Wednesday, April 21, 2010

Atrophy of Clinical Skills

I read an article today written by a rheumatologist who suggested that health care dollars are wasted because primary care physicians lack physical examination skills. I agree with this notion up to a point. We don't examine patients as well as we used to. Instead, physicans are relying more on test results. Soon your exam consist of your Wii doctor (who looks a bit older than your Wii fitness coach)asking you to hold your crotch, turn your head and cough.

The article was a bit condescending. The author complained that refering docs were not performing adequate joint exams. I responded with the following comment.

"There is definitely atrophy of our clinical skills. In third world countries where there is no availability of high tech diagnostic tools, docs rely on their clinical skills. In these countries, the primary care physician is highly valued because of a broader scope of clinical skills. They perform procedures from fundoscopic evaluations to womens health. And yes, they can even do joint exams. They know how to use a stethescope; a tool that many of my specialist friends are unfamiliar with. I may be old fashion but I still listen for renal artery bruits and clicks in patients with mitral valve prolapse. But it all becomes academic when I order a echo. And that's OK too. I agree with the notion that better clinical skills add value to our healthcare system. But there will always be the spectre of time management, lack of tort reform, consumerism, and technology that drives health care dollars.

There are many reasons I refer patients to specialists. The least of which is because I lack clinical or cognitive skills. I recognize that I am only human and I appreciate the opinion of a specialist colleague. Or maybe the patient needs more focus to a problem that is unresolved. Or maybe because the HMO will not honor my request for an MRI. Whatever the case, the specialist should appreciate and be grateful to receive my patients....with or without a physical exam. This particularly applies to those specialists who rely on cognitive skills to earn a living. They are probably the first ones to be "downsized" in a corporate health care system. After all, as the article describes, examing a joint is easy. Even a primary care physician can do it."

I have great admiration for the horse-and-buggy docs. Most patients don't realize that many of our tests for common diseases are relatively new. For example, in the old days, docs would adjust thyroid medication (dessicated pork thyroid from a bacon company)by checking ankle reflexes. They were pretty good at it. It's true that the old time physicans could diagnose diabetes by tasting the patient's urine. Diabetes doctors were not likely to kiss on the first date...That is, if they could get a date. Personally I'm glad that part of the physical exam has gone. I'm happy to let the machine handle that one.