When you reach the hospital your main duty is to take the history from and examine the patients allocated to you. A good history includes an account of the patient's illness and present symptoms, his previous health and his background, and finally you must record what you have discovered after careful examination of the whole of his body, not only that part which appears to be principally affected. You may feel that all this note-taking is very troublesome and unnecessary. Note taking is an important part of medical education. Careful, systematic note-taking and complete routine examination of the whole body in every case allocated to you will teach you method, develop your powers of observation, and will impress the details of your cases on your memory. Complete examination is essential. Omission has been followed by serious results. Try to make your own diagnosis in every case, at first this may be very difficult and often impossible, as your knowledge increases you will be able to do so more and more frequently and with greater success. Do not be afraid of making mistakes, we all make them, but if we make our mistakes in spite of having exercised care and thought, and if when we have made them we try to find out where our reasoning and observation was at fault, we may learn more from our mistakes than from our easy or sometimes fortunate successes.
Try as far as possible to make a preliminary diagnosis before the results of the clinical laboratory tests and x-rays examinations are available. In many obscure cases such a diagnosis will not be possible, nevertheless it is sound practice to try and make it. Some day you may be in such a position that these examinations cannot be made, and you may have to make an urgent diagnosis without these aids. But an even more important reason for following this method is that by doing so one acquires keener powers of observation, reasoning and deduction. The rapid progress of medicine has brought a certain danger in its train; the possibility that too much reliance may be placed on the results of laboratory tests and radiological examinations at the expense of careful clinical examination. This can never be replaced.
The history is not just what the patient says, indeed, it is often far removed from it. Many patients are quite incapable of giving a clear account of their symptoms, without your active help. Their memories may be bad, or they may be inarticulate, incapable of expressing their discomforts. Many subjective sensations are peculiarly difficult to describe in words so the patient often takes refuge in meaningless terms, for example having "blackouts." Or they use words in a different sense to that in which we use them, i.e. a patient says he feels giddy at times, suggesting that he is suffering from attacks of vertigo of labyrinthine origin, when, as a matter of fact he should have said he feels faint and is really suffering from recurrent attacks of cerebral anemia on account of paroxysmal tachycardia or transient heart block or from anemia following a gastro-intestinal hemorrhage which is worse when he stands up.
Some patients minimize their symptoms. They want to be allowed to continue working or to continue with their normal activities, or having screwed up their courage to come to the doctor, they actually minimize their symptoms lest the doctor should discover something seriously wrong which is what they fear so much. Others consciously or unconsciously exaggerate their symptoms, it may suit them to be ill, it may prevent the daughter or son leaving home, or they may think they have failed to impress the doctor last time.
The history is therefore not merely what the patient says, rather it is the truth, the whole truth and nothing but the truth, it is the facts in as far as they can be ascertained, as to the evolution and nature of the patient's symptoms against the background of his life, and the relevant events in it, and his emotional reactions to them. The truth is always difficult to obtain, indeed except in the simplest cases, all that one can reasonably hope to obtain is some approximation to it. Different clinicians often succeed in getting two very different histories from the same patient - do not think therefore that to obtain a good accurate history is relatively easy, and that the elicitation of signs more difficult and their interpretation most difficult of all. With practice you may soon become proficient in eliciting the physical signs that really matter, even signs in the lungs and heart, but it will be many years before you succeed in getting the really good history which would stand up to cross examination in a law court.
Physical examination is important as physical signs are objective and verifiable evidence of pathological change - accurate physical signs have value as undisputable evidence in the case, in spite of inconsistencies and confused data in the history. Symptoms and signs vary in clinical value in proportion to the extent to which they narrow the possibilities of diagnosis. Skill in physical examination only comes with experience, but it is not merely experience and skill in clinical examination which determines how successful one may be in eliciting the signs which provide the clues to the correct diagnosis. Detection of a few scattered petechae or of a faint diastolic murmur at the aortic areas in the early case of subacute infective endocarditis is not accomplished because the trained clinician has eyes, ears or fingers that are more acute than those of his colleagues, usually these diagnostic signs have been revealed because the observer has been prepared by other features of the history or examination to search for them.
