THE SIX PILLARS OF CLINICAL MEDICINE – PART ONE
Medicine and progress within it, is based on six pillars - the three pillars of diagnosis – the history, physical examination and investigation, the pillar of treatment, and the pillars of research and teaching. Without any of those six pillars, medicine would come to a hault.
I propose in this section that, part of the crisis of modern medicine lies in deficiencies relating to those six pillars, and that only by remedying them will its progress be restarted. In this first part, I discuss the first four pillars. I will discuss the other two in a separate section.
THE FIRST FOUR PILLARS
We are often told that the history gives away 80% of medical diagnoses (with the physical examination giving away about 10-15%, and investigations giving away 5%). We are often told that, “of all the technical aids which increase the doctor’s power of observation, none comes close in value to the skilful use of spoken words – the words of the doctor and the words of the patient”, as Brian Bird tells us in his book, ‘Talking with Patients’.
Alas, the 20th century has seen the demise of a lot of beautiful things, and one of them unfortunately is clinical acumen. The view that the history and physical examination give so much of the diagnosis cannot be upheld in this day and age. It’s more honest to say that they contribute to the diagnosis, but they certainly do not contribute to the kind of proportions of diagnosis that those who wish to believe in those proportions say.
The only field that has been spared the assault of the ‘investigator’ is probably just dermatology, a fact well pointed out by Professor J L Rees in the 17th edition of ‘Davidson’s Principles and Practice of Medicine’, “Dermatology is still, along with (arguably) psychiatry, the branch of medicine most heavily dependent on clinical skills”. He modified his view, when collaborating with O.M.V. Schofield in writing the dermatology chapter for the 20th edition of the book, saying, “as a general rule clinical skills, especially visual recognition, are perhaps of greater importance than in any other branch of general medicine” (perhaps under a better understanding of psychiatry, where diagnosis could be so variable among its most prominent specialists). Surgery too is a very clinical specialty; we are yet to devise an instrument that can diagnose appendicitis, or give an accurate description of a lump, or ulcer. But there are far more surgical conditions, than dermatological conditions, that require investigations for diagnosis.
The neurologist would like a share of that cake, of king of clinical acumen. While this possibly was the case, or should be the case, it is no more, having observed neurologists (and neurosurgeons) at work for the greater part of the last year. From what I have seen, they are the kings of investigation. I have worked in nearly every single medical specialty (with the exception of endocrinology, which I will have the pleasure to work in in a few months time) and I am yet to see anyone order as many tests as the neurology consultant or registrar. This, I am glad to say, is something the retired neurologist David Thush pointed out in a recent article in the BMJ Journal, ‘Practical Neurology’:
“When I was a medical student in the 1960s it was drummed into me that the diagnosis was made from the history, examination and special investigations, but the most important was the history. Despite the explosion of advances during the past 20 years, this is still true today, at least in clinical neurology, and yet histories are becoming increasingly shorter and they are frequently inadequate and incomplete…Medicine is becoming more mechanical. Protocols and guidelines proliferate at an alarming rate and the emphasis has switched from the history to multiple screening tests and scans. It is now difficult to be seen in the outpatient clinic or as in-patient without having thyroid function tests, B12, folate and auto-immune and clotting screens included in the routine bloods! Only the VDRL appears to have escaped from the screening profile, though even this lingers in a few centres of excellence. Such an undisciplined approach not only wastes time, money and resources but also an abnormal result may lead the inexperienced doctor on a wild goose chase.”
Many of those tests are extreme - extremely advanced (such as the PET scan), extremely painful (such as the ischaemic lactate ammonia test widely used for investigating patients with suspected muscle disease, and “involves measuring plasma lactate and ammonia produced as a result of forearm exercise under ischaemic conditions in a lasted subject” (not to say a lumbar puncture in inexperienced hands), extremely expensive, extremely demanding (I used to dread it when one of my heavily investigative neurology consultants requesting a ‘phenylalanine’ test – which I will leave the kind reader to read about to appreciate its burdens on the doctor and the patient), or extremely exotic (in terms of location – some of the neurologists tests here in England can only be analysed in France or Germany).
