Disappearing Art of Clinical Practice

In November 1966, the practical part of my MS examination was being held inAmritsar. It was very cold but the sight of my examiners – Prof. SSAnand, A.K.Basu, BNBRao, GC Sharma, Eggleston etc. had made it icy cold for the 20 odd examinees who had collected there from all over northIndia.  It was the first of the five sessions spread over 3 days. The examiners arrived for the long case. Just prior to me there was a candidate from my PG Institute, who had failed twice before. He presented a case of lump inRIF, 5 cms in diameter, firm in consistency, dull on percussion, slightly tender and mobile. The examiners asked for the diagnosis and he said appendicular mass; of course he did mention two or three other possibilities in his differential diagnosis. Prof. Anand, the internal examiner for the candidate roared- “you said the mass is mobile ?”, “ yes sir” – the candidate mumbled; Prof. Anand- “you idiot, in my 40 years of surgical career, I have never seen an appendicular mass to be mobile, I am ashamed of you, get out and come after 6 months”; and there the poor chap’s entire examination came to an end. The importance of clinical examination, elucidation of physical findings and their proper interpretations could not have been hammered more appropriately. 30 years later while examining a DNB candidate at Pune, when I found that the candidate could not evaluate the fixity of a breast lump or tell me whether the thyroid nodule had mediastinal extension or not, I became very annoyed and also very depressed. Like Prof. Anand, I could not debar the candidate from the rest of the examination, but I definitely made sure that he would not pass this time however good his remaining sessions may be. Fixity of breast tumour and mediastinal extension of a goiter are important findings and the management depends upon this.
In this era of CT scan and MRI, Ultrasound and Mammography, it is not unusual to see a large no. of clinicians, and I dare say particularly the younger ones, do not even bother to get up from their cushioned chairs to examine the patient, they coolly write down sophisticated and expensive investigations and depend entirely on their results.  Anyone complaining of abdominal malady is subjected to US or CT or MRI scan upper GI endoscopy or colonoscopy or may be both. Modern day clinicians are completely dependent upon the imaging results, little realizing that the imaging expert may be a novice and the observation and interpretation may be far from being reliable or correct one. It has been proved beyond doubt that at times the investigation results may be inaccurate, moreover the results have to pass though human eyes and minds.

A large no. of surgeons will easily testify that the actual operative findings are at a great variance with the imaging results. An imaging result of inoperable case easily turns out to be resectable and vice versa. I feel that 90% of the cases can be easily diagnosed on clinical examination alone and decision taken for the line of treatment.

A few cases managed by me during the last 2-3 years will illustrate and prove my point of view:

A 85 years old NRI has been complaining of recurrent attacks of acute abdominal pain with nausea and mild abdominal distension for almost 50 years. He was extensively investigated inCanada, no cause was found. Every attack brought him to the hospital emergency, where he was treated with analgesics and antispasmodics, IV infusions, antibiotics etc. On examination I noticed mild abdominal distension and increased bowel sounds. On detailed questioning, he gave me the history of abdominal kochs about 50 years back for which he had recd. ATT for 9 months. My diagnosis was sub acute intestinal obstruction and advised him exploratory laparotomy. The patient was surprised that I had advised him surgery without undertaking imaging investigations but he consented for it. Exploration revealed a solitary stricture in the terminal ileum and stricturoplasty cured his long standing problem Recently a former patient of mine brought her old father, who was being treated with chemotherapy for lung cancer on the basis of chest X-ray and CT scan of the chest. I could elicit history of frequency and hesitancy of micturition suggesting BHP. Rectal examination revealed a huge malignant tumour of prostate and the diagnosis was established following FNAC. We have forgotten the dictum- if you do not put your finger in the rectum then you put your foot in it. Doing a PV or PR examination should become a routine with every abdominal examination.

I can easily recollect at least three patients during the last 1 year, who were referred to me for urgent appendicectomy following US scan in two and  CECT in one patient. I was not impressed on clinical examination and rectal examination revealed hard faecal matter in all the three cases and manual evacuation and enemata cured the so called appendix patients.

