Back to basics

I was surprised to get a phone call from the editor during which he asked me to return to the Editorial Board as a stand-in for Dr Brian Day, who is rather too busy elsewhere at present to attend Editorial Board meetings. I hesitated for a nanosecond because I am surely beyond my best-before date. I withdrew from clinical practice some time ago and I withdrew from the BC College of Physicians and Surgeons recently. I am now a retired old fogey. What can someone with 53 years in this profession possibly say that has any relevance to today’s working physicians and surgeons? 

However, I agreed because working with the Board and editorial staff is glorious fun.

I thought back over the past decades and realized that we all have witnessed amazing advances in medical treatment and medical technology. For instance, in my field, minimal access surgery has reduced trauma to the patient and therefore reduced the time needed recovering in hospital. Besides, it is rather intriguing to do, resembling as it does, video games!

I have also witnessed, as we all have, some disturbing losses and distortions in practice, such as deterioration in access for patients to doctors and hospitals. There also seems to have become commonplace an abandonment or loss of our basic medical skills.

My teachers taught me to “Listen to the patient’s history and it will tell you the diagnosis,” and “If you don’t examine the patient you will make fatal mistakes”--otherwise stated as, “If you don’t put your finger in, you will put your foot into it” referring to the importance of rectal examination.

I accompanied a friend to emergency recently. It was educational for me. One young emergency physician remained in front of a computer and seemed to respond only to what he saw on the screen. Over 3 or 4 hours I did not see him leave to examine anyone. He seemed to expect the nursing staff to be the go-between for him and the patients he was treating. It reminded me of an old ditty by, I think, Tom Lehrer, that ended, “. . . and when he died he died in balance.” 

The song referred to treating laboratory results rather than the patient.

Here are some examples of the importance of a proper history and physical examination in patient care.

• In the days of my residency training there was such a thing as surgery outpatient clinics for the indigent. There was a chronic recurring patient who was the bane of the clinic. He had a persistent complaint of a whistle in his rectum. Abdominal X-rays, barium enemas, and sigmoidoscopies had failed to reassure him. After many visits a complete physical examination showed that he had advanced carcinoma of the tongue. Mind you, he probably continued to complain of his whistle.

• A patient was sent for a biopsy of a lymph node mass in the parotid region and neck--most likely a lymphoma. An examination showed a little patch of redness on the sclera on that side. His pet cat had nuzzled him there--so cat scratch fever.

• A man known to have asymptomatic gall stones was sent to emergency with severe right upper quadrant pain. Clearly, a case of cholecystitis, warranting surgery. On talking to him he was recovering from an attack of bronchitis and severe coughing. Examination revealed the source of pain to be cough fractures of his right lower ribs, a problem that would not have been resolved by a cholecystectomy.

There are many more examples of cases where a careful history and a more than cursory examination have revealed a correct diagnosis that would not have been discovered by laboratory tests or diagnostic tools or sophisticated imaging alone.

I know that it takes time to hear the patient’s full history and to do a complete physical examination. I know that economics have constrained the time that can be spent with an individual patient. How much useful information can one gain during a 3-minute family doctor appointment or a 90-second specialist consultation? Patients view such cursory attention as proof that the profession consists of uncaring money grubbers. We are losing the enjoyment of getting to know our patients and the exhilaration of solving the diagnosis and applying the right solution.

One can be a wonderful endoscopist, a technically brilliant surgeon, or have the latest laboratory and diagnostic tests at your fingertips, but if you apply the right solution to the wrong problem nobody benefits; least of all the patient.
“Listen to the history and you will be told the diagnosis.”

“If you do not examine the patient you will make fatal mistakes.”
--PMR