very challenging patients.

Bedside examination may be especially important in the hospital. In a study of inpatients,5 physical examination detected crucial findings in one-fourth of the cases and prompted management changes in many others. As the authors concluded, sick patients need careful examination, the more skilled the better.

Unfortunately, errors in physical examination are common. In a recent review of 208 cases, 63% of oversights were due to failure to perform an examination, while 25% were either missed or misinterpreted findings.6 These errors interfered with diagnosis in three-fourths of the cases, and with treatment in half.

Which brings us to the interesting observation by Kondo et al,7 who in this issue of the Journal report how the lowly physical examination proved more helpful than expensive magnetic resonance imaging in evaluating a perplexing case of refractory shoulder pain.

This is not an isolated instance. To get back to Laennec, whose stethoscope just turned 200, auscultation too can help the 21st-century physician. For example, posturally induced crackles, a recently discovered phenomenon, are the third-best predictor of outcome following myocardial infarction, immediately after the number of diseased vessels and pulmonary capillary wedge pressure.8

The time-honored art of observation can also yield new and important clues. From the earlobe crease of Dr. Frank, to the elfin face of Dr. Williams, there are lots of diseases out there waiting for our name—if only we could see them. As William Osler put it, “The whole art of medicine is in observation.”9

 

 

TECHNOLOGY: MASTER OR SERVANT?

But how can residents truly “observe” when they have to spend 40% of their time looking at computer screens and only 12% looking at people?10 To quote Osler again, “To educate the eye to see, the ear to hear, and the finger to feel takes time.”9 Yet time in medicine is at a premium. In a large national survey, the average ambulatory care visit to a general practitioner lasted 16 minutes,11 which makes it difficult to use inexpensive but time-consuming maneuvers. Detection of posturally induced crackles, for example, may require as much as 9 minutes, and a thorough breast examination up to 10.12 On the other hand, ordering tests costs little time to the physician but a huge sum to patients and society. Paradoxically, “tests” may be quite profitable for the medical-industrial complex. Hence the erosion of clinical skills.

Overreliance on diagnostic technology is particularly concerning when the cost of medicine has skyrocketed. The United States now spends $3.2 trillion a year for healthcare, and much of this money goes into technology.

In fact, high-tech might hurt us even more than in the pocket. It is a sad fact of modern medicine that when unguided by clinical skills, technology can take us down a rabbit hole, wherein tests beget tests, and where at the end there is usually a surgeon, often a lawyer, and sometimes even an undertaker. The literature is full of such cases, to the point that the risk of unnecessary tests has spawned a charming new acronym: VOMIT (victims of modern imaging technology).13

I’m not suggesting that we discard appropriate laboratory and radiologic testing. To the contrary. Yet contributions like those of Kondo et al remind us that even in today’s medicine, the bedside remains not only the royal road to diagnosis, but also the best filter for a more judicious and cost-effective use of technology.

That filter starts with history-taking (“Listen to the patient” said Osler, “he is telling you the diagnosis.”),9 and continues with the physical examination. In fact, the history typically guides the physical examination. Hence, when the patient’s symptoms point away from a particular organ, the examination of that organ may be reduced to a minimum. For instance, in neurologic patients whose history made certain findings unlikely, a Canadian group was able to cut in half the number of core items of their neurologic examination.14

Yet when the history flags a system, the clinician needs to go deeper into the examination. It’s very much what we do with laboratory tests, moving from screening tests to more advanced inquiries as we tailor our diagnostic studies to the patient’s presentation. For that we need validated maneuvers. Recent efforts in this direction have turned the art of physical examination into a science.15

Lastly, patients expect to be examined, and in fact they resent when this doesn’t happen.16 Lewis Thomas called touching our “real professional secret” and “the oldest and most effective art of doctors.”17 It may even have therapeutic value.

TEACHING BEDSIDE DIAGNOSIS

So, if bedside diagnosis is important, what can we do to rekindle it? Probably anything but continue in the old ways. Studies have consistently shown that auscultation does not improve with years of training, and that in fact attending physicians may be no more proficient than third-year medical students.18 Other areas of the examination have shown similarly depressing trends,19 thus suggesting that the traditional apprenticeship mode of learning from both faculty and senior trainees may not be helpful. In fact, it may be akin to Bruegel the Elder’s painting of the blind leading the blind, and all ending up in a ditch.