While it is claimed that “neurological history is the key to the diagnosis. The history involves not only questioning the patient but also careful observation. Many neurological illnesses can be diagnosed just by observing the patient”, that in neurology, “clinical skills remain more important than in most specialties. For example, the prime diagnostic criteria remain clinical in disorders such as epilepsy and migraine”, that investigations like CT scans “will take away the shadows of neurology, but the music will still remain" - that is certainly not the real truth.
It would be ideal, and indeed neurology has the potential to be one of the most clinical of specialties. As I said in a previous essay, “perhaps the importance of clinical diagnosis was best illustrated by the large study conducted by Chimowitz et al in the early 1990s, which showed that investigations failed to clarify the diagnosis in more than half of the selected patients. I hasten to add that there is another doctrine in neurology; that “a second examination is the most helpful diagnostic test in a difficult neurologic case””. However, it certainly isn’t at the moment; no neurologist today would send a patient who has had a seizure home without an outpatient MRI (or at least CT-scan). Hence primary epilepsy, while potentially a clinical diagnosis, has been transformed into a diagnosis of exclusion; the diagnosis you are left with once you have done all the necessary investigations.
Even with migraine – many neurologists today would consider some form of imaging to ensure there is no intracranial pathology before making that diagnosis. This is hardly display of clinical acumen. The classical music that it was is not there anymore, being replaced by a brand of akin to poor rock ‘n’ roll or metallica. However, I hasten to add that while I do not agree with this attitude of neurologists, I do understand why they over-investigate.
Thankfully, some specialists are becoming more honest about their specialties, and knowing that giving the clinical acumen so much importance is a thing of the past. Gastroenterologists now believe that a figure of up to 50% is right in terms of the diagnostic usefulness of history taking, not 80%. One textbook of gastroenterology put it thus:
“The key to accurate diagnosis and effective management of gastrointestinal problems is flawless history-taking. Since up to 50% of gastrointestinal disorders are associated with no anatomical change, no physical findings and no positive test result, diagnosis and therapy must often be based on the medical interview”.
In cardiology, the world of clinical acumen takes a completely different complexion. I remember listening to a consultant cardiologist in Newham University Hospital who when speaking to one of his gastroenterology colleagues, confessed that he never pays attention to the patient’s description of chest pain (the cardinal symptom of cardiology). The demise of cardiac clinical examination was predicted as early as 1962, by the great cardiologist Dickinson Woodruff Richards, who was a co-recipient of the Nobel Prize in Medicine in 1956 “for the development of cardiac catheterization and the characterisation of a number of cardiac diseases”. He remarked in the ‘Transactions of the Association of American Physicians’:
“One might appropriately consider the stethoscope as a symbol of another skill or set of skills, that appears to be fast disappearing from our medical scene. This is the use of our five senses, the use of simple perception, or observation”.
Both the demise of history taking and physical examination are discussed in a hilarious fashion by John Larkin, a consultant physician in his brilliant book, ‘Cynical Acumen’:
"The heart is dead easy. If you ever actually meet a cardiologist, it shouldn't take long to realise that an abundance of neurons is no prerequisite for success in the specialty. Admittedly, it is partly because they have largely abandoned all semblance of clinical assessments, pinning their diagnostic decisions on the outcome of mod-tech investigations such as echocardiograms and exercise tolerance tests. A cardiological colleague of mine admitted recently he has used his stethoscope only one in the last three years, and that was at a medical conference in Buenos Aires to kill a tarantula….Cardiac history taking is simple...this is why cardiology outpatient appointments are usually over within ten minutes of the patient crossing the threshold (even allowing for one interruption on the consultant's mobile from his stockbrocker). Basically, it boils down to whether or not you have chest pain. If you do, you have an exercise tolerance test and maybe an angiogram. If not, an echocardiogram and maybe a 24-hour tape. Unless of course you see the cardiologist in a 'private' hospital, whereupon you automatically have all four tests organised - even if you're just the guy who's come in to fix the radiator".
It would surely be much more satisfying if the various medical specialties were to return to their grass roots, to the “careful hearing to his (the patient’s) problems and a caressing hand”, to a world where a test is only ordered if absolutely necessary, and “only if it is clear that the result will influence the patient's management and the perceived value of the resulting information exceeds the anticipated discomfort, risk and cost of the procedure,” the world that Lewis Mehl-Madrona, an Associate Professor of Family Medicine and Psychiatry based in Canada wondered about, where the patient “might have told us about his illness and his recovery”, a world where “listened more and measured less”. This will have the added bonus of reducing the cost of health care, and bring the doctor a greater sense of satisfaction, for diagnosis becomes a personal triumph. As Professor Raymond Tallis brilliantly put it, “Technology is no individual practitioner’s intellectual property. Whereas a diagnosis I make using my clinical acumen is somehow my own, the one that I read from a report manifestly is not my own”.
