Introduction
If you would converse with me, you must first define your terms.
—VOLTAIRE
POINTS TO REMEMBER:
As the library at Alexandria grew one volume at a time, your repertory will grow one fact and one skill at a time. Each must be reinforced and practiced.
While digital computers use binary (yes/no, on/off) logic, the input from a clinical examination is characterized by varying degrees of uncertainty.
In determining the predictive value of a test, the prevalence of disease in a given population is a critical and often forgotten factor.
The sensitivity, specificity, and positive and negative predictive values of a test depend on the cutoff chosen for “normality.” Changing the cutoff point decreases one type of error while increasing the other type.
Accurate problem setting (or question framing) is essential to effective problem solving. Expertise in problem setting is the mark of master clinician.
How to Use This Book
This book is written for clinicians of differing levels of experience, from medical students in their first class in physical diagnosis to attending physicians of long experience. Many sections are designated for the more advanced reader. The presence of more difficult material should suggest to the beginning student that there is more to physical diagnosis than that tiny piece he1 is able to assimilate at the beginning of his studies. Neither physical diagnosis nor clinical diagnosis can be learned in a week, a month, or even a year. How long does it take to learn clinical diagnosis? I2 am still learning after 30 years. According to Tinsley Harrison, Friedman of Alabama was the best diagnostician he knew, and Friedman was still learning (and teaching) pearls when he was more than 70 years old. The best diagnostician I ever knew, Jack Myers of Pennsylvania, was, at the age of 70, entering his second decade of trying to teach a computer to think the way he did. On the other hand, I have had to tell some 24-year-old medical students that they were too old to become physicians because they had already lost their curiosity.
This textbook is intended for physicians, not for subspecialist technicians. Thus, the interviewing chapter is meant to apply to medical patients, not psychiatric patients. It is necessary to emphasize this point because of the present tendency, derived from the evolution of specialty medicine, to teach an abbreviated form of interviewing. And beneath the specialist stands the subspecialist, who may only need to diagnose four or five diseases, and so does not require much of a database from which to construct his history. Furthermore, an interview may not be considered necessary for building a relationship if the contact with the patient is to be episodic or even singular. In this increasingly prevalent situation, the whole patient has become less than the sum of his parts.
The early chapters on physical diagnosis introduce concepts in clinical reasoning that are reinforced throughout the book; they are not intended to be exhaustively descriptive. The scientific method is implicitly reviewed in the section on vital signs, wherein some small group self-experiments are described. By the time one has reached the examination of the heart, one will be reading long passages of physiology, pathophysiology, and hortative instruction.
Many of the advanced maneuvers would not belong in a routine physical examination. However, in order to learn “how to do it,” the student needs to perform a certain number of such special examinations in normal subjects. Just what constitutes an acceptable number as well as which special maneuvers ought to become routine in a given population are questions whose answers are left to the discretion of a wise preceptor.
In many sections, I describe “a method” that I have used, taught, and found to be successful. These methods are not necessarily encyclopedic. For instance, I once wrote an article on physical examination of the spleen (Sapira, 1981a), which included a review of the world’s literature and more different methods than could possibly interest any reasonable person. Although the article was published in an obscure state journal, within 2 months I was informed at the lunch table by three different persons, each of whom preferred a favorite but unique method, of all that had been left out of my article.
Throughout this work, certain “pearls” are indicated by a [
] in the margin. Their selection is based upon the author’s decades of clinical teaching. Some of them may not be pearls for you, whereas other statements might be so. You are encouraged to mark your own pearls.
] in the margin. Their selection is based upon the author’s decades of clinical teaching. Some of them may not be pearls for you, whereas other statements might be so. You are encouraged to mark your own pearls.Finally, there are marginal flags [
] to indicate certain situations indicative of a real or impending emergency, wherein the beginner should immediately seek experienced aid for the patient.
