Taking a break from political ranting, and harkening back to Surgeonsblog days, this is my latest in our local newspaper:
In medical school we were told that the
diagnosticians of old could thump on a chest and detect a lung tumor as small
as a centimeter. I'm not sure I believed it, but I've always had a love for the
art of physical diagnosis -- of touching and listening, following the clues,
learned and taught. As technology pervades, that art is becoming almost (not quite)
superfluous and antiquated, an amusing throwback. Look at that old guy,
touching his patient. Sweet, really, if a little creepy. Hasn't he heard of imaging?
Sure I have. A realist, I've ordered a ton of 'em. Still, I’d propose that what
makes a doctor a physician is the ability to use all senses, not just
technology, to figure out what's going on. It's a satisfying combination of
book-learning and experience, of sensory attunement to another person.
In those school days, revelations came in
bunches, and each discovery seemed like a little miracle. I remember sitting
across from my roommates in our apartment, getting the hang of an
ophthalmoscope, using -- as required -- my left eye to see into their left, my
right into their right. Frustrated by the photo-ruining red reflex we all know,
finally getting past it to see the eye grounds: the retina, with its
tale-telling vessels and their disease-revealing crossings of each other. And
then that retinal full moon: the optic nerve. Thumb the wheel of lenses to get
focus, get the depth right, and there it is. Breathtaking. Now I must be a
doctor. Did I hear the split heart sounds? (It’s actually la-lub, la-dub.) Who
cares? I chose surgery.
If you strum a plastic comb next to your
ear, the sound it makes is similar to that of obstructed bowel. When examining
for appendicitis, it's best to use one finger: point tenderness -- pain in one
spot and much less right next to it -- is a tipoff. If a person has localized
pneumonia, if you ask her to whisper while you listen with a stethoscope, you
can hear (theoretically) the whisper more loudly over the area of infection.
It’s called “whispered pectoriloquy.” Other findings with cool names: fremitus,
crepitus, borborygmi, rhonchi, rales (rhymes with “pals.”) Those are textbook
stuff, teachable. Gauging the tension of an abdominal wall by touch and
percussion, interpreting the sound of the thump -- that's art, based on assimilated
input over lots of encounters. To assess perfusion in shock, feel the warmth of
the knees. Looking for subtle differences in circulation to the feet? Place
each hand on a foot, hold them there, then switch: differences in temperature
will be doubled.
No matter how much data I'd checked ahead
of time -- labs, X-rays, chart notes -- I never felt I knew much until I saw
the person I was asked to evaluate, touched him or her, observed their faces, listened
to their words and the sounds of their bodies. Smelled the air in the room,
sensed the level of “sickness.” Sometimes, yes: poked my finger you-know-where.
To the patient -- who knows? -- perhaps it seems like posing. Going through
some showy ritual, a pretense. Or maybe it's mysterious and awesome, like a
conjurer, a mystic, a whole-body palmist.
After hearing the words (probably the
most important of all) and doing the exam, I've taken out appendices without
ordering scans. Same with gallbladders. Nowadays it feels like insanity,
out-necking too far. Know what? It is. Back then I’d explain why I thought it
wasn’t needed; today I’d just give up and order it.
Sometimes
I'd catch myself, still with my hand on a belly while sitting on the bed
talking to patient and family about my impression and recommendations.
Long-since having garnered the information to be had from the examination,
subconsciously I guess I liked to maintain that touch. As inspiring as it is to
be allowed to operate, literally to enter into a bond and to breach
boundaries of flesh that only a few are privileged to do, the physical exam has
a special intimacy of its own. A unique interaction with a fellow being,
heightened by practical knowledge and distilled experience, it's way more than
ritual and I hope it’s never fully supplanted by magnets and beams. Drawing on
all the senses and the ability to synthesize them, bringing together knowledge,
skill, and instinct, as human as it gets, learning by touching another person
depends on who we are and what we're made of. There's really nothing else like
it.
[Image source]
