Thursday, March 30, 2006

Declining clinical skills

Herbert L. Fred, MD, professor of Medicine at the University of Texas Health Science Center at Houston, calls it hyposkillia and believes it to be one of the more pervasive threats to our profession. In a recent editorial in the Texas Heart Institute Journal he correctly points out that over reliance on diagnostic technology has led to intellectual laziness and a neglect of basic clinical skills. J. Willis Hurst once said that you must master low technology (history, physical examination, electrocardiography) before you can make effective use of high technology (echocardiography and other imaging modalities).

I would argue that there are other factors. Extremes in evidence based medicine have produced some unfortunate consequences. The shunning of experts, for example, threatens the extinction of the master clinician-teacher. Over reliance on resources like Up To Date and slavish adherence to algorithms have become substitutes for thought. The increasing percentage of precious curriculum time spent on pseudoscience (euphemistically termed “complementary and alternative medicine”) undermines education in the basic sciences.

This dumbing down of clinical skill is ironic coming as it does in the midst of the ACGME’s core competencies initiative. Is outcome based medical education failing? A more optimistic view might be that the outcome project is early in implementation and we have yet to see its benefits. But a proposal written a few years ago in BMJ for the medical school of the future was not promising. In this Renaissance School of General Medicine “….gone will be the days of freestanding courses in biochemistry, physiology and anatomy” and “There will be no exams in anatomy, physiology, or biochemistry, and no one will need to learn by rote the entire Krebs cycle or the names of all those little holes in the skull.” This is scary.


james gaulte said...

Your post and Dr.Fred's are really on target.I have known about and admired Dr.Fred for many years, athough not personally.Everyone who claims to be a medical educator needs to read that essay.

Anonymous said...

Dr. Fred hit the nail right on the head.

However, Osler's dead and he's not coming back.

Whom do I blame? In large measure, the third party payors whom we've allowed to take over medicine.

When you're effectively allowed 7-8 minutes per patient in order to generate enough volume to cover your overhead, it's impossible to perform a true full physical exam on any patient. I don't think I've done a full physical exam since my internship.

But that's OK, the nurse practitioner in the Minute Clinic in Wallmart is ready, willing, and able.

If there's any significant disruption to our comfortable modern technology-dependant 21st century lifestyle, all the modern docs who cannot diagnose appendicitis without a spiral CT will be up the proverbial creek.

Anonymous said...

Better thought. The patient with appendicitis will be farther up the creek.