] to indicate certain situations indicative of a real or impending emergency, wherein the beginner should immediately seek experienced aid for the patient.To afford some respite from the prose, and to give the reader a chance to entertain one’s speculative powers, amidst so much concrete instruction, some objets d’art are interspersed. These figures (some of which have been doctored) serve as illustrations of phenomena that were not photographed when I encountered them clinically. In addition, they illustrate the point that one is always a physician, even at the art museum, and that medicine is a learned profession that exists within the context of Western civilization.
The beginning student should not attempt to master everything on the first reading. The text is designed to permit you to reread the introductory passages, and, when you have mastered those, to go on to the complex material. In this way, the book and your experience can be concordant. Do not expect to understand much of the material until you have seen it demonstrated in real patients (e.g., if you are seeing many patients with pulmonary disease, but no orthopedic patients, initially, concentrate your attention on the chest examination and merely skim the sections that have to do with the bones and the joints).
Dr Rene Wegria of Missouri offers an interesting study technique especially suitable for passages that do not have numbers or statements to be memorized, but rather interconnected ideas. Read a paragraph and then close the text and repeat the paragraph back to yourself in your own words, not those of the author. Then reread the paragraph to be sure you understood it. If you cannot paraphrase the passage correctly, read it again and repeat the procedure. Do not go on to the next paragraph until you have mastered the first one.
It is important for you to be an active, not a passive, reader. To help in this regard, there are various quizzes throughout the book, or sometimes simply questions. As soon as you come to a question, attempt to answer it, and write down your answer. Too many students and “educators” alike act as if learning were a passive act. It is not like getting a suntan. You cannot simply show up and wait for it to happen! On the rare occasion when an answer to the quiz is not given, the author means to imply that just attempting to solve the problem should make the answer apparent.
Even better than reading actively is to teach the material, out loud, to imaginary students. It has been said that one remembers 14% of what one hears, 22% of what one sees and hears, and 91% of what one teaches others (Jones, 1990). The technique is recommended by a widely used home school curriculum (Robinson, 1997) and has been used with remarkable success by students who were mostly self-taught, even in learning very difficult scientific material.
For the Junior Student. The mind grows slowly, one skill or fact at a time. Therefore, you are encouraged to read about each patient seen every day and to try to learn at least one new fact about that patient and his disease. Similarly, you may wish to introduce one new maneuver a day from this book.
The greatest library known to the ancients, and possibly the greatest library of all time, was the one at Alexandria. It was built by requiring that no ship could dock in the harbor unless it brought payment of a book. Thus, the library was built one book at a time.
Unfortunately, the library at Alexandria was burnt in a tumult. The one at Constantinople was also burnt, but only so that the manuscripts could be used to heat the water for the public baths. It is said to have taken weeks to consume that library.
The mark of degenerate societies is that they foolishly consume the accumulated wisdom of their predecessors. So, too, is the accumulated wisdom of the clinician consumed by time and senility. Like the library at Constantinople, the only evidence of a former vigor may be the length of time it takes to burn out.
For the Attending. One curriculum is to have the students begin the interviewing course by taking the chief complaint the first week. The physical diagnosis course begins concurrently, with the students determining the vital signs of the same patient. The first case record consists only of the chief complaint and the vital signs, and whatever differential diagnosis that the students can develop. Each week, a portion of the history and the physical are added. For instance, in the second week, the students are asked to compose a history of the present illness (in addition to the chief complaint) and to record the general appearance as well as the vital signs. The next week, the integument is added, and the following week, the lymph nodes. By then, the students may be comfortable with the concepts involved in the history of the present illness and may begin adding the other portions of the history.
This system slows down the bright students, and the class does not get to the examination of the heart until half the course has passed. Also, the course is very expensive in terms of faculty time. The advantage is that any student of reasonable intelligence can be taught to do a thorough history and physical and to construct a differential diagnosis.
A Disclaimer
It is assumed that students will learn interviewing and physical examination by practicing on adults before venturing to see special populations including pediatric and obstetric patients. Growth and development from infancy through puberty, and the progress of a pregnancy, are fields in themselves. Students will need textbooks of pediatrics and obstetrics and will probably also want to obtain tables of normal vital signs, head circumferences, growth curves, and developmental milestones in small books that will fit in a pocket, black bag, or desk drawer. This book will include certain pathologic findings as manifested in pediatric or pregnant patients. The well-baby and prenatal examinations, however, are beyond the scope of this book.
