Saturday, May 05, 2007
They told me in medical school that the diagnosticians of old could thump on a chest and detect a tumor as small as a centimeter. I'm not sure I ever believed it, but I've always had a love for the art of physical diagnosis -- of touching, feeling, listening to the body, and coming to an understanding. As technology invades and pervades, that art is becoming almost (not quite) superfluous and antiquated; an amusing throwback. Look at that old guy, touching his patient. Sweet, really, if a little creepy. Hasn't he heard of ultrasound? Actually, I have. A realist, I've ordered a ton of 'em. Still, I think that more than anything else what makes a doctor a physician is the ability to use the senses to figure out what's going on. It's a wonderful combination of book-learning and the accumulation of experience, of sensory attunement to another person. It's very cool.
In med school, things are revealed one or two at a time, and each finding seems like a little miracle. I remember sitting across from my roommates, getting the hang of an opthalmoscope, using -- as is necessary -- my left eye to see into their left, my right to their right. Frustrated by the red reflex, finally getting past it to see the eye grounds: the retina with its tell-tale vessels and their disease-revealing crossings of each other. The best of the best: the optic nerve. Thumb the wheel to get focus, get the depth right, and there it is. Breathtaking: now, I'm a doctor. Hearing the split heart sounds? Well, I went into surgery.
If you strum a plastic comb next to your ear, the sound it makes is similar to that of obstructed bowel. When examining for appendicitis, it's best to use one finger: point tenderness -- pain in one spot and less right next to it -- is a tipoff. Those things are textbook stuff, teachable. Gauging the tension of an abdominal wall by touch and percussion, judging the sound of the thump -- that's art, based on assimilated input over a lot of cases. If you want to assess perfusion in shock, feel the knees. Looking for subtle differences in circulation to the feet? Place each hand on a foot, hold them there, then switch: differences in temperature will be doubled. Tricks, picked up on the street. They have ultrasounds to see if your bladder is full, measure the exact number of cc's of urine in it. I can get close enough with a thump and a touch. So could you.
No matter how much data I'd checked ahead of time -- labs, Xrays, chart notes -- I never really got the true sense of things until I saw the patient, touched him or her, listened to their words and the sounds of their bodies. Saw their faces. Smelled the air in the room, or their bandages. And yes: poked my finger into their rear end. To the patient -- who knows? -- perhaps it seems like ritual, like posing. Going through the doctor motions. Or maybe it's mysterious and awesome, like a conjurer, a mystic, a whole-body palmist.
Following a careful history and physical exam, I've taken out appendices without the benefit of an ultrasound or CT scan. Same with gallbladders. Even colons, sometimes. Nowadays it feels a lot like insanity, hanging out there too far. Know what? It is.
Every once in a while I'd catch myself, still with my hand on a belly while sitting on the bed talking to the patient and family about my impression, my recommendations. Long-since having garnered the information to be had from palpation, I somehow liked to maintain that touch. As inspiring as it is to be allowed to operate, literally to enter into a bond and to breach boundaries of flesh that only a few are privileged to do, the physical exam has a special intimacy of its own. A unique moment of connection with a fellow being heightened by practical knowledge and distilled experience, it's way more than ritual and show and it ought never to be fully supplanted by magnets and beams. Drawing on all the senses, and the ability to synthesize them; bringing together knowledge, skill, and instinct, as human as it gets, the exam depends on who we are and what we're made of. There's really nothing like it.