Monday, January 05, 2009

High technology and declining clinical skills

Over at Bob Wachter’s blog there’s a fascinating discussion on this topic, prompted by a NEJM perspective piece written by Dr. Abraham Verghese. Verghese laments the declining emphasis on the teaching of basic clinical skills, particularly physical examination, in today’s technological environment.

Please read the whole thing, but it seems to me that Wachter, though concerned about the threats to the human dimension of the doctor-patient relationship, has his reservations on the practical value of basic clinical skills today. Acknowledging the poor skills of today’s trainees---

(Let’s be honest – many of our physical exams are now perfunctory performances in a Theater of the Absurd whose audience is comprised of coders and insurers.) That can’t be good.

---he says this:

It seems to me that with everything today’s residents and students need to do and learn, the chances that we can revive the painstaking Oslerian physical exam are zilch, akin to the chance that we can resurrect the study of Latin in medical school.

Even if we could create a new generation of expert physical examiners, would it be worth the time and trouble? I doubt it.

Wow. He goes on to cite examples of poor performance characteristics of some aspects of physical examination.

Two questions are being raised here. First: Is basic clinical examination of practical value apart from the human dimension of “laying on of hands?” I would submit that in this era of runaway medical costs it may be more important than ever! J. Willis Hurst of Emory once said that if you don’t master low technology (history and physical exam) you are bound to abuse high technology, citing untold unnecessary echos, CT scans and nuclear studies. (Occasionally evidence wins out over the abuse of technology. For one of the best examples of that in all of medicine consider the rise and fall of the PA catheter).

Second, given that some feel the ancient clinical skills are irretrievably lost, can we afford the effort it would take to revive them? I would submit that we can’t afford not to. While we can’t turn the clock back to Oslerian days we can maintain a reasonable degree of basic clinical skill if we make it a priority in our quest of life long learning. I believe it’s part of the learning curve of high level clinical expertise that should characterize the hospitalist career.

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