Advanced physical diagnosis courses have thus been advocated, and indeed implemented at many institutions, but usually as electives. Faculty development programs have also been recommended. Still, these interventions may not suffice.

Cutting the cord to technology by serving in a developing country

My hunch is that the rekindling of physical diagnosis may require extreme measures, like putting ourselves in a zero-tech, zero-tests environment. Years ago, I had that kind of cold-turkey experience when I spent a month in a remote Nepali clinic with neither electricity nor running water—and, of course, no cell phone and no Internet. In fact, my only tools were a translator, a stethoscope, and my brain and senses. It was both terrifying and instructive, very much like the time my uncle tried to teach me how to swim by suddenly throwing me into the Mediterranean.

Maybe we should offer that kind of “immersion” to our students. A senior rotation in a technology-depleted country might do a lot of good for a young medical mind. For one, it could remind students that physicians are not only the “natural attorneys of the poor,” as Virchow famously put it,20 but also the ultimate citizens of the world. To quote Dr. Osler again, “Distinctions of race, nationality, color, and creed are unknown within the portals of the temple of Æsculapius.”21 Such an experience might also foster empathy and tolerance for ambiguity, 2 other traits whose absence we lament in today’s medicine. More importantly, if preceded by an advanced physical diagnosis course, a rotation in a developing country could work miracles for honing bedside skills, especially if the students are accompanied by a faculty member who can be both inspiring and gifted in the art and science of bedside diagnosis.

Ultimately, this experience could remind our young that the art of medicine is much harder to acquire than the science, and that medicine is indeed a calling and not a trade. Osler said it too, and these are indeed provocative thoughts, but short of provocations and out-of-the-box ideas, the tail will continue to wag the dog. And in the end it will cost us more than money. It will cost us the art of medicine.

“... with the rapid extension of laboratory tests of greater accuracy, there is a tendency for some clinicians and hence for some students in reaching a diagnosis to rely more on laboratory reports and less on the history of the illness, the examination and behavior of the patient and clinical judgment. While in many cases laboratory findings are invaluable for reaching correct conclusions, the student should never be allowed to forget that it takes a man, not a machine, to understand a man.”

—Raymond B. Allen, MD, PhD, 19461

From Hippocrates onward, accurate diagnosis has always been the prerequisite for prognosis and treatment. Physicians typically diagnosed through astute interviewing, deductive reasoning, and skillful use of observation and touch. Then, in the past 250 years they added 2 more tools to their diagnostic skill set: percussion and auscultation, the dual foundation of bedside assessment. Intriguingly, both these skills were first envisioned by multifaceted minds: percussion by Leopold Auenbrugger, an Austrian music-lover who even wrote librettos for operas; and stethoscopy by René Laennec, a Breton flutist, poet, and dancer—not exactly the kind of doctors we tend to produce today.

See related article

Still, the point of this preamble is not to say that eclecticism may help creativity (it does), but to remind ourselves that it has only been for a century or so that physicians have been able to rely on laboratory and radiologic studies. In fact, the now ubiquitous and almost obligatory imaging tests (computed tomography, magnetic resonance imaging, positron-emission tomography, and ultrasonography) have been available to practitioners for only threescore years or less. Yet tests have become so dominant in our culture that it is hard to imagine a time when physicians could count only on their wit and senses.

CLINICAL SKILLS ARE STILL RELEVANT

Ironically, many studies tell us that history and bedside examination can still deliver most diagnoses.2,3 In fact, clinical skills can solve even the most perplexing dilemmas. In an automated analysis of the clinicopathologic conference cases presented in the New England Journal of Medicine,4 history and physical examination still yielded a correct diagnosis in 64% of those very challenging patients.

Bedside examination may be especially important in the hospital. In a study of inpatients,5 physical examination detected crucial findings in one-fourth of the cases and prompted management changes in many others. As the authors concluded, sick patients need careful examination, the more skilled the better.

Unfortunately, errors in physical examination are common. In a recent review of 208 cases, 63% of oversights were due to failure to perform an examination, while 25% were either missed or misinterpreted findings.6 These errors interfered with diagnosis in three-fourths of the cases, and with treatment in half.

Which brings us to the interesting observation by Kondo et al,7 who in this issue of the Journal report how the lowly physical examination proved more helpful than expensive magnetic resonance imaging in evaluating a perplexing case of refractory shoulder pain.