A patient of intestinal obstruction was being treated as a case of acute pancreatitis with paralytic ileus. Exaggerated bowel sounds with metallic tingling clearly gave the diagnosis of mechanical obstruction but no one had put his stethoscope on the tummy. All of us have been taught these basic steps right from third year of our undergraduate days but we easily forget the golden teaching. Present day surgeons of course do not carry a stethoscope anymore so the auscultation is already a forgotten step.

A young man of 30% electric burn complained of abdominal pain and I was called to see the case. The plastic surgeon in charge  of the case, the GE specialist , dermatologist had  seen the patient and he was being treated with antibiotics, analgesics, purgatives, tranquilizers etc. and then the opinion of a general surgeon was sought. He had superficial burns on the left side of abdomen and left thigh but was complaining of pain on the right side. He had guarding, tenderness in the right lower abdomen and I could elicit psoas spasm also. I lifted the bed sheet below the waist line and I was horrified to see a huge swelling in his right thigh, very tender, raised temperature and his distal pulsations were absent on that side. There was some oozing of blood stained fluid from two three puncture sites in the femoral region. The nurses have been puncturing the femoral vein to obtain blood samples resulting in huge false aneurysm of femoral vessels with secondary infection. He was being dressed on alternate days but no one had bothered to examine him completely.

I was once called by a very senior urologist to examine a senior faculty member who was complaining of pain and swelling in the lower abdomen and was being treated as a case of BHP for the last six months.  There was a large globular mass in the suprapubic region which was thought to be distended urinary bladder. I asked the patient to go and pass urine, he did that but the swelling did not regress at all. Subsequently he was found to be having leomyosarcoma infiltrating into urinary bladder and sigmoid colon.

I can easily recall three female cases of cancer breast seen by me last year, one chief engineer, another one wife of a CEO of a corporate hospital, and third one being Professor in an university , all three of them had  lump in the breast , FNAC were carried out , all were reported as negative and cleared for cancer. But the swellings went on increasing, they came to me for second opinion and  clinical  examination revealed locally advanced stage, FNAC repeated elsewhere were positive. False negative reports are not uncommon for in cytology but if your clinical examination is good then you should ask for repeat FNAC  or may be for excision biopsy but only if you have done the clinical examination and your fingers tell you that the lump looks suspicious.
Detection of cervical lymph node in a breast cancer case or an inguinal lymph node in a patient of anal canal or genital cancer completely alters the stage of malignancy but we still do not bother to do complete examination. Similarly not measuring a breast lump exactly with a scale or caliper can easily alter the staging of the disease and thus the line of the management.

Worst instances of non application of clinical examination are seen in emergency or triage areas. Haemodynamically unstable patients, even of head , abdominal and  chest  injuries are sent to radiology department for CECT, MRI, US scan etc. and they spend 2 to 3 hours over there unattended and uncared for; and scores of instances can be easily found when  the patients have crashed down. We forget that only two or three decades earlier these investigations were non existent and careful, repeated bed side clinical examination could elicit the same information

Absence of clinical examination have converged our vision to a tubular one, we do not see a patient in totality. Take for example a patient of blunt trauma to abdomen, Ultra Sound scan shows laceration leading to haemoperitoneum, he is taken to OT without a detailed clinical examination and the patient collapses after intubation as no one detected the massive haemo-pneumothotax in him.

Failure to undertake proper clinical examination not only leads to incomplete diagnosis but also leads to misguided management.

It seems the present day doctors are treating the images, photos and laboratory reports of the patient and not the human patient. The money spent on useless investigations is the bonus that the patient pays for the careless attitude of the doctor.  Clinical examination can be performed any where and at any time. The best part is that clinical examination can be made repeatedly and this is of immense value not only for diagnosis but also to evaluate the progress of the disease. A patient of acute abdomen may not give the diagnosis of acute appendicitis at the first clinical examination but a repeat examination conducted after 1 to 2 hours later if demonstrates the presence of guarding, rigidity and tenderness   then the diagnosis is obvious. You do not require a CECT to diagnose appendicitis.  It is also important to remember that the clinical examination results can be elicited by different clinicians and compared.

It is also important to remember that in the present era  when patient –doctor relationship is of so much importance, it is the clinical examination that brings the two together as  it involves human touch and some closeness between the two , which is not possible in any technology, however advanced it may be.