(574) 453-3131 | Contact Us | FAQ

Home The Lost Art of Medicine: Can It Be Retrieved?

The Lost Art of Medicine: Can It Be Retrieved?

post image

An article in JAMA Neurology espouses the notion and belief that as diagnostic technologies have advanced in their detection of strokes, for example, the neurological examination has become less important.[1] Indeed, the exam has become so unimportant that it is now considered a mere empty ritual. The authors of the study, however, go on to mention that this is a contradiction of sorts, insofar as the neurological examination has achieved an almost sacred and untouchable status among medical students, residents, and trainees in neuroscience. The neurological exam has not changed a great deal in the last century, although the field of neuroscience has expanded tremendously. The implication is that, based on this new acumen, the neurological examination can become updated, and, perhaps, more sophisticated. But it has not. Thus, the authors suggest that the interest of neurologists, and more specifically stroke neurologists, has waned in the field of behavior and its underlying anatomy. This, in the authors’ minds, is a failure, insofar as the effects of such interventions on brain function are unrecognized.

Despite the keen observation of the contradiction inherent in today’s neurological diagnoses, namely that diagnostic technologies have become more important while the neurological examination has become less so (all the while retaining its sacred status), the authors fail to recognize that the neurological exam will always eclipse technology because, it, alone, combined with the patient’s history, can initiate the dialogue. Without such a narrative, the diagnostic technology may not even be relevant in the first place.

Of course, having said this, one is reminded of physicians—and even neurologists—who despite a non-convincing history and normal neurological examination, may still order a myriad of tests and imaging studies to ensure that medico-legally, at least, they’re “covered” from any potential malpractice claims. This is perhaps one of the principal reasons that unnecessary studies are ordered. For example, one study found a causal relation between higher resource use (whether this was related to more studies or a different type of care, such as caesarean deliveries by obstetricians) and a reduced risk of malpractice claims. However, as the authors in this study contend, it is unclear whether patients who receive more resources experience better outcomes and have less reason to sue, or whether outcomes are similar, and the additional care simply averts lawsuits.[2]

As physicians-in-training, we were always reminded of the importance of a patient’s history and physical examination, more so than any lab exam or diagnostic study. The patient was the classroom. The art of medicine emanated from them alone. The history and physical exam were the necessary steps to hone in on a diagnosis.[3] This is still played out in medical television dramas, such as House and Grey’s Anatomy, but in the day-to-day world of clinical medicine, this is the exception and not the rule. As neurologists, the exam is even more vital, because there are much more intricacies and subtleties inherent in the neurological examination. Salvatore Mangione has acutely perceived and succinctly stated the problem with technology insofar as it, “unguided by bedside skills, took physicians down a path where tests begot tests and where, at the end, there was usually a surgeon, and often a lawyer, sometimes even an undertaker.”[4]

Abraham Verghese, a physician and senior associate chairman for the theory and practice of medicine at Stanford University, has always advocated for the return to the physical examination. Besides yielding vital information and allowing doctors to ascertain what laboratory tests and diagnostic technologies to order, the physical exam, in his opinion, also earns the trust of the patient and transforms the interactions between two strangers as a meaningful encounter. This is a lost art, and an art that’s even more vital to a neurologist, who delves into the intricacies of an individual’s brain.

However, the notion that technology is the evil culprit here is not an adequate conclusion. It is the misuse of technology that is the problem here. Tests/imaging and a sound history/physical exam benefit from one another. One bolsters the other, because, after all, we cannot visualize every organ and a physical exam will not yield information that cannot be deciphered in the first place. On the other hand, as the authors of a study contend, technology “cannot detect a tender spot in the abdomen or a raised jugular venous pulse or how a patient feels that morning.”[5]

The question remains, then, if physicians can reclaim the physical exam and history and wrest if from technology’s grasp. Do physicians, in particular neurologists, consider the physical examination obsolete in the era of modern diagnostic imaging, given constraints in time or perhaps inexperience and lack of confidence in a sound exam, which could potentially lead to a malpractice claim? Or is it simply because physicians have become lazier? Perhaps, there is no incentive in performing an exam given the reimbursement and the time spent? Whatever the reasons, it is only through a conscious effort and willingness to immerse oneself in the “classical” mode of training wherein physicians can reclaim the lost art of medicine, which has always been there for the taking.


[1] Krakauer, J.W., Hillis, A.E., “The Future of Stroke Treatment:  Bringing Evaluation of Behavior Back to Stroke Neurology.”  JAMA Neurol. 2014 71(12):1473-1474

[2] Jena A et al.  Physician spending and subsequent risk of malpractice claims: observational study. BMJ. 2015; 351: h5516.

[3] Med J Armed Forces India. 2017 Apr; 73(2): 110-111

[4] Mangione S. The stethoscope as metaphor. Cleve Clin J Med. 2012;79:545-546

[5] Med J Armed Forces India. 2017 Apr; 73(2): 110-111

 

The Lost Art of Medicine: Can It Be Retrieved?
Pedram Navab

Pedram Navab is a board-certified neurologist and sleep medicine specialist who currently resides in Los Angeles. He is a Fellow of the American Academy of Sleep Medicine and has a special interest in insomnia, narcolepsy, and parasomnias. When he's not practicing medicine, you can find him writing novels. His latest book is This Will Destroy You, a medical mystery/thriller published by Spuyten Duyvil Press (2019).

Comments

BRIAN HUDES
BRIAN HUDES says:
Sep 28, 2021 AT 2:43 PM
I think that many specialties face the same dilemma. I have met cardiologists who do not carry a stethoscope. As one once told me, "if I need to know what is going on in the heart I get an echocardiogram". In my specialty, the physical exam has been usurped by the CT scan, ultrasound and MRI/ MRCP not to mention the dynamic HIDA scan. This despite the fact that based on the physical exam I have found numerous patients who require cholecystectomy despite a normal array of imaging tests. The proof comes in the the form of the pathologists report of ischemic/ gangrenous gallbladders that were missed by imaging but found on physical exam. Medicine is not what it was and it is not necessarily all an improvement. I will admit to feeling like a dinosaur at times, sticking to an analytic approach to patients, combing the history, the physical and lab/radiology data to make a diagnosis. This said, I see too many upper endoscopies being done, too many colonoscopies being done and too little physical exam or thoughtful evaluation being done. Patients expect tests to be done to give the answer to what is wrong. The doctors words are not proof. Yes, I can and have adapted to the new paradigm and been unhappy with it and myself. Doing and ordering tests that I know won't be helpful but they expected as part of a protocol. So, it is time for me to go. I started in my career as a physician to be the one to evaluate, treat and care for my patients. Meaning, these people who came to me were now my responsibility and I viewed as medically belonging to me. Now, physicians are shuffled around and hospitals and practices barely even mention the name of a doctor rather they announce how many providers they have for you to see. I am not a provider, I am a doctor, a physician. I am not an interchangeable part. I refuse to participate in the system any further if I am viewed as just another provider, another cog in the machine.
Reply