Things palpable

When I was in first-year medical school at U of C, our four-member clinical skills group met once a week with a preceptor to review history-taking and physical examination on a hospital patient. We would each have a chance to show our stuff. Our preceptor was an experienced, well-respected cardiologist. We spent at least 2 hours with the patient before presenting the case to him at the bedside. I vividly recall one occasion where I felt very confident that I had done a good job. I reviewed the history then came to the physical exam and said, “Examination of the fundi was normal.”

The preceptor interjected, “You’re sure they were normal?

“Yes,” I reiterated. To my dismay I was informed that the patient had one glass eye.

I felt like a complete idiot. Not only had I not taken a thorough enough history and done a proper exam, but I was doubly embarrassed because my father was a GP on faculty who was coordinating the physical exam teaching at the time, and an anatomy professor to boot. I learned a lesson, but I’m sure this happens to many of us at one time or another (the other lesson I learned—never try to put one over on a cardiologist!). I think most of us try to take shortcuts occasionally—it’s natural when in a busy practice, but every time I have done so, something comes back to haunt me, and I’ve done a disservice to my patient.

I must be a slow learner, though, because it took a few more errors of omission, or laziness, before I realized that you can’t take shortcuts. I recall examining only one foot of a diabetic patient and missing a potentially serious infection in the other (the patient had neuropathy and no symptoms), not picking up an infected tongue piercing in a diabetic with uncontrolled hyperglycemia (not common, but the patient didn’t want to tell me he’d had it done and thought the discomfort was just expected post piercing). These examples are perhaps simple but emphasize the importance of always fully examining a patient.

We live in age of sophisticated technology and in medicine have at our disposal an array of advanced testing methods and imaging studies. Patients now come to our offices with their total body MRI scan reports (for which they have paid privately) that require assessment. A typical report that I see shows small (<1 cm) thyroid nodule, osteopenia, small renal/adrenal cyst, etc. Are these significant? Generally not, but we are obliged to investigate as best we can. I have sent a number of these thyroid nodules for fine needle biopsy (as I can’t palpate them myself) and usually get back a report saying “indeterminate” sample. Now what? We now have to follow up with ultrasound to see if the nodule enlarges (or not), but statistically these are benign. The incidence of thyroid nodules increases with age and most are of no consequence. How many health care dollars are we spending chasing things that are possibly not necessary to chase? If I had examined this patient I wouldn’t have palpated a thyroid nodule, end of story. The likelihood of this person having thyroid cancer is small, but if the nodule grew and became palpable I would clearly have done a biopsy and would still likely be monitoring it without treatment. On the other hand, an acquaintance of mine had an MRI that showed severe arterial calcification. He went on to angiogram and coronary bypass surgery. He was ecstatic that this had been diagnosed and treated before he experienced any symptoms. However, he succumbed to lung cancer a few months later; the MRI report had indicated this was a benign-appearing lesion. Would a thorough bedside assessment have made any difference? In this case probably not; it is unlikely that these problems would have been picked up on history or physical exam.

In the end though, the outcome would not have changed and he would have probably been spared costly surgery and a lot of angst.

I liken our job to that of a today’s mechanic. If we take our car in for assessment now, it is hooked up to a diagnostic machine that spits out codes telling the mechanic the problem, sometimes incorrectly. In the old days the mechanic would start, rev, and idle the engine, listen to the various sounds it made, and, using his experience and knowledge, would make a diagnosis and repair it. Now, because of computerization, the mechanic is forced to follow a series of automated steps. As physicians we are often relying on a vast array of tests, which are excellent and important tools, but I believe cannot (at least not yet) replace our experience and “sixth sense.” Will we get to a point where the doctor/patient interaction is unnecessary—Star Trek style? Perhaps, but I hope that’s long after my time.

—SEH