Alas, this will not be the case until certain things are recognised, and certain things are remedied, for a number of reasons.
The decline of the efficacy of history taking is not related to any decline in the ability of new doctors to ask the right questions, or to take a history. Medical schools and postgraduate exams ensure that this skill is well established in the individual prior to qualification. I think the problem lies somewhere else, namely the patient.
History taking is not simply a yes-no exercise. It is a very powerful tool, which is affected by the patient’s intelligence, and linguistic, educational and social factors.
We live in the age of the declining intelligence of man. Patients, being members of the human race, are therefore becoming less intelligent. Many seem unable to tell the difference between a sharp pain and a dull pain, a productive cough and a vomit, a faint and a dizzy spell. Some don’t even know where their pain is; how many times have we the juniors seen the patient point to one region of the abdomen as the site of pain, only for it to change a few minutes later when the consultant arrives into another site (and report “it was never in that site” (that they were pointing to earlier), making one look very silly and improficient. This happened to me one night recently, when I saw a young lady come with what sounded like appendicitis, with pain in the periumbilical region, only for it to change later when the surgical SHO came down, saw the patient, diagnosed gastritis and cursed me for an inappropriate referral (it is easier to move a mountain than get a surgeon out of his bed sometimes). I can only attribute this case to a deficiency on the patient’s side (on a side note, I do not know as yet how he, my curser, explained her raised white cell count, her fever, and her general feeling of unwellness; unfortunately, the patient self-discharged and left our diagnostic dilemmas unresolved).
I do not blame the cardiologist who thinks descriptions of chest pains are redundant, a conclusion he or she comes to by seeing thousands of patients who do not fit the ‘classical’ description of cardiac chest pain - patients who describe their pains as sharp, stabbing, only to have a raised troponin and abnormal angiogram, and patients who describe their pains as 'exertional and like a pressure', radiating to the left arm, with sweating and shortness of breath – the classic description of myocardial ischaemia, only to have a negative ETT (in other words, insignificant ischaemia). How many times have we, the juniors, seen obese Bengali ladies come with pain all over, or slim Pakistani men coming with abdominal pain, only to be diagnosed with an MI afterward and ending up in CCU? I can't help quoting the brilliant John Larkin yet again:
"Cardiac pain is tight...heavy...gripping...the patient clenches his fist involuntarily when describing it (a dead giveaway) ...it radiates into the jaw..and particularly the left arm" All essentially true, but basically useless. Why? Because everybody knows all that. Everybody. That includes the patient. A generally unrecognised feature of the medical consultation, when we take a history in order to elicit a diagnosis, is that such diagnoses are made by knowing something about their symptoms that the patient doesn't. This isn't simply an exercise in one upmanship. Once the patient has decided that they have, for example, angina, they will be delighted to give you the story that they know you want to hear. Thus you will only be making the diagnosis that the patient has already made for him - or herself - and what is the point of that? You might as well cut out a middle man and let them do their own coronary artery bypass graft (a study vetoed by a decidedly overzealous Ethics Committee in my last hospital). Symptoms lose their value once the patient knows about them. To my mind the best example of this is the 'pain going down the left arm' fallacy, and I present it thus:
IF A PATIENT VOLUNTEERS (I.E. BEFORE YOU HAVE ASKED WHETHER) THAT A CHEST PAIN GOES INTO THEIR LEFT ARM, THEN THAT PAIN IS LESS LIKELY TO BE CARDIAC
They've all read about it. They've all seen Superman’s Dad having a heart attack consisting entirely of left arm pain (beautifully underplayed by Glen Ford). It’s not that you can’t trust patients (though we will be assessing this concept later). It’s just that you can no longer trust the symptom. It has lost…the element of surprise. Far be it from me to outcrazy the retired General in Airplane who refuses to put on the landing lights to help the stricken passenger aircraft because “that’s exactly what they’ll expect us to do...” But I stand by the contention that the pain-going-right-down-the-left-arm pointer no longer points in the right direction.”
