The Clinical Approach: Dumbing It Down
"Errors using inadequate data are much less than those using no data at all."|
"The religions we call false were once true."|
The word "clinical" according to dictionary.com is "concerned with or based on actual observation and treatment of disease in patients rather than experimentation or theory" ... or "extremely objective and realistic; dispassionately analytic; unemotionally critical:" as in "She regarded him with clinical detachment."
"Detachment" indeed! Let us start with something left out of the dictionary definition: The History. In my first Second Opinions newsletter June 11, 2004: Medical Diagnosis: Test First, Talk Later? I referred to studies done in 1984 by Dr. Sherrie Kaplan and colleagues at the University of California, Irvine. The researchers found that on average, patients interviewed were interrupted 18 seconds after beginning to explain their complaints and problems. Just how often does communication between doctors and patients collapse? Research shows that only 15% of patients fully understand what their doctors tell them, and 50% leave their doctors' offices unclear about the advice they received. Fewer than 2% of patients got to finish their explanations. Dr. Kaplan's studies suggest that the typical number of questions women ask during (the rare) 15 minute visit is six, while a male patient asks none. Confirmation of these findings was reported 15 years later in a follow-up by members of the same group in the 1999 JAMA.
Many physicians, possibly the majority, continue to neglect the long-honored tradition of first listening to the patient's description of her complaint, her story, then performing an appropriate physical examination. But this takes time, certainly more than 18 seconds, perhaps as long as half an hour or more. Yet the clinical history remains the principal key to diagnosis. Fifty years ago, Platt asserted that most diagnoses could be made on history alone. More than a century ago, Dr. William Osler, the great clinical teacher, exhorted his students, "Listen to the patient, He is telling you the diagnosis."
The Decay of the Physical Examination
When I was a second year medical student, the stethoscope in the pocket of the lab coat or dangling from the neck was proof that we were about to arrive as Real Doctors at the bedside. (Now med students get to do this the First year.) We even flaunted our new devices at lunch when we occasionally dined next to undergrads. We were taught in a semester course called "physical diagnosis," not only history-taking, but, among other things, how to use this marvelous instrument to listen to the heart, lungs, abdomen, even the neck, head and extremities for all sorts of strange body sounds described as murmurs, bruits, crackling rales, wheezes, bowel sounds, etc. At no time, however, were we ever given the impression, nor did we stop to imagine, that the stethoscope should be applied anywhere but the bare skin.
How things have changed! Today, the stethoscope, a status symbol of medical expertise, worn by doctors, technicians, nurses, emergency crews, is draped, around, never dangling from, the neck. Nor is this wonderful instrument very often confined to the pocket; it simply stays-encircling, Draped. Fair enough, I say, let the stethoscope, like a mood, Hang Out any which way. But, where seeks the end of the instrument? Not usually on the skin, but rather against the shirt or blouse, perhaps even the sweater. Who has time for the patient to undress, even if doing so permits one to hear something? It should be obvious at least to users that body utterances are so contaminated by adventitious and muffled sounds caused by clothing that listening via stethoscope becomes nothing more than an extravagant ritual. Consider this observation the next time you watch a medical ad or show on TV, or when you visit the doctor's office or hospital. Speaking of TV brings to mind Grey's Anatomy where the actors often wear the stethoscope ear pieces pointing backwards! (The ear canals point forward.)
Among other things, we also learned about palpation in physical diagnosis: feeling, touching the patient. I recall vividly the professor who lectured class on the abdominal examination, "Whenever you examine the abdomen, whether the patient is draped or you have to pull down the shorts, pants or panties, make sure you see the top of the pubic hairs." Now it's easier and quicker. Just feel the abdomen through the clothes, no matter what the patient is wearing. (In the words of 007: "A dry martini please, shaken, not stirred.")
Time pressures hardly excuse the physician from ignoring the sadly neglected clinical approach which has become subordinated to indiscriminate requests for various testing procedures in a misguided search for some diagnostic shortcut. The format and style of our website is intended to reflect this long-accepted medical wisdom, now a tired cliché-that signs and symptoms, and therefore a careful medical history and physical examination provide a major clue to the correct diagnosis in more than 90% of patients.
Marginalizing the clinical approach is a form of exploding medical correctness and partly a result of our love affair with any form of novelty. To paraphrase Andy Worhol, in the future, every new test and drug "will be famous for 15 minutes." Aldous Huxley, the author of Brave New World, once defined progress as "better toys."
Physicians are not excused from listening to the patient tell him, sometimes in excruciating detail, where it hurts, nor should anyone assume that a stethoscope or fingers on a hand can discover anything important through layers of clothing. Show this to your doctor if you think it's appropriate, as in, "Doctor, can you really hear if I have pneumonia through my sweater?"
On Specialization, the Decline of the Clinical, and the Ascendancy of Testing
Speaking of the "amputation" of society, each trade and profession "ridden by the routine of craft…The priest becomes a form; the attorney a statute-book; the mechanic a machine; the sailor a rope of the ship" [And the doctor an MRI?]
Emerson in The American Scholar, quoted by Cynthia Ozick in
Harper's The Moral Necessity of Metaphor, May 1988
Martin F. Sturman, MD, FACP
Copyright 2011, Mathemedics, Inc.
EasyDiagnosis is an automated online service that analyses existing medical symptoms and predicts likely causes and conditions. Click here to find out more about this unique service and click here to try one of our modules for free.