Physical examination

Some grumbles of the man from Pluto:

"The physical sign stated on the summary is not right. There is now ascites."
"You cannot rely on signs from trainees ... and young fellows."

For us practising on earth we know that physical signs change with time, and two equally able physicians often have some discrepancy in their physical findings on the same patient. (That is why the Royal College asks for two examiners to sign on the "agreement on physical signs".)

That's a minor point. The important thing is: why on earth we need this kind of examination ? I must say I am absolutely happy to have a physician who cannot detect any heart murmur or ballotable kidneys or apical lung fibrosis. Yes, it is nice to be able to do so, but lack of that skill is not really a fatal sin to bar someone from practising medicine. Not only can we compensate for the deficiency by imaging, technological advances have actually replaced the need of doing a substantial bulk of physical examination in real life clinical medicine. Yes, we have (some of) ECG and chest X-ray in MB and MRCP examination, but they play a really minor part in these examinations as compared to their value in actual practice.

There are of course clinical skills that are of vital importance and need to be mastered - fundi (say, for papilloedema), meningism, GCS, diabetic foot, or even thyroid status. Strange enough the very first item on this incomplete list - alas, fundi - is exactly the one that our man from Pluto believes not important and was deliberately removed from MB examination.

An equally important but even more brutally neglected area of "professional competance" - according to our educationalists' jargon - is the ability to take care of patients with common chronic medical problems in an out-patient setting. For example, how to handle a diabetic patient who comes back for a routine follow up - without any specific complaint. I said brutally neglected because this kind of skill is not only absent in the examination, it is actually not (properly) taught in the current medical curriculum - most of the emphasis goes to acute and emergency medicine. Students do not have to attend out-patient sessions nowadays, and when they graduate and practice medicine, they just find themselves in an utterly unfamiliar battlefield. Yes it is important if my doctor can revive me from a diabetic coma, but I would prefer him to take good care of me so that I do not have a coma at all.

(Note. This is a copy from my notes on Facebook some time ago.)