“Half of us are blind, few of us feel, and we are all deaf.”
– Sir William Osler
This incident occured in my third or fourth year of medical School in Leipzig (outside the US, most medical schools are 6-year programs). We were on a medical-surgical (med-surg) floor one afternoon with one of our instructors for a session on the Physical Exam. Before we went off to terrorize our patients, he warned us to pay attention and observe. He asked us not to be too distracted by what the patients said – to listen but also to watch. To use all five senses.
I marched off to my patient – a 60-something year old woman who was in the hospital with an unknown-to-me cardiac condition. My job was to talk to her, examine her and figure out her condition and the cause. The patients are usually asked by the instructors beforehand not to divulge their diagnoses.
Well, my patient was as garrulous as they come. She thought I was the cutest thing she ever saw and I allowed her to pinch me cheek and pull my hair (I had a ‘fro then!). Soon she told me what her ailment was – Atrial Fibrillation (a condition where the heart beats iregularly) – and all the medicines she was on. Well, who was I to complain? I had my diagnosis and treatment. I stepped out, feeling like the second coming of Hippocrates. I had totally forgotten why I was in the room in the first place.
Well, I presented my patient to my instructor who promptly asked me what the cause of her Atrial Fibrillation (A-fib) was. Having neglected to examine her, I promptly responded that it was idiopathic, a fancy term for ‘I don’t know’. He asked me to list the causes of A-fib, which I did. He asked me if the lady could have Hyperthyroidism (an overactive thyroid gland and a cause of A-fib). I said no.
At this point, most of the other students were back. He introduced my case to the group and asked me to lead the group to my patient’s room. The instructor was a tall man and he was right behind me when I opened the door to the patient’s room. From the door, one saw the patient resting in bed and she turned her head to look at us as we entered. From about 12 feet away, one could see the goiter (a large swollen thyroid gland) bobbing in her neck. I wanted to vanish!
It’s a lesson I’ve never forgotten – to observe, to watch, to feel, to smell and listen. Do I do it well or all the time? Of course not but I try.
The power of observation is as important to the practice of medicine as the power of taste is to a chef. A doctor needs to be able to notice that jaundiced skin, that throbbing mass in the abdomen, those engorged veins in the neck, those blue lips, the child who is alwsys squatting instead of playing, those trembling fingers, that deviated tongue, that strange gait.
We need to listen to the patients’ answers but above all know what to ask. We need to examine patients and really listen to those breath sounds and make out those murmurs. We need to be able to smell those almonds on a patient’s breath.
The practice of observing the patient has been dealt a serious blow by the use of technology in medicine. In this age of CT-Scans and MRIs, why even bother? What not let technology do all the work? An echo will soon tell you if the patient has valvular disease so why does one need to know what aortic stenosis sounds like?
First, it makes one a better doctor then it forces a one to be interested in that human in front of him or her. You have to be truly interested in another person to observe them closely.
It also does save time and money. It cuts down the amount of useless tests. Sure, we do a lot of tests to cover our butts (Defensive Medicine), but there are also cases where a good physical exam does make a huge difference.
Further, it gives one a better picture of the patient. One may pick up other ailments that the patient may not even know about.
Our colleagues who practice in developing countries will tell you most times, all you have are your five senses.
(At this point, a shout out to all the doctors in Ghana and to two esteemed colleagues – one who spends half his time working in Haiti and the other who volunteers with Doctors Without Borders).
Recently, the practice of observation has been dealt another blow. Since electronic medical record-keeping became mandatory in most medical practices and hospitals, I often take time to observe other colleagues and nurses working. It is a sad sight. One sees extremely well-trained and dedicated professionals observing not the patient, but a screen. A culture that already suffered from the lack of observing the patient has been worsened by the need to chart electronically.
Then is the notion that the practice of medicine is nothing but a series on protocols and best practices and that the best results are obtained when everyone sticks to these protocols and best practices. Well, the jury is still out on the wisdom and effectiveness of that. As most practitioners will tell you, no two patients or two cases are ever the same.
Lastly, just the volume of patients one has to deal with plus production pressure make it sometimes really challenging to really observe well.
I look on in despair and wonder what William Osler would say if he was alive today. He aptly once wrote:
“Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become expert.”
We have all become experts but are we in the process forgetting how to see, hear, feel and smell? If we do forget, what kind of experts do we become then? I wonder, I really do…