Death of Clinical Judgement

I recently reviewed a CT scan with one of our young stellar radiologists. He was interrupted twice by the Peninsula ER doctor who needed the information on two seriously ill patients. I watched as the radiologist  immediately retrieved the digital images on these two abdominal scans. He reviewed the results with the ER physician over the phone and gave him invaluable, specific information which allowed a prompt and correct disposition to be made. The anatomic accuracy and specificity of the images is nothing less than awesome.

I reflected to my own experiences working as the Peninsula ER Doc 41 years ago (many of the new docs covered the ER before there was an official ER specialty).

I remembered how we would agonize over a patient with “unclear” abdominal pain and  examine the abdomen over and over, rechecking the  WBC and UA. We would then ultimately decide if the patient needed to go to surgery, not knowing if we made the correct  decision.

We used clinical skills to arrive at the decision  - the senses of touch, sight, sounds, even smell and the subtle changes in patients reactions to our examinations and interviews. The sum of all of this represented clinical judgment – a skill we all needed to practice our craft. While some physicians were better at it than others, we all possessed “it”. Those who excelled at it were “master” clinicians.

I recall my years of cardiology training, spending hundreds of hours learning to examine the heart, going to rheumatic and congenital heart clinics and attending auscultation courses in distant cities. As a medical student, if I could not hear the murmur elucidated by the professor on morning rounds, I went back at night to reexamine the patient to train my ear and become a competent diagnostician.

I spent the last 40 years trying to teach these physical diagnosis skills to generations of medical students at UCSF.  They will never have to achieve the skill levels that our generation needed. Why waste all that time learning a skill that can be bettered by the technology of ultrasound? The echocardiogram not only diagnoses the lesion, it quantitates it as well. I now know how the 19th century physicians felt when the chest x-ray was invented.    

All their skills in percussion of a lung cavity were no longer needed now that one could “look into” the chest with Roentgen’s rays.

The engineers and technical people have transformed our profession by devising and perfecting radiation, ultrasound, nuclear techniques  -  all modern ways to look into the body and get the answers that eluded physicians for centuries.

Alas, clinical judgment is a double-edged sword, since it is no longer taught, needed or wanted with technology making the diagnosis. Physicians will (or already have) become health care managers who coordinate the various  modalities of diagnosis. Perhaps they too will someday be replaced by artificial intelligence.

In my fifty years of participation in the study and practice of medicine I have witnessed the evolution  of this art/science that has gone from the “horse and buggy stage” to the space age: electrical cardioversion; pacemakers and defibrillators (first external and then miniaturiaed and implantable); balloon angioplasty, followed by bare stents and drug eluting stents; ablation of arrhythmias; coronary angiography and cardiac surgery, both coronary and valvular -  just to mention just a few advancements in my own specialty.

It has been  an “exciting ride” to witness and participate in the evolution of  medicine over the last half century. Clinical judgment may be dead, but the medical world is now a better place as our diagnoses and treatments have become more accurate and precise.  Nonetheless, I mourn the loss of clinical judgment.

I was fortunate to span both worlds. I am a “dinosaur” with the latest generation 4G IPhone. Ω

Dr. Goldschlager is an internist and cardiogist and practices in Burlingame and Daly City.