This is not an isolated instance. To get back to Laennec, whose stethoscope just turned 200, auscultation too can help the 21st-century physician. For example, posturally induced crackles, a recently discovered phenomenon, are the third-best predictor of outcome following myocardial infarction, immediately after the number of diseased vessels and pulmonary capillary wedge pressure.8

The time-honored art of observation can also yield new and important clues. From the earlobe crease of Dr. Frank, to the elfin face of Dr. Williams, there are lots of diseases out there waiting for our name—if only we could see them. As William Osler put it, “The whole art of medicine is in observation.”9

 

 

TECHNOLOGY: MASTER OR SERVANT?

But how can residents truly “observe” when they have to spend 40% of their time looking at computer screens and only 12% looking at people?10 To quote Osler again, “To educate the eye to see, the ear to hear, and the finger to feel takes time.”9 Yet time in medicine is at a premium. In a large national survey, the average ambulatory care visit to a general practitioner lasted 16 minutes,11 which makes it difficult to use inexpensive but time-consuming maneuvers. Detection of posturally induced crackles, for example, may require as much as 9 minutes, and a thorough breast examination up to 10.12 On the other hand, ordering tests costs little time to the physician but a huge sum to patients and society. Paradoxically, “tests” may be quite profitable for the medical-industrial complex. Hence the erosion of clinical skills.

Overreliance on diagnostic technology is particularly concerning when the cost of medicine has skyrocketed. The United States now spends $3.2 trillion a year for healthcare, and much of this money goes into technology.

In fact, high-tech might hurt us even more than in the pocket. It is a sad fact of modern medicine that when unguided by clinical skills, technology can take us down a rabbit hole, wherein tests beget tests, and where at the end there is usually a surgeon, often a lawyer, and sometimes even an undertaker. The literature is full of such cases, to the point that the risk of unnecessary tests has spawned a charming new acronym: VOMIT (victims of modern imaging technology).13

I’m not suggesting that we discard appropriate laboratory and radiologic testing. To the contrary. Yet contributions like those of Kondo et al remind us that even in today’s medicine, the bedside remains not only the royal road to diagnosis, but also the best filter for a more judicious and cost-effective use of technology.

That filter starts with history-taking (“Listen to the patient” said Osler, “he is telling you the diagnosis.”),9 and continues with the physical examination. In fact, the history typically guides the physical examination. Hence, when the patient’s symptoms point away from a particular organ, the examination of that organ may be reduced to a minimum. For instance, in neurologic patients whose history made certain findings unlikely, a Canadian group was able to cut in half the number of core items of their neurologic examination.14

Yet when the history flags a system, the clinician needs to go deeper into the examination. It’s very much what we do with laboratory tests, moving from screening tests to more advanced inquiries as we tailor our diagnostic studies to the patient’s presentation. For that we need validated maneuvers. Recent efforts in this direction have turned the art of physical examination into a science.15

Lastly, patients expect to be examined, and in fact they resent when this doesn’t happen.16 Lewis Thomas called touching our “real professional secret” and “the oldest and most effective art of doctors.”17 It may even have therapeutic value.

TEACHING BEDSIDE DIAGNOSIS

So, if bedside diagnosis is important, what can we do to rekindle it? Probably anything but continue in the old ways. Studies have consistently shown that auscultation does not improve with years of training, and that in fact attending physicians may be no more proficient than third-year medical students.18 Other areas of the examination have shown similarly depressing trends,19 thus suggesting that the traditional apprenticeship mode of learning from both faculty and senior trainees may not be helpful. In fact, it may be akin to Bruegel the Elder’s painting of the blind leading the blind, and all ending up in a ditch.

Advanced physical diagnosis courses have thus been advocated, and indeed implemented at many institutions, but usually as electives. Faculty development programs have also been recommended. Still, these interventions may not suffice.

Cutting the cord to technology by serving in a developing country

My hunch is that the rekindling of physical diagnosis may require extreme measures, like putting ourselves in a zero-tech, zero-tests environment. Years ago, I had that kind of cold-turkey experience when I spent a month in a remote Nepali clinic with neither electricity nor running water—and, of course, no cell phone and no Internet. In fact, my only tools were a translator, a stethoscope, and my brain and senses. It was both terrifying and instructive, very much like the time my uncle tried to teach me how to swim by suddenly throwing me into the Mediterranean.

