"But Whatever Happened to Physical Diagnosis?"
OLD DOCTOR AS PATIENT
With apologies to Sir Archibald Doggerel, OSJ,OBE
In the ER against my will
the doctor there stood tall and still
around his neck a stethoscope
which quickly gave me added hope
But it was just a decoration
like a TV show sensation
What's your name? Where do you hurt?
listened to my lungs right through my shirt
through the shirt, through the blouse
is he the only doctor in the house!?
Checked my liver with his knuckle
didn't know it's my belt buckle
Off to X-ray for a scan
then ABGs, is that a plan?
Why not have me just undress
check my heart, lungs, and the rest
ask me if my toes are numb?
I may be old, but I'm not dumb
I'm a patient, show some caring
save me from my silent swearing
maybe it's my own neurosis
but whatever happened to physical diagnosis?
George Finlayson,MD
Dr. Finlayson (alpha omega alpha, Western Reserve University, 1953) is retired from practice in Internal Medicine.
Thanks to Alpha Omega Alpha's The Pharos, the first publisher, for permission to reprint the poem from the Summer 2006 issue in this blog.
This poem clearly reflects several wrong medical professional behaviors which unfortunately can happen, and perhaps not uncommonly. First is the usual "rush" in emergency room attention and care which if not controlled can lead to taking inadequate amount of time for a necessary history and performing an appropriate physical exam. But then, this doesn't have to occur in an emergency room but also in a busy doctor's office. Then the rush to the next patient continues with requesting testing with an order but without a thought out and supportive physical diagnosis. (In other words, the testing is believed to make up for the inadequate history and physical.)
Finally, there is the VIP treatment sometimes given to physician patients where the attending physician may, for one reason or another, not wish to disturb the patient with taking a detailed history or subject the doctor patient with what the attending doctor might consider an embarrassing or uncomfortable or overly detailed physical examination.
The old doctors had less tests and more time and more attention to the patient. Whether they could do a better job in diagnosis and treatment of the disease than more modern medicine is doubtful. But one thing is clear, they had the time to do a better history and physical and their treatment of the whole patient might be looked upon as superior. What do you think? ..Maurice.
posted by Maurice Bernstein, M.D. @ 4:14:00 PM
7 comments
7 Comments:
I think that's BS (respectfully because you appear to be sincere person, Dr. Bernstein). I don't want doctors to treat the "whole me." If I have a problem, I want it fixed. If they can't, I want to know what they plan to do and what evidence based protocols support their recommendation and what probabilities of success.
And, if we can avoid a physical with more tests so much the better. Physical exams are a bit of a degradation.
Doctors are presumptious. They aspire to priest/magician/uber scientist--and given current reimbursement incentives will fail at all three. I think if they aspired to be plumbers we'd all be better off.
Anonymous, of course, I understand that you would want your problem "fixed" and so would virtually all other patients. However, considering the "whole patient", both the physical and the emotional is what medicine is all about since both components are part of the person and involved in the disease or burden that the patient carries. Doctors in the past with more time and less pressures from HMOs, could treat the "whole patient" much better at the time but obviously they were missing some of our current diagnostic techniques and medical procedures and medications.
You are wrong, however, if you think that tests will ever replace or encroach heavily on the practice of performing physical examinations. It is the physical exam, in addition to the patient's history, that directs the doctor to the appropriate test which is then used to either support or rule out a tentative diagnosis.
If patients feel that the physical exam is a "degradation" that is a matter of how the process is carried out in the doctor-patient relationship. If there are elements in the process that need to be corrected, either by the patient or the doctor to mitigate "degradation" and to make the experience truely productive and comfortable for both parties, they should be acted upon.
Yes, in some ways doctors are "presumptious" but not in the roles you describe. We must make certain presumptions in the establishment of a diagnosis and in the decision of what to tell the patient about reasonable treatments. Both are open to many variables physicians can't know or control and so we are left with presumptions. If students who desire to become physicians start out with the aspirations you describe, they will soon loose all that once they get into the "down and dirty" frontlines of what medicine is all about.
Finally, I'm not sure that plumbers would ever want us in their guild. ..Maurice.
Pertinent post!
As an ancient retired doc I recalled days when I spent a full hour with a patient, spending 25% of your time obtaining the history, 50% in the physical exam from checking every square inch of the skin to your toe, to your finger in the anus, the next 15% for consultation and recommendations. The rest are spent on your notes and often your texts or journals.
We depended as well as our tools: instruments, labs, x-rays.
Today the tools often are used as products that many will evaluate as results.
As we improve and marvellous inventions offer more for us, we should never substitute our learning over technology.
With little time nowadays, minutes will have to valued in using the touch and look that still diagnostic judgement will be better than the lab in the distant future.
Dr. Bernstein, I think that a lot of tests (and referrals to specialists) would be unnecessary if the physician just simply took time to observe for a few seconds.
At first glance, simple things can look far more complicated than they actually are, and complex things can seem deceptively simple. A physician who doesn't watch, listen, poke and prod ... may not even know which questions to ask.
Sometimes, it appears that physicians use tests as a way to put distance between themselves and their patients ... and rather than a diagnostic tool used by a medical professional, the test becomes the diagnostician, and the physician becomes a mere technician who interprets it.
That sort of medicine is not only impersonal, it's also incomplete.
Unfortunately, it appears to the inexorable direction medicine is taking today ...
A Consumer Reports publication reminds its readers that a "hands on" physical exam by the doctor "can detect ailments no amount of X-rays or CT scans can." The publication suggests that there are parts of the physical exam that physicians sometime omit but they should be omitted. The publication advises that readers should make sure their physicians:
"examine your thyroid, examine the back of your eyes, feel for enlarged lymph nodes in your armpits, neck and groin, check your pulse in your wrist, neck groin and feet and listen for bruits [abnormal sounds suggesting arterial blockage] in neck and abdomen."
Good advice. But would you feel up to giving this advice to your doctor? ..Maurice.
The client states:
"Doctors are presumptious. They aspire to priest/magician/uber scientist--and given current reimbursement incentives will fail at all three. I think if they aspired to be plumbers we'd all be better off."
Let me kvetch. I work for the approval of only one person - the patient. Reimbursement is not the reward - it is the thrill of achievement, a thrill that has become disreputable (as cocaine and sexual indulgence have become honorable pastimes.) That's what I do. So sue me.
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