Re-Birth of Clinical Judgement
As a resident in Internal Medicine in San Francisco during the early 1980s, I remember a cardiologist who was a former Stanford professor. He would spend 30 minutes examining a patient’s heart and then describe all the abnormalities he found. The residents would then look at our 2D echo report and were amazed at how accurate he was. I have sitting on my desk, a stack of 78 rpm records of just heart sounds. The ability to do that type of examine is now a lost art, but does that mean we no longer have clinical judgment?
I was talking to one of my colleagues, a cardiologist a few years older than me. He relayed a story of his medical student days when his hospital had just acquired a body ultrasound. He saw a patient with abdominal pain and the ultrasound revealed a leaking AAA. The residents and attending missed the diagnosis. He was not even sure if the physicians saw the results or ignored them, but he took matters into his own hands. The student read about AAA’s, put the patient in trendelenberg, as the text suggested, elicited pain and confirmed the diagnosis. Soon the patient was in the OR, with his life saved.
The rapid growth of medical technology has presented us with much more data and information than we could ever hope to attain on even the best exam. When MRIs were first used, radiologists noticed all sorts of unusual findings. I recall debating over what to do regarding “subtle white matter abnormalities”. We needed to develop new abilities to determine whether these findings were significant or not. Is it easier to make a diagnosis when patients have symptoms and findings on examination? Symptoms as well as findings can be misleading. Surgeons were often judged on their clinical acumen by how many normal appendicies they removed. It was expected that a certain percentage would be normal. No one had the ability to assess certain patients who had all the classic signs and symptoms. If you did not operate on patients without appendicitis, you probably missed some who did. The use of the CT scanner has enabled us to confirm a presumed diagnosis and provide better care.
Many diagnostic tests have greatly expanded our understanding of disease processes. For example, even the best cardiologist never realized the significance of diastolic heart failure until sophisticated echocardiograms and other cardiac imaging came about. The 19th century physician may have been better at examining a lung, but that physician had little in the way of tools to help patients, having no antibiotics, etc. Just surgery or a “physic”. Now we have so many different medications it requires even more skills and clinical acumen to determine which ones to use. For instance, in order to determine which antibiotic out of many to choose, one needs to get a more detailed history than ever before. Has the patient traveled? Have they done something to put them at risk of a resistant organism? Which is the best cephalosporin to use?
Our current climate of health care reform necessitates better efficiencies in the way we practice. No longer can the invasive cardiologist do a cardiac catheterization, review the films with their colleagues and then go back a second time to do an angioplasty. The doctor now has to make a decision on the spot and get it all done at one procedure. One principle we follow at Kaiser Permanente is to “do today’s work today”. A patient can come in the morning at one of Kaiser’s facilities for an evaluation of carpal tunnel syndrome and go home that night having it diagnosed and surgically treated! There certainly is testing involved, but it takes excellent clinical skills to put it all together before sending a patient for a procedure.
Does this mean that with the advent of technology, good examination skills are no longer needed? Of course not. Today’s diseases, as in times past, often present with a constellation of symptoms and findings that require excellent clinical skills to determine next steps. Technology provides us with more frequent and accurate data to help amplify our clinical skills. I feel clinical judgment is even more essential today than it was years ago because there is so much more information available and so many more options in the way we treat patients. What I see as lost is the ability of the doctor, on examination, to have a better sense of what is going on inside their patient’s body and mind. The rapidly growing amount of information has made us more and more specialized. It has become easy to lose a sense of the person, the whole being, and to break our patients down into parts. It takes even stronger clinical judgment to put the pieces together. Ω
Dr. Granich is the Chief of Palliative Care Medicine at Kaiser Permanente in South San Francisco.