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It is generally agreed that the ability to perform a skilled physical examination has become a lost art in modern medicine. The last few generations of newly minted medical graduates have failed to develop the skills that were once considered part and parcel of a competent practitioner. This trend is universally deplored, but nothing or no one seems capable of reversing it. Indeed, some of the leaders of medicine in this supertechnical age are beginning to look upon this as a natural development and are turning to technological solutions for these human failings.
In no field has this been so apparent as in cardiovascular medicine, a specialty that a half century ago attracted this writer expressly because of the assumed ability of a well-trained cardiologist to arrive at a correct diagnosis in a patient simply by taking a good medical history and performing a thorough physical examination. An electrocardiogram was granted as the only supplement to these other diagnostic modalities. The models of such acquired skill were people like W. Proctor Harvey, Samuel A. Levine, and Aubrey Leatham. Their papers and monographs were required reading (1, 2). All qualified cardiologists, and even seasoned physicians of any stripe, were expected to have superior abilities along these lines and transmit such knowledge to students and residents in training. However, recent studies evaluating these skills among students, housestaff, and even faculty have shown a 20% to 80% error rate in recognizing actual or simulated findings (3–7).
It seems that our recent medical graduates are more at ease in discussing the splitting of a strand of DNA than that of the second heart sound, the key to differentiating many innocent murmurs from such serious conditions as atrial septal defect, aortic stenosis, pulmonic stenosis, pulmonary hypertension, and left bundle branch block. Innocent or “functional” murmurs are so common among normal children, anemic patients, and pregnant women, among others, that they cry out for such differentiation at the bedside or the office. However, it seems that such patients too often are sent off for chest films and echocardiograms to compensate for the physician's inadequacy.
In the face of such diagnostic shortfalls, some of those responsible for the training of physicians have simply given up and taken the view that the lesser of two evils, depending on machines for diagnosis, is better than having no diagnosis at all. The downside of this, however, is considerable. Although hand-held echocardiograph machines are now available, the cost is not negligible. Consider equipping each American graduating class, approaching 20,000 each year now, plus practicing physicians with these devices. Then there is the question of competency among noncardiologists in interpreting the findings. Regional wall motion abnormalities—the hallmark of coronary heart disease, one of our major health problems—are one of the most difficult of findings to interpret accurately. Small vegetations located on the valves in infective endocarditis may be missed by one not expert in the technique. Missing such findings may work to the harm of the patient by giving a false sense of security to the nonexpert examiner, just as misinterpretation of normal variants as abnormalities may lead both him and the patient astray.
In addition to the cost of diagnostic procedures is the anxiety, the days patients spend wondering whether or not some serious heart disease is present. Of equal importance is the effect of further separating doctors and patients in this age of rampant technology. Whatever the medical value of the encounter between healers and their subjects has been, the possible beneficial effect of the contact in itself is not negligible. Although earlier monarchs often used the “royal touch” for scrofula, it might be wondered how many of their subjects with what we would now call “psychosomatic ailments” might have benefited from that laying on of hands. The simple performance of the physical examination can constitute a strong tie binding together doctor and patient in our increasingly impersonal medical world.
With the left middle finger pressed against the chest and the other fingers elevated so as not, by contact, to dampen any reflected sound sensations, the left hand adapts a configuration much like that of the classical ballerina's extended hand. In preparation to strike its opposite, the right hand adopts a similar appearance as the middle finger “plexor” repeatedly descends briskly by graceful flicks at the wrist. The exercise becomes almost terpsichorean in character.
With the physician exhibiting intense concentration as he follows this with auscultation over the chest, the whole proceeding can be appreciated on a more primitive level. The doctor's percussion represents his tapping on the thoracic “door” to the patient's inner being, and with auscultation, his head bent close over the stethoscope, he listens for a reply. The great cardiologist Paul Dudley White used this aspect of the physical examination to great psychological advantage at times when confronted with a severely agitated patient. He might mutter as an encouragement, “The first sound seems just fine.” The anxious subject might think to himself, “Well, the first sound is good; perhaps the others are as well.”
