Rules

(My friendly colleague made the following reply the next day.)

Dear Szeto,

Thanks for confirming my querries about the RCP approach. But why such rigid rules? Why isn't it enough to inspect by leaning over the bed or couch and turn the head to take in the mid-line perspective? Why sit down in a crowded ward (kneel down on the dirty floor is even worse) when you can raise the bed to maintain the same flow of movement from the shoulder down to the arm, the elbow, the forearm, the wrist, and the hand? ... I was once asked by a colleague and a surgeon of the Royal College of Surgeons of Edinburgh why the recommendation to palpate the abdomen sitting down (or kneeling down). It is not part of their recommendations... The fact is these "rules" are seldom adhered to in day to day practice: not a good way to inspire the next generation of doctors... Should we not encourage our students to learn to understand and not to memorize, to be imaginative and creative, and to be able to put information in the correct perspective?

Sincerely, et cetera.

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Dear Professor X,

If you want the trivia, here are some:

• Carotid pulse character is better determined by thumb than other fingers because the former have good sensation without "sensory noise" from, say, index finger.
• We kneel down to examine abdomen because, contrary to what you say, we hardly have a bed in general ward that we can elevate.
• We inspect the abdomen from the end because we can compare the two sides without prejudice.

There are many rules that appear to be arbitrary but in fact crystallization of wisdom over centuries.

Sincerely,

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Don't get me wrong. By no means I think he is wrong and I am right - in fact it is quite the opposite: Medicine could only be interesting because very often rigid rules of practice could not be applied in real life and we have to adjust and modify according to the actual situation and our understanding of the underlying principle. My humble opinion is, however, one could only be creative and flexible after accumulating substantial experience from prolonged practice.

You would not ask a first-day surgical house officer to perform a creative liver resection, would you ?