We recognize what we know. The student in his early stages should know that he is able to appreciate obvious symptoms and signs presented by the patient even though his mind may be almost a blank in clinical matters, but there is frequently an equally useful set of signs which are only to be found when specially looked for. A slight enlargement of the thyroid or minimal exophthalmos may be overlooked unless there is in the clinician's mind the thought that the rapid pulse may be of thyroid origin. A few lymphatic glands which from the softness of their consistency could easily have escaped observation may be readily found if leukemia is for some reason suspected from the history or the finding of an enlarged spleen. With the possibility of Addisonian anemia in mind enquiry as to the occurrence of a sore tongue and pins and needles in the legs may elicit an answer in the affirmative even when these symptoms have not even been volunteered by the patient. It is usually true to say that if after a well-taken history the clinician has no reasonable idea of the likely differential diagnosis, then it is unlikely that he will be much wiser after a full examination. In fact, a good history often gives the important clue to the correct assessment of physical signs which are more apparent to the clinician who is aware that they might be present from the history.
A final diagnosis is often as dependent on an accurate history as on a clinical examination. Physical examination can only be fully interpreted in its context of history. Careful history-taking and assessment are the very essence of diagnosis and provide a task as difficult and perhaps even more beset with pitfalls than physical examination. Thus loss of power in the legs may be due to an injury to the cord following an accident, or to a meningomyelitis from an infection such as syphilis or to disseminated sclerosis, or to compression from a spinal tumor. The symptoms and signs produced by these different causes are more or less identical but the history of the first is acute and sudden and dramatic, the second subacute over days, while a slow and gradually progressive development over months indicates the findings are probably due to spinal compression. Furthermore, many symptoms are purely subjective. They are abnormalities experienced by the patient, such as trigeminal neuralgia, and are accompanied by no outward or visible sign of disease. It is only by his description that we can learn anything of their nature and distribution.
To know exactly what signs to look for in any particular case demands enough knowledge of disease to enable the clinician to have in mind, from the very outset of the physical survey, some tentative idea as to the nature of the case suggested by the history. It is well at first to keep an open mind so as not to prevent other ideas pertinent to the case entering the mind. This means that the process of differential diagnosis begins to take form at the very onset of a clinical examination. Some teachers advise the student to reserve all such speculation until he has collected the whole of his data, but if this forbearance is exercised, the great advantage gained by looking for particular physical signs is lost. The eye and the hand see and feel the things which they take with them, the power of seeing and feeling. It is impossible to keep the mind blank, whilst an exhaustive history is being taken and a clinical examination is being carried out. It is desirable to encourage the play of tentative ideas, and so make a deliberate search for abnormalities - this process becomes automatic in time.
The exercise of humility, some tolerance and the persistence in a logical method will prevent any notions obtained early in the case from becoming fixed ideas and dominating the mind. Other ideas must not be discarded, and facts taken out of their true context must not be wrongly used to strengthen a preconceived idea. The clinician must be logical in all his thoughts.
There is a technique of the mind as well as of the eye, the ear and the hand, and the informed mind is quite as essential as our five senses and invaluable for their most useful employment. It is not only what you find at the bedside, it is also what you bring to the bedside. The eye sees what it takes with itself, the power of seeing. It is the mind that sees and in like manner the hand and the ear. In time there comes to some - slowly, painfully, after much experience, an expert facility born out of patient practice in the fullness of time - recognized as the clinical sense. To those who do not have these sense momentous things can happen under their very eyes but are not observed. In the first aphorism of Hippocrates he warns us that experience is fallacious yet we must confess that when experience leads us astray the cause is the faulty interpretation of facts which would be clear if we but had the eyes to see. In medicine experience is unavailing unless that common sense which is said to be the least of our senses is also brought to bear upon our daily problems.
The Clinical Approach
Whenever a patient comes to a doctor two questions must be answered “What is the matter with patient?” and “Why has he come?” This is the beginning of real medicine. Many patients are helped by having found a ready and sympathetic listener. Many problems can be helped by simple explanation and reassurance.
There is no method of assessing how, why, when and where his disease developed unless time is spent in eliciting a careful history. Disease is only made manifest to us by the symptoms it produces. Symptoms bring the patient to the doctor, they are the voice of disease and usually the first indication. The history of the illness tells us the evolution of the malady. The previous health, personal and family history are all important. They tell us what man has the disease, which is as important as what disease the man has. That matters is how he has reacted to his disease. You must assess and deal with sick people, make a habit of assessing him by observations made as he recounts his story and answers your questions. You must understand the physical and psychological reaction of the patient to his disease—understand him as a person—as a human being—the only true clinical assessment. Only by skill in observation and interpretation in the light of adequate knowledge and experience, only by exercising care and patience, and by cultivating wisdom and judgment, can the greatest of medical accomplishments—skill in diagnosis—be a skill.