Maybe we should offer that kind of “immersion” to our students. A senior rotation in a technology-depleted country might do a lot of good for a young medical mind. For one, it could remind students that physicians are not only the “natural attorneys of the poor,” as Virchow famously put it,20 but also the ultimate citizens of the world. To quote Dr. Osler again, “Distinctions of race, nationality, color, and creed are unknown within the portals of the temple of Æsculapius.”21 Such an experience might also foster empathy and tolerance for ambiguity, 2 other traits whose absence we lament in today’s medicine. More importantly, if preceded by an advanced physical diagnosis course, a rotation in a developing country could work miracles for honing bedside skills, especially if the students are accompanied by a faculty member who can be both inspiring and gifted in the art and science of bedside diagnosis.

Ultimately, this experience could remind our young that the art of medicine is much harder to acquire than the science, and that medicine is indeed a calling and not a trade. Osler said it too, and these are indeed provocative thoughts, but short of provocations and out-of-the-box ideas, the tail will continue to wag the dog. And in the end it will cost us more than money. It will cost us the art of medicine.

References
  1. Allen RB. Medical Education and the Changing Order: Studies of the New York Academy of Medicine, Committee on Medicine and the Changing Order. New York, NY: Commonwealth Fund, 1946.
  2. Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med 1992; 156:163–165.
  3. Roshan M, Rao AP. A study on relative contributions of the history, physical examination and investigations in making medical diagnosis. J Assoc Physicians India 2000; 48:771–775.
  4. Wagner MM, Bankowitz RA, McNeil M, Challinor SM, Janosky JE, Miller RA. The diagnostic importance of the history and physical examination as determined by the use of a medical decision support system. Proc Am Med Inform Assoc 1989: 139–144.
  5. Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet 2003; 362:1100–1105.
  6. Verghese A, Charlton B, Kassirer JP, Ramsey M, Ioannidis JPA. Inadequacies of physical examination as a cause of medical errors and adverse events: a collection of vignettes. Am J Med 2015; 128:1322–1324.e3.
  7. Kondo T, Ohira Y, Uehara T, Noda K, Ikusaka M. An unexpected cause of shoulder pain. Cleve Clin J Med 2017; 84:276–277.
  8. Deguchi F, Hirakawa S, Gotoh K, Yagi Y, Ohshima S. Prognostic significance of posturally induced crackles. Long-term follow-up of patients after recovery from acute myocardial infarction. Chest 1993; 103:1457–1462.
  9. Silverman ME, Murrary TJ, Bryan CS, eds. The Quotable Osler. Philadelphia, PA: Am Coll of Physicians; 2008.
  10. Block L, Habicht R, Wu AW, et al. In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? J Gen Intern Med 2013; 28:1042–1047.
  11. Blumenthal D, Causino N, Chang YC, et al. The duration of ambulatory visits to physicians. J Fam Pract 1999; 48:264–271.
  12. Barton MB, Harris R, Fletcher SW. The rational clinical examination. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA 1999; 282:1270–1280.
  13. Hayward R. VOMIT (victims of modern imaging technology)—an acronym for our times. BMJ 2003; 326:1273.
  14. Moore FG, Chalk C. The essential neurologic examination: what should medical students be taught? Neurology 2009; 72:2020–2023.
  15. Simel DL, Rennie D. The rational clinical examination: evidence-based clinical diagnosis. JAMA & Archives Journals. New York, NY: McGraw-Hill Education/Medical; 2009.
  16. Kravitz RL, Callahan EJ. Patients’ perceptions of omitted examinations and tests: a qualitative analysis. J Gen Intern Med 2000; 15:38–45.
  17. Thomas L. The Youngest Science: Notes of a Medicine Watcher. New York, NY: Viking Press, 1983.
  18. Vukanovic-Criley JM, Criley S, Warde CM, et al. Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: a multicenter study. Arch Intern Med 2006; 166:610–616.
  19. Paauw DS, Wenrich MD, Curtis JR, Carline JD, Ramsey PG. Ability of primary care physicians to recognize physical findings associated with HIV infection. JAMA 1995; 274:1380–1382.
