Our ability to detect things by simple examination skills is being eroded by technology, says Jobbing Doctor
Around three months ago, I had a patient who came to see me. He was looking quite unwell, and was obviously anaemic. I took a history (as you do) and examined him, including an abdominal examination. He had a clear abdominal mass, and so I referred him. Quickly.
An everyday story of GP-folk so far. Many readers will have similar experiences. I carried on with my work, occasionally thinking of him, and awaiting a preliminary report so see if my proffered diagnosis was up to scratch.
The letter returned around 10 days after he was seen.
‘Dear Jobbing Doctor…..thank you…blah blah….unwell…blah blah…’
Jobbing Doctors normal skip past a slavish reiteration of the history, and like to get to the meat of the letter.
‘On examination there was no abdominal mass, and……’
What? I could not believe this. The mass was not faecal (unless it was the biggest and hardest turd in living memory). I was being told by a hospital doctor that the mass did not exist. I knew I was right, and carried on reading the other 80 letters (I get around 80 a day as senior partner). This information rankled.
They decided to do more tests (as they do) and that included an abdominal ultrasound. The next letter described, quite clearly that there was a mass in the abdomen, just where I said it was.
Now, I don’t normally grant myself superhuman powers. This is a mass that any of my partners would have felt. Why was it that the surgical doctor could not detect it?
I have found this experience more and more commonly. In primary care we need to rely on our clinical examinations skills much more often, as we don’t have the luxury of scanning everything in a conveniently close X-Ray department. Our ability to detect things by simple examination skills is being eroded by technology.
When was the last time that you saw anyone using a Pinard (foetal) stethoscope? Would the junior obstetricians of this era be able to assess the size of a pelvis on vaginal examination? How many of the modern day doctors and nurses would be able to listen to a heart carefully enough to hear a pericardial rub, or a quiet murmur? They don’t need to, because they just do an echocardiogram.
Jobbing Doctor teaches medical students. This includes the examination of many of the cranial nerves (well, II – VII inclusive) and the neurological examination of the limbs. I used to think that we weren’t the best people to do this, and hospital doctors might be better, because they do these all the time. I’m beginning to think, however, that we are some of the few remaining clinicians who can make a diagnosis without having to get a test to prove it. Teaching medical students is a good way to keep your examination skills up.
Are we teaching clinical examination as a pointless exercise? Will some of the most wonderful eponymous skills be lost? Lhermitte’s sign. Phalen’s test. Chvostek’s sign. And who could ever forget the amazing sign of Whispering Pectriloquy? These will end up just as scrabble words.
My hospital doctor friend has reminded me that medicine changes. I am regarded as impossibly medieval by my colleagues as I write with a fountain pen, have a half pint bottle of ink on my desk, and have a rocker blotter. I also take blood pressure using my ears, stethoscope and a mercury sphygmomanometer.
I listen to a chest with the intention of assessing what I hear, and not doing it to go through the motions.
The Jobbing Doctor is a general practitioner in a deprived urban area of England.
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