It is important, therefore, to know the environment as well as the physical condition. The good clinician takes into account social and economic factors, conditions of work and leisure, standards of housing, clothing, diet and personal habits. What difficulties, anxieties, fears, conflicts he has to meet and try to overcome - we search for stress. He sees the ill worker as the father and breadwinner, the woman in childbirth as a wife and mother, the handicapped child as an educational problem and a source of anxiety to its parents. We see sick men and women, all differing in their individual responses, both physical and psychological to their disease.
Examine the whole patient - body and mind - not merely that part of the body which appears to be the source of complaint. You must be expert in psychological as well as physical signs. You must know what kind of a person you are dealing with and how valid is his evidence. You must assess his intelligence, education, memory and symptom threshold. Determine whether there is overstatement, understatement or the truth.
When you have received the history - you should know a good deal about the person you are dealing with. You should also know something about the disease which has attacked him and how he has responded to it. You must know if he is ill or merely inconvenienced.
The clinician at the bedside is the only link between the human being who is ill and the vast knowledge and resources available for a cure, resources accumulated over the years by human intellect, energy and investigation. Although the doctor himself may not possess the knowledge, he has access to both know ledge and facilities, through a consultation or by sending the patient to a special centre. The doctor's skill, carefulness and care make possible the contact vital for recovery.
Medical science and clinical art are both essential for correct diagnosis and treatment. They are not matters of intellect alone. The clinician's soundest judgment comes from a fine integration of his cerebral cortex with his hypothalamus. What is happening in your mind and emotions during the years in which you learn the basic sciences of medicine and proceed to your clinical studies may make, for many people, later on, the difference between invalidism and health, or even between life and death.
The practice of medicine is a way of life which transcends the making of a living or a career. It is an excellent calling, demanding all we have to give of mind and heart, of knowledge and of wisdom.
The clinical side of medicine must not be obscured by the scientific. Science alone is inadequate. On many occasion s without clinical skill the basic fact on which a patient’s health depended might not be elucidated. A good doctor must have the clinical flair, a receptive mind, and courage to expose himself daily to human situations. He must have wisdom as well as knowledge.
All these qualities do exist in the good clinician. We must never lose the individual touch; we must accept our responsibility. Thus radiography might indicate a gall stone but only a sound clinician would know if its removal would cure the patient. At the consultation a new facet may be revealed; a woman might be asked "Are you happy?" and she might burst into tears and reveal the true state of affairs.
The student, in order to begin to unravel the problems which patients may present to him, will always have to learn how to elicit the sacred facts. Correct observations properly recorded are sacred fact not to be disputed. Interpretations and comments are both open to be disputed and changed.
These will come only from taking accurate case histories, accounts of circumstances and symptoms of patients, and from the acquisition of very considerable skill in physical examination. The data so obtained must then be arranged in some sort of mental pattern or picture so that it can be compared with previously recorded clinical experiences.
You must learn to appreciate not only words but also appearance, behavior, gesture and facial expression. You must appreciate the general demeanor of the patient - his personality and emotional tone, his alertness, how he reacts to questions, his attitude to his illness and to you, his doctor. The items in the history should be integrated into the impression of the patient's illness and his physical and emotional reaction to it.
We are dealing with sick people all differing in their individual responses to their disease, not merely cases. We must not forget the patient as a living person with a mind as well as a body. The patient is not a thing, but a person, the doctor must know that and remember it, and make the patient feel that he appreciates him as a person. The psychic and soma react on one another and cannot be separated. The clinician must have insight and a comprehensive view.
If physical examination fails to reveal organic disease, emotional problems and fears must be explored. Many physical diseases with recognized pathological processes have important psychological causes, and many diseases formerly regarded as "mental disorders" are now known to have important physical causes. The psychological approach to every sick person is just as important as is the physiological and physical approach. The psychosomatic approach sees the patient with his personality and his disease in relation to his whole environment. It deals with the sick person skillfully and intelligently as a human being - noting his individual responses, both physical and psychological to his disease.
You must become adept with the cherished and clinical instruments which will be your precious life-long friends - the stethoscope, percussion hammer, ophthalmoscope. Choose the type of stethoscope which best suits you - people differ - but remember the most important thing about a stethoscope is what lies between the two earpieces when in use.
Remember as you examine the patient he is likewise assessing you. You may shatter his confidence in your sensitiveness by a careless clinical examination. Never examine the abdomen with a hand that is cold or has long finger nails which can produce discomfort and always palpate first an area which you know is not tender. Be very gentle - you can feel far more when you have gained the patient’s abdominal confidence.