I also believe the patient has a big part to play in the decline of the physical examination. It is because of the all too frequent complaints about the ‘attitude’ and communication skills of doctors made by patients that have made medical schools shift the focus from a refinement of clinical acumen to a focus on communication skills. Medical schools and related societies wish for the medical profession to survive, and for its members to be appreciated by society, even if it means a sacrifice of some of its principles, one of which is the emphasis on the importance of the clinical assessment of the patient. They cannot really be blamed for this; all studies and audits of patient complaints show that poor communication is by the most common reason for them. Even when clinical care is substandard, it is poor communication, not the clinical care they receive, that causes patient dissatisfaction; as one recent study showed:
“The majority of the complaints were directly related to clinical care, poor communication, attitudes of staff and nursing care. However, 99% of patients were satisfied with an explanation and an apology indicating that almost all have been due to a lack of good communication than due to real deficiencies in the clinical care. The hospital management has investigated the majority of cases within 20 days and has made several policy changes after the investigations.”
It is at least partly due to this new emphasis that physical examination skills have declined, affecting even our consultants, in whom the decline of such skills can often lead to a great deal of embarrassment, and rebound distrust by the patient, which can only reflect negatively on the doctor-patient relationship; the patient will then come to believe that only a test, a machine or analyzer, will tell him or her exactly what is wrong, to the further detriment of clinical skills and the great pleasure of the machine. I recount fully here an anecdotal story that happened a few months ago, which I emailed to my friends:
“I was on a ward round with a young consultant physician about 6 months ago, and we encountered a patient who was seen by my colleague, who was clearly not jaundiced. Even a blind man could have said that. My colleague went through the history, and the patient’s blood results. She noted his bloods at 7 am - she was very tired and mistakenly wrote his bilirubin at 111. The consultant noted this and then announced to us, "Yeh, I thought he looked jaundiced". He was not jaundiced - and with a bilirubin of 111, he would be a lemon, not just jaundiced. I could not believe it. So, I went across to the nearest computer terminal, looked at the results. Bilirubin - 11. I was in two minds - shall I tell the consultant the true result, or shall I leave him with the satisfaction of diagnosing 'jaundice' through his 'clinical expertise'. I had to tell the truth, and I can't describe how bad I felt for him. He didn't show much of a response. I felt so bad, I couldn't even ask him if he wanted to cancel the liver screen he requested in view of the ‘clinical jaundice’ and false result. I left it at that.”
Even today at work, a patient I saw who had a testicular lump, who was examined by two different GPs in the space of one month; the first diagnoses a varicocele, the second (with the lump showing no change) diagnosed epidydimorchitis, and gave his antibiotics. The patient came to hospital (accident and emergency) because he wanted an expert opinion; he has a feeling now that, because there is so much variability between what GPs say, he cannot trust them (Clinically I could not tell what it was myself, although the best I could do was arrange and ultrasound scan to comfort the patient, knowing that it is more sensitive than our declining clinical examination skills). He reminded me of the famous words of that great master of verse, Omar Khayyam:
“Myself when young did eagerly frequent
Doctor and Saint, and heard great Argument
About it and about; but evermore
Came out by the same Door as in I went”
I myself have noted this interobserver variability first hand; working for a cardiology firm which had three cardiology consultants, where all those three would see the same patient on different days of the week, and their cardiac ausculatation examination findings would read as follows (until the echocardiogram shows ‘the truth’):
Day 1 – Heart sounds I—II. Ejection systolic murmur radiating to right carotid
Day 2 – Heart sounds I-II. No added sounds. No murmurs
Day 3 – Heart sounds I-II. Pansystolic murmur with diffuse radiation.
