A pediatrician reflects on how the art of medical practice has been lost over the years and how teaching it to new pediatricians can lead to better care.
The mother has tears in her eyes; as through an interpreter, I explain to her the significance of her 8-year-old son’s multiple café au lait spots and inguinal and axillary freckling.
She has brought him to our clinic all his life, for ill visits and yearly physical examinations, and nobody has explained to her the significance of these physical findings.
Her son has neurofibromatosis-1, a hereditary condition with far-reaching possible future consequences. She is, however, pleased to know now why her father in Mexico has brown spots and lumps all over his body. This is the third family this year that I have had to inform of this diagnosis. All 3 have been bringing their children to our clinic as their primary care provider for years.
Our next patient, a 5-year-old girl, has come for a sore throat. History elicits a runny nose and minor cough for the past 3 days, and physical examination shows a normal-looking throat without exudates, no cervical nodes, and no fever. The lungs are clear.
As I get ready to explain to the mother that this is a viral disease of little significance, I get handed a laboratory slip: A quick-strep test is positive for beta-hemolytic streptococci. Now I have no choice. Though this girl is almost certainly a carrier, and though I have only seen 3 acute rheumatic fever cases in 50 years of private practice, and all of these were new immigrants from Mexico, I have to treat her for 10 days with penicillin for medical-legal reasons.
Who I am and what I do
I am an “older” pediatrician, long retired, who volunteers at this downtown clinic for the poor. The clinic is staffed with paid family physicians and physician assistants who see the patients. Until recently, I was the only pediatrician. I volunteer 1 day a week to see pediatric patients and act as consultant for the medical staff. Most of the family physicians at the clinic are young and recently trained.
A few months ago, the local university medical school, which has a family practice residency program, started sending a first- or second-year family practice resident for me to mentor for a month at our clinic and teach him or her some community pediatrics. Though I have taught pediatric residents for many years on the inpatient service of our children’s hospital, this is my first experience in an outpatient setting. It has been an eye-opener.
What I learned so long ago
Pediatrics/Medicine 101 in my medical school and residency training all those many years ago taught us aspiring future physicians the importance of a good history and physical examination. That is how we were encouraged to try to arrive at a diagnosis so that we could formulate a treatment plan.
It was stressed that to thoroughly examine a patient, it is important to take the patient’s clothes off. It is just not possible to adequately evaluate the skin, listen to the heart and lungs, palpate the abdomen, or feel for femoral pulses and undescended testicles through several layers of clothing. This was a mantra repeatedly pounded into us.
It was reinforced some time later in my final year of medical school. During the summer I spent some weeks with a missionary physician in the jungle in central India. We saw many patients daily that had come on foot or bullock cart from miles away. To help us, we had a basic x-ray machine and a laboratory where we could perform simple blood counts, urine examinations, and if time permitted, stain smears on a glass slide to look for bacteria or malaria parasites.
Most if not all our diagnoses were made through the use of the history and physical examination. This missionary doctor was the best diagnostician I have ever met, far exceeding even the best professor at my medical school, and I learned a lot from him. I was surprised to see what basic, good care these patients received in this very primitive setting.
You must undress the patient!
When the family practice residents come, I have them see a patient while I observe. One and all, the first thing I have to teach them is: To adequately examine a child, you must have the mother take the child’s clothes off. I now understand why the child with neurofibromatosis was seen at our clinic for many years without anyone noticing the café au lait spots. Nobody had ever totally removed the child’s clothes so that they could really look him over.
The “not undressing the patient” problem is not an isolated one but seems to be ubiquitous in our metropolitan community. I recently saw a new physician (internist) for a first physical. He was very nice and seemed caring, but I could have had a melanoma the size of my hand on my posterior thigh, and it would have been missed. He did not have me take any of my clothes off.
Hold off a minute on those labs
Pediatrics/Medicine 101 in my training so many years ago also included that the physician used the laboratory and radiology not as a “shotgun” approach in making a diagnosis, but that the diagnosis is made first, by history and physical examination, and that the laboratory and radiology are then used to confirm the diagnosis,if necessary.
Our second patient, the child with the viral illness, should never have had the quick strep test that forced us to treat a viral illness with antibiotics and substantially increase the cost of this visit. Nor should the next patient we saw, a 6-year-old girl seen for follow-up for a simple urinary tract infection (UTI), have had a complete metabolic panel drawn at her first visit for this UTI when a simple urine and urine culture were all that was necessary. I have no idea what the previous physician was looking for or hoped to find when the panel was ordered.
I believe that the complete history and physical examination are still taught early on in medical school. However, now much more emphasis during medical school and residency training is put on the science of medicine rather than on the importance of the art of medicine, time spent on physical contact with the patient.
The residents that spend time with me state that, yes, they were once taught to undress their patients, but it really has not been reinforced in their specialty training. The young physicians now are faced with a large number of patients, there is barely time that can be spent with each one, and then more time is taken up to complete the electronic medical record.
With the new radiology procedures available and the new multitude of laboratory test panels that look for any and all abnormalities, there is little, if any, emphasis put on encouraging the good history and physical examination in the advanced training programs for new physicians. This seems to include all specialty training.
The value of a good exam
I realize that I am a dinosaur and possibly have outlived my time, still practicing what I was taught so many years ago. Still, I hope that though I have these eager, young, family practice residents for only a brief time under my wing, I am possibly doing some good in trying to get them to learn some of the old ways that have served so many physicians so well for so many years. Yes, this is Pediatrics 101, and yes, it needs to be reemphasized that physicians of all specialties need to learn to appreciate the value of a good, thorough physical examination. It will make them better doctors in the future.
Dr Weinberg is a pediatrician, Salud Clinic, West Sacramento, California.