Tuesday, December 29, 2009


Another question I’ve had with regards to the first two years of medical education regards the teaching time proportion of clinical skills versus the well known evils of basic sciences. For the record, I think CMS is doing a pretty good job striking that balance. Most schools have a class like Essentials of Clinical Reasoning that teaches differential diagnosis and the basics of how to think through the process of diagnosis, testing, and treatment. I feel fortunate to attend a program that places emphasis on the physical exam and History of Present Illness. We’ve been told that nearly 85% of diagnoses can be made from the HPI / physical alone, yet apparently plenty of third-year medical students show up for clerkships lacking the skills to properly examine or question a patient. Couldn't schools afford to back off on the level of detail in Cell Biology in order to better prepare students in skills that could help make better doctors and cut down on the cost of healthcare?

I’ve just finished reading a book called “Every Patient Tells a Story” (Thanks, Faye and Ron) by Lisa Sanders. Dr. Sanders writes for the New York Times as well as acting as the medical consultant for House. Told through a series of vignettes, Sanders dedicates a considerable portion of her novel to stressing the value of “the lost art” of good physical exam skills. It should come as no surprise that the availability of high-tech testing devices has caused physicians to shunt diagnostic authority. Why trust techniques that are older than Abe Vigoda when you can convince the atoms in a patient to align their spins and tell you their secrets? Sanders argues that the physical exam allows you to find, in about thirty minutes, items of concern you may not know to look for with tell-tale signs that give almost as much certainty. While she doesn't bring up the issue of cost, that's a massive concern as well. Testing is an expensive burden on the system if used egregiously.

What does this have to do with me? A week before winter break, we were tested on a full* head-to-toe exam. Over the first half of our school year, we learned the exam one system at a time. Then, with an instructor in the room and cameras rolling, we took turns with a partner playing either the patient or the doctor. 30 minutes, 110 items on the checklist, an ophthalmoscope, an otoscope, a reflex hammer, a stethoscope, a tuning fork, a tooth pick, a cup of water, and our mental list. Hi, I’m Aron Bender and I’m a first year medical student. It’s nice to meet you. We’re going to conduct a full head-to-toe physical today. I’ll go wash my hands and we’ll begin. Our exam skills are incomplete, however. I can technically perform each of the items on the exam list, sure. I've never actually heard Mitral valve stenosis or felt a thrill. I guess this goes back to the 10,000 repetition theory.

On a somewhat related note, how and why I get nervous will always be a source of amusement to me. I’m ordinarily able to remember each of the list items because they follow in a logical progression through each system and I’ve done each technique a dozen times or more. I neglected the Babinski test until the very end of the exam when it struck me that I hadn’t done it. Always the bullshitter, I told my patient / fellow med student that I like to finish with the Babinski because I’m already testing vibratory sense in his big toe. Put in the mock exam room with a clipboard-toting fellow at drafting distance behind my right shoulder, my calm went to hell. It’s like someone drove a hovercraft into my mental office, sending all the neat stacks into a flurry. Two weeks later in one of my Dad’s exam rooms with a real patient, my nerves leave my brain alone. Sterile situation? Panic! Out in the field? Cool. Despite the way I approach problem solving, the way I process information, and the only way I accept argumentation, there’s a portion of my brain that must like being the last outpost of irrationality clanging around in there.

* Rectal exams will have to wait until next year. I can live with that.