How many of us are guilty of looking at the chest X-ray first, which showed bilateral pleural effusions, before seeing the patient and documenting in the notes “reduced expansion bilaterally, stony dull to percussion, reduced air entry bibasally, with area of bronchial breathing above dull areas” (in practice, no one checks for TVF or vocal resonance any more), as if to illustrate our clinical brilliance, when we probably never heard what bronchial breathing sounds like or never tapped any stones. How about the gentleman who has been drinking 50 units of alcohol a week for many years, who we expect to have a degree of hepatomegaly before palpating his abdomen, and whether we have felt big livers before or not, ‘hepatomegaly’ becomes a feature of our examination findings. What about the 80 year old gentleman who has bilateral ankle oedema and is coming short of breath - bibasal coarse crackles becomes an instant expectation and maybe even ‘imposed’ on the patient, with the knowledge that very few people of that age group are spared a degree of cardiac impairment. If he was exposed to asbestos (based on the history), many a medical mind, working backwards, would transform those coarse crackles into fine crackles. If he was a smoker, he's got that and a bit of a wheeze, or he had it before he was cured by your ingenious administration of your harmless salbutamol nebuliser – knowing that very little if any harm could be caused by that; If anything, it may have a placebo effect - after all, you're the doctor, and you told the patient it will make them feel better - and if the patient is 'better' after you have given it, it will look good on you. The wheeze that wasn’t there in the first place is not there when the consultant listens to his chest, and so he has increased trust in your management. You win both ways.
I once saw a patient with florid pulmonary oedema. A just qualified doctor who wanted to impress the final year medical students with his clinical acumen takes them to listen to his chest. He takes his mammoth stethoscope, listens over the chest and reports back, pointing to the regions involved, "Coarse crackles right base, fine crackles left base, and bronchial breathing in the right midzone". The poor medical students were convinced, and impressed. I knew the patient’s diagnosis myself, and had listened to his chest earlier. I proceeded to examine him again, in the fear that he might have developed new signs. He displayed none of them - it was just a wet chest, what was expected.
It cannot be denied that our expectations influence what we feel and hear, but there is the ever so small probability that we never felt or heard anything in the first place!
As can be seen this is a major problem with the physical examination; there is a great deal of interobserver variability. The patient perceives this as a great deficiency, and he or she will never be satisfied until a test is performed.
The transformation of medical practice into a kind of supermarket for the customer, whose satisfaction is the only important thing, has meant that tests are arranged to please the patient and reassure them. Nothing will satisfy or reassure many patients complaining of chronic tension headaches, which are so obviously tension, other than a CT-scan of their head. Nothing will reassure the patient who is so obviously tired for non-medical reasons, who has heard of hypothyroidism from one of her friends, other than the result of TFTs. They are under the incorrect assumption that those tests are 100% sensitive and specific, which we all know they are not. There is a great deal of inter-observer variability even with those tests, a fact that ultimately tells us that there is no way that one can achieve the truth in medicine – a very important philosophical concept that I will discuss in another section. The interobserver variability of some of those tests we so cherish as gold standards was highlighted brilliantly by Steven McGee, an associate professor of internal medicine in the University of Washington:
“For most of our diagnostic standards – chest radiography, computed tomography, angiography, magnetic resonance imaging, ultrasonography, endoscopy, and pathology – interobserver agreement is less than perfect…Even with laboratory tests, which present the clinician with a single, indisputable number, interobserver agreement is still possible and even common, simply because the clinician has to interpret the laboratory test’s significance. For example, three endocrinologists reviewing the same thyroid function tests and other clinical data of 55 consecutive outpatients with suspected thyroid disease, the endocrinologists disagreed about the final diagnosis about 40% of the time. Computed interpretation of test results performs no better: in a study of pairs of electrocardiograms taken only 1 minute apart from 92 patients, the computer interpretation was significantly different 40% of the time, even though the tracings showed no change…So long as both the material and the observers of clinical medicine are human beings, a certain amount of subjectivity will always be with us”.
The other explanations for the rise in investigations, besides the decadence of our clinical skills, reduced trust of patients in our clinical judgment, and the desire for patient satisfaction, include our realization of the rarity, if not the absence of pathognomonic signs. There are very few illnesses with clear pathognomonic features. A lot of illnesses share the same clinical manifestations, and more invasive investigations are necessary to separate them. Also, as the study and practice of medicine evolves, we are finding out that many of the symptoms and signs that were previously labelled as ‘pathognomonic’ by our predecessors are actually not so.
