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Lessons From the Bedside Exam ...

Posted Feb 13 2009 5:24pm

Lessons From the Bedside Exam

By PAULINE W. CHEN, M.D.
13 feb 2009--Over the last year, in articles and interviews, Dr. Abraham Verghese, the critically acclaimed author of two nonfiction books and a professor of medicine at Stanford University, has been reminding doctors, medical educators and medical students about the importance of the physical exam, or what he refers to as “bedside skills,” in modern medical practice. But the most eloquent and moving argument to date has come in his newest book, a novel.

“Cutting for Stone” is the story of Dr. Marion Stone, a conjoined twin who is separated from his brother shortly after birth. Born of an Indian nun and raised in Ethiopia, he searches across continents for his English father and his own identity. It is an epic tale, populated by a series of unforgettable characters. I was drawn in from the very first page.

But Dr. Verghese’s book is more than an engrossing read. It is a tribute to great doctoring, a novel that sent me searching frantically for my old medical school physical exam textbook.

Take, for example, one character’s description of typhoid fever. “’ Coma vigil,’ he said....’See how her eyes keep roving as if she’s waiting for something? A grave sign. And look at the way she picks at the bedclothes — that’s called carphology, and those little muscle twitches are subsultus tendinum.’”

Or another character’s lecture on the descriptive names for different physical signs: “’Yes! A treasure trove of words! That’s what you find in medicine. Take the food metaphors we use to describe disease: the nutmeg liver, the sago spleen, the anchovy sauce sputum, or currant jelly stools. Why, if you consider just fruits alone you have the strawberry tongue of scarlet fever, which the next day becomes the raspberry tongue. Or how about the strawberry angioma, the watermelon stomach, the apple core lesion of cancer, the peau d’orange appearance of breast cancer...and that’s just the fruits! Don’t get me started on the nonvegetarian stuff!”

After reading through several of these passages about doctoring, I could not help but feel about Dr. Verghese as the young Marion Stone did about his first doctor-teacher. “He invited me to a world that wasn’t secret, but it was well hidden. You needed a guide. You had to know what to look for, but also how to look. You had to exert yourself to see this world. But if you did, if you had that kind of curiosity, if you had an innate interest in the welfare of your fellow human beings, and if you went through that door, a strange thing happened: you left your petty troubles on the threshold.”

The magical power of Marion Stone’s first doctor-teacher reminded me of my own early awkward attempts to teach young doctors. I strived to convey the importance of looking, touching, listening and even smelling, but inspiring the kind of excitement Dr. Verghese’s novel does is difficult for clinical teachers. The cards — and the glittering allure of technology — are stacked against us.

I recall one day, after finishing rounds with the residents in the I.C.U., when the head nurse pulled me aside. “The residents barely touch the patients,” she whispered, her eyes darting back and forth to make sure no one else was listening. “What they are reciting during rounds is what is charted or what they see on the monitors and radiology reports.”

When I confidentially mentioned the nurse’s concern the next morning, none of the residents — three smart and hard-working young doctors — denied the charge. And as I lectured them about the importance of human touch in relationships, even for individuals who were sedated and unconscious in the I.C.U., they smiled politely, gamely even, the effort accentuating the dark bags under their eyes.

But I could not get too upset. I understood what drove them to shortchange their patients’ bedside exams. I knew, as well as they did, that there was probably more information to be gleaned from radiologic studies, blood tests and monitors than from a rubber tube connected to a metal bell, fingers tapping against the chest, and a palm laid on the belly. And when time was short or when you were uncertain, it seemed far more efficient — and exact — to go by an objective radiologic study than by your subjective physical exam.

In fact, compared to the screens that beeped, the consoles that displayed the latest radiographs, and the machines that whistled and whirred before coughing out test results to the 10th decimal point, my sermon about the laying on of hands seemed, well, quaintly retro, a leftover from the days of the traveling doctor who carried a black bag of tricks.

I spoke to Dr. Verghese recently and asked him about his novel and the ascent of technology at the cost of bedside skills in modern medicine.

“I actually love bedside skills,” he said to me over the phone. “And that is probably the most autobiographical part of the novel. It harkens back to when I was a student. My teachers were magically seeing things we students could not see; I wanted so much to be part of that magic society.”

I asked Dr. Verghese what inspired him to become an outspoken advocate of these skills in modern practice. He recounted several incidents that occurred early in his practice and described the experience of a close friend with breast cancer. She had initially traveled to a famous cancer center for treatment but returned to her hometown to finish her chemotherapy.

“I pressed her on why she came back,” he recalled. “And she said, ’They did everything just right — efficiency, caring, even valet parking — but they didn’t really examine my breasts too well.’”

Dr. Verghese reflected on his friend’s reaction. “You and I might argue that the cancer center doctors did examine her well, that they could see her better with scans and markers than they could with their hands. But to my friend, it was a sign of inattentiveness.”

But how, I asked him, could overworked clinicians squeeze more detailed exams into their already overbooked schedules?

“The busy practitioner struggles with time pressures,” Dr. Verghese responded. “But hurrying through makes us just hurry through. We order a lot of tests because we think we are saving time or because we are uncertain. If you spend more time listening to a patient or being more thoughtful, you end up saving time.”

“I have no illusions about the limitations of the physical exam,” he added. “But I increasingly feel that the exam is an important ritual whose importance has diminished for doctors because we have other ways of getting information.”

“But it is still just as important for the patients,” he continued. “The importance of the ritual of one patient baring his or her soul and body cannot be underestimated. Rituals are terribly important to human beings because they signify transformation. This is how you earn your right to say, ’I am your doctor.’ If as a doctor you shortchange the ritual, you end up making patients feel you aren’t interested. They lose trust.”

He then remarked wryly, “We could inaugurate the president by an e-mail from the Chief Justice, but there’s a reason we have an inauguration.”

Dr. Verghese described the bedside clinical teaching rounds he holds every Wednesday with medical students. “I renew my faith in medicine when I see these students get excited. I want them to feel the awe and privilege of being at a patient’s bedside.”

“It’s so easy for the doctor to just slide into a room and not think,” he said. “But for the patient it is high drama and hugely symbolic. I want us to remember that all the time.”
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