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The Lost Art of Medicine: Can It Be Retrieved?

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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

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