For instance, we were all taught in medical school that Virchow’s node, an enlarged hard supraclavicular lymph node is pathognomonic of gastric cancer; this is now recognised to be false, and it has a differential diagnosis which includes lymphomas, various intra-abdominal malignancies (such as pancreatic), breast cancer, lung cancer, and infection (e.g. of the arm). We were taught that jaw clicking is pathognomonic of TMJ syndrome, but now we recognise that, “Although often present in TMJ syndrome, jaw clicking is not pathognomonic since many people who have jaw clicking are asymptomatic”. Roth’s spots, white centered retinal hemorrhages considered by some to be pathognomonic for subacute bacterial endocarditis, are now recognised to “appear in leukemia, diabetes, and many other conditions”. Another former sign that used to be believed was exclusive to infective endocarditis is Osler’s nodes, but, “Although first described in association with
infective endocarditis, and always looked for in this disease, Osler's nodes are not pathognomonic of this condition since they also occur in typhoid fever, gonococcal infection and systemic lupus erythematosus.”
Speaking of Osler in this context, he remarked in his brilliant ‘Aphorisms’, “One swallow does not make a summer, but one tophus makes gout and one crescent malaria”.
This is also now recognised to be untrue, as evidenced by many recent articles, such as an article entitled simply, ‘Tophaceous pseudogout (tumoral calcium pyrophosphate dihydrate crystal deposition disease)’, published in the journal ‘Human Pathology’ (1995 Jun;26(6):587-93) and another published in the journal of ‘Dermatological Surgery’ (2002 Jul;28(7):636-8) entitled, ‘Gouty tophi: a squamous cell carcinoma mimicker?’ which showed “the first report of gouty tophus of the periungual region presenting as a hyperkeratotic lesion. Initial clinical diagnosis favored SCC and histologic evidence suggested a possible early SCC”.
The following table from one online encyclopaedia article shows all the so called ‘pathognomonic’ signs, but precedes it with the statement, “None or very few of the examples here are pathognomonic in the true sense of the word. For example, Parkinsonism is not only seen in Parkinson's disease.”
Duchenne's Muscular Dystrophy
Trousseau sign and Chvostek sign
Systemic Lupus Erythematosus
Chipmunk facies (parotid gland swelling)
Leonine facies (thickened lion-like facial skin)
Pseudomembrane on tonsils, pharynx and nasal cavity
New bilateral Exophthalmos
Cullen's sign (bluish discoloration of umbilicus)
Chronic hemorrhagic pancreatitis
Grey-Turner's sign (ecchymosis in flank area)
Rose spots in abdomen
Kernig's sign and Brudzinski's sign
Levine's sign (hand clutching of chest)
Patent ductus arteriosus
Pain produced with attempts to sleep on one's back
Acute Myeloid Leukemia
Bilateral internuclear ophthalmoplegia
The recognition, through evidence based medicine that some disorders can never be diagnosed clinically is probably the one thing that has given a death sentence to the exclusivity of clinical skill. Investigations are absolutely necessary.
For example, looking at the evidence base for the diagnosis of deep vein thromboses, Ball and Phillips (2002) state that, “DVTs cannot be safely diagnosed or excluded on history and physical examination alone. Imaging studies are necessary”. Looking at aortic dissection, they state that, “no individual sign or symptom is very helpful in diagnosing aortic dissection”. Sometimes a major surgical procedure can be the investigation tool; a good example is the appendicectomy; there is still a significant number of negative appendicectomies done – mainly because the historic and physical examination findings are inconclusive.
Another reason for the ascent of investigations no doubt has to be the ascent of the overwhelming cloud of litigation. A few years ago, Judge Fallon was quoted by Oscar Craig, the Chairman of the Cases Committee in the Medical Protection Society to have said:
“I am glad to say that in this country there is no need to carry out unnecessary tests as a form of insurance. It is not in this country desirable, or indeed necessary, that over protective and over examination work should be done, merely and purely and simply as I say to protect oneself against possible litigation”
I don’t know how true that was when it was first said in the 1990s, but it certainly is not true now. Indeed, protecting oneself against litigation is a reason given by N. J. W. Cheshire and C Bicknell as reason to request investigations in the last edition of ‘Clinical
Surgery in General’ (published in 2004):
“Although you may be certain in your own mind about the diagnosis and appropriate management, you may need to protect yourself against future claims of incompetence against you, or the patient may wish to have objective evidence available in claims against a third party following, most commonly, an accident”
Investigations have also become of great importance in the screening for specific disorders (i.e. detecting those patients with sub-clinical abnormalities before they manifest themselves in symptoms, signs and more serious pathology) as well as excluding serious potential causes of symptoms and signs. For example, the entire practice of breast surgery is based on the following axiom: “all patients should be assessed by triple assessment”. This is all done with one aim in mind - to exclude or detect breast cancer early, as “delay in the diagnosis of breast cancer is now a common reason for patients taking legal action against medical practitioners”(p.6). Any elderly patient complaining of rectal bleeding or features of anaemia must nowadays have a full endoscopic assessment of their bowels. The central axiom of colorectal surgery is: any elderly patient with iron-deficiency anaemia or presenting with rectal bleeding has colorectal cancer until proven otherwise. Even if the most blatant haemorrhoids are seen, we are advised by arguably the biggest figure in gastroenterology in the world, Dr. Kurt J. Isselbacher, the Mallinckrodt Distinguished Professor of Medicine at Harvard Medical School, that “they must not be regarded as the cause of rectal bleeding or iron deficiency anaemia until a thorough investigation has been made of the more proximal gastrointestinal tract”.
