The Art
As novice medical students, we were taught to look, feel, and observe the form and function of the human body and to use all of the human senses-sight, smell, touch, and, most important, hearing or active listening. We must listen to actually understand what patients are telling us through their personal account of what is troubling them and how they perceive insults to their well-being, or the health of others for whom they are concerned. We were taught that the mastery of this time-honored art was a solemn responsibility passed on to us by Hippocrates and Sir William Osler and from other generations of those who have mastered the art of physical diagnosis. We auscultated with stethoscopes, we percussed (by tapping) hollow spaces (lungs, abdomen), and we were able to appreciate the rhythm's cacophony of the heart, and strident breath sounds.
Losing the Art and Gaining Technology
The history of radiology began in 1785 with the experimentation of William Morgan. During the 1850s, further experimentation was conducted using cathode rays. However, it was not until 1895 that Wilhelm Conrad Roentgen discovered and named the x-ray. He is credited as the father of radiology and later won the Nobel Prize in Physics in 1901. In the decades to follow, we saw the advent of magnetic resonance imaging (MRI), computed tomography, echocardiogram, and ultrasound. All of these technologically advanced diagnostic wonders allowed us to look into the body without the laying of hands. I was taught how to diagnose grade I, II, or III ligamentous tears of the talofibular ligaments of the lateral ankle (the most common ankle sprain). I remember how flummoxed I was the first time I saw a medical student order the x-ray and MRI to diagnose the ankle sprain. Was he wrong? No. As primary teacher for "Problem-Based Learning and Clinical Decision Making," I knew he was taught the use of "Bayesian Theory" to assess the sensitivity and specificity of a test and the probability that there would be something to treat or not, and once pathology was diagnosed, the intent to treat and not to treat was a calculation he was taught to make. The problem with the uber-use of highly sophisticated, technically expensive diagnostic equipment is just that it is expensive.
A Renaissance of Physical Diagnosis
In this month's continuing medical education activity on page 465, Sibbald et al introduce a 1-minute renaissance test that is sensitive, specific, and easy to use-high touch and low cost. As the article demonstrates, the lessons learned in a high-volume austere practice can be generalized to any practice in any setting in the world. The one caveat is that, like any other test, there is operator training and operator-dependent consideration. You must be trained to do this procedure. Given that this is a continuing education article, after comprehending the material and taking the test, you will become an expert in the 1-minute test and apply time-honored physical examination and diagnostic acumen.
"I joke, but I only half joke, that if you come to one of our hospitals missing a limb, no one will believe you till they get a CAT scan, MRI, or orthopedic consult." -Abraham Verghese, MD, MACP, professor, Theory and Practice of Medicine, and senior associate chair of the Department of Internal Medicine, Stanford University School of Medicine, Stanford, California.
Richard "Sal" Salcido, MD
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