Sunday, September 06, 2009

The canary in the coal mine:

My next door neighbor was very upset when his doctor did not want to see his whole body, did not even ask him to undress. I got to thinking about that and thought they are treating him just like Erik. I always thought the doctors didn't listen to his heart because Erik is mentally and physically handicapped, and the doctors were too upset about the sight of this small wasted body with broken bones. I haven't been to a doctor for a while. So, I can't say I was not being looked at. The last time a doctor saw me, I had a mammogram. I guess the doctor couldn't help but look at my breasts. That doctor actually felt for lumps. But apparently the physical exam is dead. To get to the point, I had noticed that often doctors don't examine their patients any longer.

The eye-opener came with a book Every Patient Tells a Story, by Lisa Sanders, M.D. (Sanders has been advisor to the popular TV series "House"). She writes in her book that doctors rarely perform physical examinations any more. She goes into great detail why that is the case and points out how important this exam is and how much time and expense is wasted because the skill of the physical examination is being lost. Three paragraphs point out what her thoughts are on that subject:

In many ways the heart exam stands as a symbol of the entire physical exam--the neurological exam is probably the most complex. Nor is it the most technically difficult exam--looking at the retina of the eye may get that honor. And it's not the most time-consuming exam--that would probably be the psychiatric exam. But the heart exam was the first examination developed in modern medicine and the one most strongly linked with the physician's role as diagnostician and caregiver.

Moreover, the heart exam is a subtle exercise and requires well-developed skills to detect the nuanced variations from expected heart sounds. A thorough understanding of the anatomy and physiology of the heart and the circulatory system is essential in interpreting these quiet deviations and identifying the lesion they suggest. As such, it has the function as the proverbial canary in the coal mine, the first alert that physician skill and interest in the physical exam was waning.

Salvatore Mangione chose the heart exam to test in his 1992 study of doctors' skills not only because it was an area in which he had noted waning skills but also because of this position in the pantheon of examination abilities. He describes it as the "tip of the iceberg" of the physical exam--the most apparent component to doctors and patients alike of this much larger practice, this sensual science of the body, the physical exam. Technology is eroding, melting away this ancient, massive, and essential part of the way a physician knows the human body.

If and when the physical exam is saved, says Mangione, we will know it when the heart exam is restored to its former preeminence as the signal of a highly skillful well-trained physician.

Physicians rely too much on technology; they are neglecting the more subtle signs of beginning illness by avoiding the healing touch. In order to save time and money the physical exam by a doctor should be an essential part of their set of skills.


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