All of those, and others, are the reasons for the rise in investigations. Because they all carry risks, and for other reasons I mentioned before, it would be more welcome if clinical assessment itself takes a bigger part to play in diagnosis. It will be impossible, and indeed wrong to stop doing investigations altogether; that would mean a return to the medicine of our ancestors. But, by augmenting the power of the history and physical examination there will be a lot of improvements to medical care as it stands. Our patients’ mentality needs to be changed too, but that will be a lot more difficult than the changes I propose with regards to the history and physical examination.
This, I feel can only be accomplished by a scientific approach to history taking and physical examination. We have too much respect for tradition, and as Osler brilliantly put it, “We doctors have always been a simple, trusting folk! Did we not believe Galen implicitly for fifteen hundred years and Hippocrates for more than two thousand years?”
It is only in the developmental of sceptical, scientific attitude towards all that we cherish in our history taking and physical examination that we will cause them to progress. This will improve our diagnostic skills significantly, and help us retrieve the trust of our patients that was once the case, and reduce the sense of dismay that many have developed towards doctors over the years.
Take for instance Tolstoy, when he describes Ivan Ilych and his doctor in his brilliant story of that name:
“Then dropping his former playfulness, he begins with a most serious face to examine the patient, feeling his pulse and taking his temperature, and then begins the sounding and auscultation…Ivan Ilych knows quite well and definitely that all this is nonsense and pure deception, but when the doctor, getting down on his knee, leans over him, putting his ear first higher then lower, and performs various gymnastic movements over him with a significant expression on his face, Ivan Ilych submits to it all as he used to submit to the speeches of the lawyers, though he knew very well that they were all lying and why they were lying.”
In the novel ‘Silent Snow, Secret Snow’, Conrad Aiken described a patient, Paul Hasleman, who developed schizophrenic hallucinations, who:
“Despite his psychotic state, the boy retains sufficient insight to understand that Doctor Howells, who has been summoned because of his 'curious absent-mindedness' is approaching the problem from the wrong angle. He: "stood before the doctor under the lamp, and submitted silently to the usual thumpings and tappings. "Now will you please say 'Ah!'?" "Ah! “Now again please, if you don’t mind.” “Ah.” “Say it slowly, and hold it if you can” -- “Ah -- h -- h -- h -- h” -- “Good.” How silly all this was. As if it had anything to do with his throat! Or his heart or lungs!””
If medicine is to retrieve its former glories and degree of respectability, it ought to ground itself in true scientific principles, and true science, as the great Miguel de Unamuno stated “teaches above all, to doubt and to be ignorant”. A true scientific approach will not care for the great names of Virchow or Osler (whose nodes are not pathognomonic), of Murphy or McBurney or Homan (whose signs have been shown to have sensitivities as low as 48%, 50% and 10% respectively), but only for the truth. Abraham Flexner put it well back in 1910:
“Scientific medicine…brushes aside all historic dogma. It gets down to details immediately. No man is asked in whose name he comes – whether that of Hahnemann, Rush or of some more recent prophet. But all are required to undergo rigorous cross-examination. Whatsoever makes good is accepted, becomes in so far part, and organic part, of the permanent structure”.
Indeed, it is “the critical sense and sceptical attitude of the Hippocratic school (that) laid the foundations of modern medicine on broad lines”, as the great Osler correctly pointed out.