By gently palpating the abdomen with obvious concern for the patient's sense of well-being, the physician can further strengthen that important bond: “Does it hurt here? How about here? Tell me if this bothers you.” All this in a tone of concern and sympathy.
The performance of a skilled physical examination involves not merely esthetics and psychology. When evaluated objectively—which is not done too often—it can hold up quite well to critical scrutiny. Splitting of the second heart sound (the audible separation of aortic and pulmonic valve closure) is not a rare, esoteric finding; it can be detected in almost 80% of all normal individuals from 6 to 74 years of age (8). Enlargement of the left ventricle determined by percussion and palpation correlates well with computed tomography (CT) (9). Although not as reliable as CT scanning, physical examination to detect pleural effusions is comparable to conventional chest radiography (10). The third heart sound, occurring with filling of the ventricle, detected by experienced physicians matches up well with that recorded by phonocardiography (11). Even a century and half after Laennec, ways have been found to improve upon percussion and auscultation (12).
Sadly, those most capable of passing on these skills to physicians in training have more or less disappeared either as the result of death or retirement. The remaining few, at least in the experience of this writer, who offer such services are politely rebuffed. It is like allowing the few remaining Stradivari and Guarneri to lay about abandoned in some obscure closet, lost to the ears of the world.
The current vogue of using troponins and other biological markers for the diagnosis of heart failure is bewildering to any seasoned physician worth his salt (if you will pardon that word in this context). Although this may be difficult in a patient with longstanding lung disease and superimposed cardiac decompensation, in the majority of patients the diagnosis can be made with the exchange of a few words followed by an examination of the neck veins, chest, abdomen, and lower extremities.
This all does not mean that emerging clinicians may be forever denied the rewards of such skills. Physical diagnosis is largely self-taught. Through constant application and correlation with other objective data, any physician can become competent if he or she so wishes or is compelled to do so.
About 15 years ago at the main general hospital in Nairobi, the chief of medicine received a group of American physicians on tour. An ethnic Indian, she was nonetheless a loyal Kenyan who, upon finishing her medical training probably in the United Kingdom, returned home to serve her country. Back in Africa, she found that her hospital could not afford the luxury of chest x-rays for use in the diagnosis of chest diseases despite their frequency in that part of the world. As she conducted us through wards filled with sufferers from pulmonary tuberculosis and other chest diseases, she related how she had come to rely on physical diagnosis for her assessment of patients; how she had become quite proficient in this; and how only rarely and in very complicated cases did she feel the need for radiologic confirmation.
Such commitment recalls another vignette involving Dr. White. He was listening intently to the chest of a patient referred to him with a heart murmur. The medical resident prematurely inquired, “Dr. White, do you hear the murmur?” White responded tersely, “I am not yet finished with the first heart sound.” It is this systematic, intense, and unhurried kind of analysis that can reap great diagnostic gains for all who wish to become masters of the art.
And it is the art of medicine that creates bonds, this time not between patient and doctor but between teacher and student. When I was still making ward rounds, I always relished being presented with a patient with aortic regurgitation. With a captive audience of students and housestaff in tow, it was always great fun to indulge in the colorful history of this disease. While pointing out the characteristic murmur of aortic regurgitation, I was also sure to highlight its other dramatic physical signs: the collapsing Corrigan pulse; Quincke's pulse (arterial pulsations visible in the finger nail beds); DeMusset's sign (bobbing of the head, named after the French literary figure who had the disease); and the diastolic whoosh elicited in addition to the systolic one as the pressure of the stethoscope was adjusted over the femoral artery (Duroziez's sign).
It was not all cardiology in this respect. About once every 2 or 3 months we would approach the bedside of a patient who seemed obviously hypothyroid, and this had been completely missed by the housestaff. Nothing gave one greater joy than to grab a reflex hammer from some unsuspecting tyro and demonstrate the characteristic slow return of the brachial and Achilles reflexes in the myxedematous patient. “Better get some thyroid tests on this patient,” I would advise—and often enough I would be right.