Opinion Check the patient,not just the scan

Of course,we still teach medical students how to properly examine the body. In dedicated physical diagnosis courses,students learn how to do a complete exam of the body’s systems. But all that training can be undone the moment the students hit their clinical years. Then,they discover that the currency on the ward seems to be getting tests ordered and getting results,having procedures like colonoscopies done expeditiously,calling in specialists,arranging discharge.

The consequence of losing both faith and skill in examining the body is that we miss simple things,and we order more tests and subject people to the dangers of radiation unnecessarily. Just a few weeks ago,I heard of a patient who arrived in an E.R. in extremis with seizures and breathing difficulties. After being stabilised and put on a breathing machine,she was taken for a CT scan of the chest,to rule out blood clots to the lung; but when the radiologist looked at the results,she turned out to have tumours in both breasts,along with the secondary spread of cancer all over the body.

In retrospect,her cancer should have been discovered long before the radiologist found it; before the emergency,the patient had been seen several times and at different places,for symptoms that were probably related to the cancer. I got to see the CT scan: the tumour masses were visible to the naked eye — and certainly to the hand. Yet they had never been noted.

Too frequently,I hear of (and in a study we are conducting,I am collecting) stories like that from all across the country. They represent a type of error that stems from not making use of basic bedside skills,not asking the patient to fully disrobe. It is a more subtle kind of error than operating on the wrong limb; indeed,this sort of mistake is not always recognised,and yet the consequences can be grave.

In my experience,being skilled at examining the body has a salutary effect beyond finding important clues that lead to an early diagnosis. It is a ritual that remains important to the patient. Recently my ward team admitted an elderly woman who had been transferred from her nursing home in the night because of a change in her mental status. A CT of the head and all other tests were determined to be normal; the problem had been dehydration,and she was better,ready to go back. But the patient’s lawyer daughter was unhappy with the plan to return her mother to the nursing home,and was waiting impatiently to see me and contest the transfer.

After introducing myself to the patient and to her daughter,I did a thorough but quick neurologic exam. I put the patient through her paces: mental status,cranial nerves,motor and sensory function,used my reflex hammer and pointed out interesting things along the way to my interns and students. I then said to the daughter that her mother seemed back to normal. To our surprise,the daughter seemed comforted,and now had no objection to her mother’s return to the nursing home. We all felt that the daughter witnessing the examination of the patient,that ritual,was the key to earning both their trusts.

I find that patients from almost any culture have deep expectations of a ritual when a doctor sees them,and they are quick to perceive when he or she gives those procedures short shrift and wrapping up in 30 seconds. Rituals are about transformation,the crossing of a threshold,and in the case of the bedside exam,the transformation is the cementing of the doctor-patient relationship,a way of saying: “I will see you though this illness. I will be with you through thick and thin.” It is paramount that doctors not forget the importance of this ritual.