Elizabeth Eisenhauer, Professor of Oncology at Queen’s, shared with me an op-ed piece from the New York Times by Abraham Verghese, a Professor for the Theory and Practice of Medicine at the Stanford University School of Medicine. Published last February and entitled, “Treat the Patient, Not the CT Scan,”1 the article focused on the need for medical educators to constantly remind us, and our learners, of the importance of the physical exam. Verghese opined that Watson, the computer of Jeopardy fame, might well be just as good, or even better than a physician at arriving at a diagnosis. Watson, Verghese reminds us, would have access to the entire data set of all patients in the hospital. It would also be constantly digesting current information from the web, and would be able to, in an algorithmic fashion, prioritize diagnoses and treatment for any patient.
But Verrghese goes on to say that “this computer record creates what I call an “iPatient” — and this iPatient threatens to become the real focus of our attention, while the real patient in the bed often feels neglected, a mere placeholder for the virtual record.” He suggests, that Watson may have not been able to answer this Jeopardy question “An emergency treatment that is administered by ear… What are words of comfort?”1
Jill Max, from Yale Medicine, agrees with Verghese. She suggests, “Physicians once relied on seeing, hearing and touching a patient to make a diagnosis. Technology has enhanced and sometimes replaced those skills, but many doctors lament their decline.”4 She tells the story of a young patient who presented with pulmonary embolism. He was admitted to hospital and had every test known to mankind, all of which were negative. Then, an experienced physician, noticing that the patient was muscular, did what is known as an Adson’s test. She reports… “Duffy, professor of medicine (hematology), had an idea what the problem might be. To confirm his suspicions, he performed a simple test known as Adson’s maneuver: With the patient’s arm straightened, Duffy placed a finger over the pulse at the wrist and then moved the arm behind the young man’s back. When he asked the patient to turn his head, the pulse disappeared; when he looked forward, the pulse returned. Duffy deduced that the man was suffering from thoracic outlet syndrome, a compression of the blood vessels beneath the collarbone that cuts off blood flow to the arm. Surgery repaired the problem.”
To be sure, we at Queen’s, as at every other medical school, go to great pains to teach our students the art and science of history taking and physical examination. In fact, we have a whole center dedicated to that element of our curriculum. But often, as soon as our students get to the wards of a hospital, they end up spending countless hours of their day in front of a computer. There is a risk that all of our teaching about the importance of the history and physical can be undone by the focus on “the data” and our obsession with technology.
Jennifer Gibson, in her Brain Blogger Feed column, suggests “the health care system and its practitioners are under increasing pressure to provide efficient, effective, and consistent care to patients. Patients want to be treated as an individual, not a case number.”5
We have long since been convinced that “patient-centered care” is fundamental to modern medical practice. Undoubtedly holding dearly to the long held art of the physical examination is central to patient-centered care.
If you have any stories about your experiences with importance of “the physical examination,” please share them with our readers, or better yet, please stop by the Macklem House…my door is always open.