A scientific approach to history taking will mean understanding why certain symptoms present as they do. We get taught in medical school how the various diseases present, but rarely do we have an explanation of why this particular presentation of this symptom occurs. If we have that grounding, we would be more able to make certain diagnoses. Scientific history taking may explain to us why certain patients present the way they do. It might suggest to us that symptom description is not a valid method of helping in diagnosis. For instance, maybe ischaemic cardiac pains can be sharp in some, tearing in some, pleuritic in others, rather than the central crushing chest pain we are taught about in medical school. Indeed, it would be most interesting if we have an evidence-based analysis of history taking. I am not aware of any major publication on this issue, other than that for a few symptoms. We have a good reason of why, for example, ischaemic pains should radiate to the left arm, due to shared embryonic origins, but the reasons for other features are never explained. I can easily give a few reasons just by thinking about the issue, but I don't know how accurate they are. Scientific history taking will help in this.
One of the symptoms that has been analysed as such is orthopnea, and it illustrates how a scientific approach to history taking will mean more efficient histories; in patients coming in with a long history of shortness of breath, it is usual to ask about orthopnoea, and it is regarded as an indicator of congestive cardiac failure. Evidence based analysis however shows that it is a ‘poor symptom’, in that it also “occurs in a variety of disorders, including massive ascites, bilateral diaphragm paralysis, pleural effusion, and severe pneumonia”. As explained by John Larkin:
“We often ask patients if their dyspnoea is worse in any particular position (e.g. lying down). This ‘orthopnoea’ has been largely hijacked by the cardiologists as a major pointer towards pulmonary oedema …left ventricular failure…cardiac dyspnoea. But to be honest, most dyspnoeas are worse when lying flat. Asthma certainly is. That funny coughing/breathless thing you get with a virus in winter (may be a mild version of asthma itself) seems to be. And any time you watch some athlete finish a marathon or the 10000 metres and lie flat on the ground, they’re pretty quick to get themselves up again and continue their recovery in at least a seated position. So pretty much any dyspneoa is worse when lying flat.”
How much more beautiful would medicine be, I wonder, if we could deduce everything, including the nature of symptoms and their proper descriptions, from an understanding of normal anatomy and physiology? It would increase the power of history taking exponentially. Alas, I am pessimistic regarding the prospects of this, that since the human body is so complex an organism- affected by so many factors - sociological and psychological as much as physiological, and contrary to what the Marxists believe, the historical materialists, we can never predict these two things. But we can at least hope.
Thankfully, the science of evidence-based physical diagnosis has growing at a much faster rate than evidence based history taking. Although “scientific principles were not applied to the clinical examination until the mid-1970s,” and “before then, the sparse literature that addressed the clinical examination was dominated by case reports and case series that provided anecdotal evidence, which often overstated the usefulness of the physical examination”, nowadays many proponents of the clinical examination “now demand proof of reasonable reproducibility and accuracy before they accept the value of specific components of the history and physical examination”. This is an excellent step in the right direction. As explained in ‘Cecil’s Textbook of Medicine’:
“The clinical examination can be studied with the same principles as those applied to more traditional tests, such as laboratory results or diagnostic images. For each component of the history and physical examination, there is an associated sensitivity (the percentage of patients with a disorder who have an abnormal finding), specificity (the percentage of patients without a disorder who have a normal finding), and measure of precision (the agreement beyond chance between two observers). Current research on the clinical examination uses likelihood ratios (LRs) that inform clinicians how likely they are to observe a particular finding in a patient with a given condition compared with a patient without the condition.”
There is a rise of publications on ‘Evidence-Based Physical Diagnosis’; there is a prominent journal by that name, and several books, such as the one by Steven McGee which deal with this important topic extensively.
All this will only serve to bring back medicine to its roots, and give it the solid foundation it so deserves for its reformation. It is, I believe, partly due to its being grounded in firm roots that surgery gets the greater part of its strength; the more mature a specialty is, the better rooted it is in those traditions. Specialties like neurology, which is arguably the youngest medical specialty, and hence the least mature, is going through an obsession with ‘investigations’, like an overexcited child. With a reformation in clinical diagnosis, it will undoubtedly benefit and grow out of this uncalculated excitement, realising how futile or harmful many of its tests are, and thus become wiser and more mature, learning from the surgeon, the king, the wise man of the kingdom of medicine.