Art and science

Use it or lose it is a frequently heard old adage. I wonder if it also applies to our style of medical practice in 21st century Western medicine. An old friend of mine worked as a physician on the cruise ships for many years after graduation from medical school. His responsibilities were primarily directed to the treatment of very minor ailments and the pursuit of social excess. When he returned from abroad he decided to re-enter hospital medicine and enrolled in a residency program. I remember his difficulties with this process, since he had forgotten almost everything that he had learned.

In this age of super-specialization, it must be difficult for the subspecialists to maintain their general clinical skills. For instance, I always find it rather sad when people requiring ophthalmic surgery present to the office clutching a hospital preadmission form. Clearly a very basic physical examination with measurement of blood pressure, pulse, and chest auscultation is now beyond the clinical scope of many physicians. Of more concern is the young doctor who decides on a career in the walk-in clinic scene. In this situation, a generalist physician is exposed to minor ailments, and has strong incentives to refer any patient who could be perceived as time-consuming to either the family physician or to a specialist for more detailed assessment. Clinical skills must suffer under these conditions. As the current general practitioner population continues to diminish due to poor remuneration and retirement, it is inevitable that primary care will become increasingly dependent on a population of physicians who have lost their clinical abilities.

Technology is a wonderful aid to good clinical medicine, but a very poor substitute. When time was less of a luxury in general practice, I would occasionally entertain medical students at the office and help teach them some of the rudimentaries of clinical examination. I remember a final-year student performing a very clumsy physical examination on one of my patients and being totally incapable of eliciting any of the abnormal physical signs. However, his theoretical knowledge was excellent and when given the clinical findings, his differential diagnosis was impressive. I have noticed over the last few years that long wait lists now precede many radiological investigations. This trend promises to worsen given the pressures on our health care system. Hence at a time when we are most likely to become more reliant on our basic skills, we are breeding a population of physicians who are rapidly losing these essential capabilities. The practice of medicine will always be a combination of art and science, and no health care system can function in denial of this basic tenet.

—MHG