  20. Brown TM, Fee E. Rudolf Carl Virchow: medical scientist, social reformer, role model. Am J Public Health 2006; 96:2104–2105.
  21. Osler W. British medicine in Greater Britain. The Medical News 1897; 71:293–298.
References
  1. Allen RB. Medical Education and the Changing Order: Studies of the New York Academy of Medicine, Committee on Medicine and the Changing Order. New York, NY: Commonwealth Fund, 1946.
  2. Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med 1992; 156:163–165.
  3. Roshan M, Rao AP. A study on relative contributions of the history, physical examination and investigations in making medical diagnosis. J Assoc Physicians India 2000; 48:771–775.
  4. Wagner MM, Bankowitz RA, McNeil M, Challinor SM, Janosky JE, Miller RA. The diagnostic importance of the history and physical examination as determined by the use of a medical decision support system. Proc Am Med Inform Assoc 1989: 139–144.
  5. Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet 2003; 362:1100–1105.
  6. Verghese A, Charlton B, Kassirer JP, Ramsey M, Ioannidis JPA. Inadequacies of physical examination as a cause of medical errors and adverse events: a collection of vignettes. Am J Med 2015; 128:1322–1324.e3.
  7. Kondo T, Ohira Y, Uehara T, Noda K, Ikusaka M. An unexpected cause of shoulder pain. Cleve Clin J Med 2017; 84:276–277.
  8. Deguchi F, Hirakawa S, Gotoh K, Yagi Y, Ohshima S. Prognostic significance of posturally induced crackles. Long-term follow-up of patients after recovery from acute myocardial infarction. Chest 1993; 103:1457–1462.
  9. Silverman ME, Murrary TJ, Bryan CS, eds. The Quotable Osler. Philadelphia, PA: Am Coll of Physicians; 2008.
  10. Block L, Habicht R, Wu AW, et al. In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? J Gen Intern Med 2013; 28:1042–1047.
  11. Blumenthal D, Causino N, Chang YC, et al. The duration of ambulatory visits to physicians. J Fam Pract 1999; 48:264–271.
  12. Barton MB, Harris R, Fletcher SW. The rational clinical examination. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA 1999; 282:1270–1280.
  13. Hayward R. VOMIT (victims of modern imaging technology)—an acronym for our times. BMJ 2003; 326:1273.
  14. Moore FG, Chalk C. The essential neurologic examination: what should medical students be taught? Neurology 2009; 72:2020–2023.
  15. Simel DL, Rennie D. The rational clinical examination: evidence-based clinical diagnosis. JAMA & Archives Journals. New York, NY: McGraw-Hill Education/Medical; 2009.
  16. Kravitz RL, Callahan EJ. Patients’ perceptions of omitted examinations and tests: a qualitative analysis. J Gen Intern Med 2000; 15:38–45.
  17. Thomas L. The Youngest Science: Notes of a Medicine Watcher. New York, NY: Viking Press, 1983.
  18. Vukanovic-Criley JM, Criley S, Warde CM, et al. Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: a multicenter study. Arch Intern Med 2006; 166:610–616.
  19. Paauw DS, Wenrich MD, Curtis JR, Carline JD, Ramsey PG. Ability of primary care physicians to recognize physical findings associated with HIV infection. JAMA 1995; 274:1380–1382.
  20. Brown TM, Fee E. Rudolf Carl Virchow: medical scientist, social reformer, role model. Am J Public Health 2006; 96:2104–2105.
  21. Osler W. British medicine in Greater Britain. The Medical News 1897; 71:293–298.
Issue
Cleveland Clinic Journal of Medicine - 84(4)
Issue
Cleveland Clinic Journal of Medicine - 84(4)
Page Number
278-280
Page Number
278-280
Publications
Cleveland Clinic Journal of Medicine
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Cleveland Clinic Journal of Medicine
Topics
Imaging
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Article
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When the tail wags the dog: Clinical skills in the age of technology
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When the tail wags the dog: Clinical skills in the age of technology
Legacy Keywords
clinical skills, technology, Hippocrates, Raymond Allen, Sir William Osler, Laennec, Auenbrugger, physical examination, auscultation, diagnosis, Salvatore Mangione
Legacy Keywords
clinical skills, technology, Hippocrates, Raymond Allen, Sir William Osler, Laennec, Auenbrugger, physical examination, auscultation, diagnosis, Salvatore Mangione
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