Since I have been in practice, medicine has changed drastically over the years. Technology and improved practice standards have given way to great changes in the care of patients. When I first started in medicine, there were no electronic charts, most notes were handwritten, and computers were not a standard part of practice. CT scans were relatively new and the MRI scan was not yet invented. Medical students were trained to do a comprehensive history and then a physical exam. Part of the history had to include a detailed account of how the condition the patient has had developed over time. Another part was a detailed exam, including looking at the patient, often with minimal clothes obscuring the body. These are very simple things – listening to a story and looking at the patient.
Unfortunately, many doctors have lost the skill to be able to evaluate a patient. Oftentimes the patient has a classic story to tell and it fits exactly to a particular medical problem. Just spending a couple of minutes listening and asking some questions will lead you to the solution, and it probably matches a common or uncommon medical problem. After many years in practice, looking and listening to a patient tells most of the story of what is wrong. Adding a physical exam will fill in the missing parts most of the time. The fancy diagnostic studies usually are a confirmation of the problem.
Relying On Technology
Many doctors are now trained using technology. The patient history is on the computer and the first thoughts are what do the studies indicate. If the picture (imaging) shows problems, then that must be what is wrong. Treating a test or picture can be okay, but the body has a remarkable way to adapt to changes, and the true problem is usually more complex then the picture and the way to navigate to a solution is to stop and ask the patient what is wrong, then correlate to an exam and picture.
Last week being old school paid off. A new patient showed up at my office frustrated that she had years of pain and no explanation. The patient had been everywhere, including the Holy Grail –The Mayo Clinic – and still no answer on what was wrong. The patient did have a confusing history, but it was important and the details gave the clues. Watching the patient walk and looking at her legs and arms was truly remarkable. The patient was in her 20’s and was significantly weak with loss of muscle bulk.
She had a significantly abnormal exam and likely had a serious muscle and nerve disorder. If the previous physicians only took the time, they would have figured out there was a problem and could have guided the patient towards better solutions years ago. Now, hopefully the patient can get the right diagnosis and help. It may take time and a few more tests, but an answer can be found. One of the best skills a doctor can have is the ability to listen and look at a patient. It is simple, but medicine has changed and doctors are rarely paid to take the time to do the basics.
Thomas Cohn, MD
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