Saturday, April 01, 2006

In defense of clinical skills

On March 30 I lamented the decline in clinical skills and linked to an editorial by Herbert L. Fred, MD on the same subject. A lively discussion on several other blogs followed, and Clinical Cases and Images has compiled those links along with some related content.

I was appalled by the personal attacks leveled against Dr. Fred, particularly by some of the commenters at Kevin’s blog. I have to agree with Retired Doc that these ad hominem arguments (which in effect characterize Dr. Fred as an anachronism out of touch with today’s medical climate) shed little light on the issue and fail to address Dr. Fred’s arguments concerning deficiencies in clinical training.

Dr. Fred longs for renewed emphasis on basic clinical skills. If we dismiss his views just because he’s an old timer entrenched in medical academia we must dismiss similar views of other great teachers such as Henry JL Marriott, J Willis Hurst, Proctor Harvey and David Spodick.

Some commenters responded with a defense of high technology, correctly arguing that plaintiff attorneys drive excessive use through defensive medicine and that many of today’s imaging modalities have supplanted outmoded bedside techniques (a neurologist gave the example of bedside ocular plethysmography). These are valid points but seem to miss the core of Dr. Fred’s argument. In my reading of the editorial high technology is good but its effectiveness is limited by poor clinical skill on the part of the user.

I like the analogy of the shotgun and the rifle. A shotgun approach may be appropriate in limited situations. In the critically ill patient with refractory hypotension of unknown cause the clinician is challenged to make an appropriate differential diagnosis containing all life threatening conditions, then address each one in limited time. Such cases may call for a wide spectrum of expensive tests on the front end. Even in those situations basic clinical skill is essential for correct interpretation of results. But more often the rifle approach is called for with selective testing used in a specific and focused manner. We should all strive for expert clinical marksmanship.

For me the challenge of developing and maintaining excellent clinical skills is part of the joy of medicine that keeps me going. I’m reminded of the great teachers I encountered as a student at Vanderbilt Medical School, in particular the late Thomas E. Brittingham who, as the principal teacher of third year students on the medicine rotation, emphasized the foundational importance of bedside clinical examination. He once said “What you learn in becoming a good medical observer will be useful to you always. Contrast this with the ‘facts’ which you learn from your books. It is said that half of what we are taught in medical school will have been shown to be wrong during the first 10 years after we have graduated.” These lines were from a letter he sent to students about to start the rotation. It was an inspiring pep talk which served to remind us of the power of basic clinical observation. I saved the letter and reread it occasionally when day to day practice begins to feel like a chore.

For those wishing to refresh clinical skills or needing a dose of inspiration I highly recommend Sapira’s Art and Science of Bedside Diagnosis.

Update: Clinical Cases and Images points us to a wonderful collection of instructional videos on physical diagnosis.


Clinical Cases and Images said...

I'm not "an old-timer" (it depends on how you define "old-timer", of course) but I still think that physical exam is a very important part of the patient-physician interaction. If the history can really give you the correct diagnosis 90% of the time, we should be able to diagnose people over the phone...

Again, as a free alternative to buying a book, one can review this large collection of free physical exam teaching videos by some medical schools (link).

Anonymous said...

What do you think of this for someone who wants to become a doctor? Seems like pretty good pre-med-school education.