after posting yesterday’s photo of my grandpa’s medical tools from 1952, Brandon commented that he was surprised at how little things have changed. and it’s true. even the trusty stethoscope evolved a bit, but has remained largely the same since the 1940s. i found myself wondering if the lack of technological advancement in physical diagnosis tools is a reflection of the fact that doctors are relying more on other diagnostic technology. technology that has come giant leaps and bounds in the last 50 years.

then, yesterday in Physical Diagnosis class, our professor handed out an article from the New England Journal of Medicine.

I remember well my first course about physical diagnosis, which took place at the beginning of my second year of medical school. The preceptor was an intense but likeable oncology fellow who was clearly ambivalent about the value of the skills he was teaching. Of course, he dutifully trained us in the appropriate mechanics — palpating for lympahdenopathy, performing a comprehensive neurologic examination, and the like — and uttered the usual homilies about their importance. But the emphasis at our weekly sessions was on the normal findings. Once, in response to a question, he scoffed that it would take two days to perform the physical exam described in our textbook. Even as he went through the motions of teaching physical diagnosis, he appeared to be dismissing it.

I encountered similar attitudes toward physical diagnosis throughout my internship and residency. We residents were apt to regard the physical exams as an arcane curiosity — after all, who had the time to concentrate on proper technique when you had to round on 15 patients? Even if you said that you’d heard a diastolic opening snap or a midsystolic click, no one believed you, or people thought you were showing off, or they assumed your observations were derived from something other than a physical exam. Technology ruled the day, permitting diagnosis at a distance. Some doctors didn’t even carry a stethoscope.

In a 1992 study at Duke University Medical Center, 63 residents were asked to listen to three common heart murmurs that had been programmed into a mannequin. Despite being tested in a quiet room and having all the time they wanted — hardly conditions encountered in real practice — roughly half could not identify mitral regurgitation or aortic regurgitation and approximately two thirds missed mitral stenosis.

Not surprisingly, medical educators whose job it is to ensure the proper transmission of medical skills, have found these results troubling. They worry that a vital art, as they like to call it, is being extinguished. But is the demise of physical diagnosis a crisis or a natural evolution?

~ Sandeep Jauhar, M.D, Ph.D. from “The Demise of the Physical Exam” NEJM

two of our instructors in Physical Diagnosis lab are local practicing doctors here on Nevis. they are wonderful women with strong personalities and wry senses of humor.

and their hands-on technique is impeccable down to the finest detail.

i watched Dr. R take a precise blood pressure in milliseconds flat like she could do it in her sleep. and Dr. N carefully (and oh-so patiently) corrected my chest percussion over and over and over until my awkward fingers started doing what i wanted them to. i would probably trust these ladies to make a diagnosis based on physical findings alone more than most doctors i have met in North America. they may not be high-level super sub-sub-specialists, but they are experts at the fine art of hands-on diagnosis.

is it because they don’t have the opportunity to rely on the same technology that we have in North America? even if there was an MRI or CAT scan machine on the island, most folks couldn’t afford to pay for that sort of confirmatory test. they trust their doctor’s touch because they have to. their doctor’s have made diagnoses based on physical findings alone over and over and over again because they have to.

i will never argue that Wenckebach’s method of identifying arrhythmia is more accurate than a EKG. or that abdominal palpations more true than an xray. but i am very happy to be learning this vital set of medical techniques from such detail-oriented instructors. even if i don’t get to use these skills as often in a noisy, bustling high-tech hospital back home, i feel it’s a basic foundation essential to my education and understanding of the human body. besides, i may end up back in Africa someday. and there certainly aren’t a lot of MRI machines out there.

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