Diagnostic Equipment to Purchase
The Sphygmomanometer
Be sure that the blood pressure cuff that you purchase is sufficiently long; you will also eventually need an extra wide one for accurate measurement of blood pressure in large arms (see Chapter 6). If you purchase an aneroid pressure gauge, which is less expensive than the now-endangered mercury manometer, be sure that it does not have a pin stop. Calibrate it according to the method in Chapter 6.
The Ophthalmoscope
These are the minimum requirements for a satisfactory ophthalmoscope:
An on-off switch (a rheostat is unnecessary)
A circle of light (you do not need the other apertures, although they are fun and may sometimes be helpful)
A focusing wheel
Additionally, you may be wise to purchase an instrument whose handle will also take the otoscope head to avoid buying two separate power sources.
If you have astigmatism, you may prefer to examine patients while wearing your glasses. If so, purchase an ophthalmoscope with a rubber cushion on the facing, so that it will not scratch your lenses.
See Chapter 10 for a discussion of the optional features on ophthalmoscopes.
Tuning Forks
I prefer to use a 1,024- or 512-Hz tuning fork for the Rinne and Weber tests (see Chapter 11) because high-frequency sounds are often the first ones lost in sensorineural defects, which are the hardest to detect. For testing vibratory sensation, the 256- or 128-Hz tuning fork is suggested (see Chapter 26).
Any tuning fork needs to have a sturdy handle with a base broad enough to ensure good contact with the bony prominences, along with tines that are weighted or sufficiently supple to vibrate for a reasonable period of time. Many of the free tuning forks that medical students receive from drug companies are worth what the students pay for them.
The Stethoscope
In 1821, R.T.H. Laennec (The Treatise on Mediated Auscultation, Vol. 1) wrote the following:
I was consulted in 1816 by a young woman who presented some general symptoms of disease of the heart, in whose case the application of the hand and percussion gave but slight indications, on account of her corpulency. On account of the age and sex of the patient, the common modes of exploration being inapplicable, I was led to recollect a well-known acoustic phenomenon, namely, if the ear is applied to one extremity of a beam, a person can, very distinctly, hear the scratching of a pin at the other end. I imagined this property of bodies might be made use of in the present case. I took a quire of paper which I rolled together as closely as possible, and applied one end to the precordial region; by placing my ear at the other end, I was agreeably surprised at hearing the pulsation of the heart much more clearly and distinctly than I had ever been able to do by the immediate application of the ear.
The student should purchase a stethoscope with two different heads: a flat diaphragm, useful for picking up high-pitched sounds, and a bell, which, when softly applied, is better for detecting low-pitched sounds. Some bells have a rubber rim, which helps prevent the examiner from pressing so hard as to convert the bell into a diaphragm by tightening the skin beneath it. It is also useful for auscultating skinny, bony chests, as it is capable of forming a seal, which cannot be achieved with a metal-rimmed bell. You should be able to switch from one head to the other quickly and easily.
The length of the tubing is usually 12 in. or more. It has been scientifically proved that the shorter the tubing, the better (Rappaport and Sprague, 1941); but for tubing less than 12 in., what one loses in comfort (and consequently in the ability to concentrate) is offset by the gain in proximity. The very long-tubed stethoscopes (rarely seen nowadays) date from an era when the physician wished to keep as great a distance as possible between himself and a potentially infectious tubercular patient.
The most important criterion for the earpieces is that they be comfortable in your ears. Under no circumstances should you ever purchase a stethoscope with uncomfortable earpieces. Most medical supply houses will have sets of interchangeable earpieces so that one can get a comfortable set. (You might also find that you can hear much better with one style of earpiece.) Also check to be sure that the earpieces are slanted forward in approximately the same vectors as your external ear canals; some are slanted more than others. Because you will keep your first stethoscope for about 20 years, choose it with care, and do not buy it with the expectation that you will “adjust to it.”
If you wish to compare the acoustic properties of two stethoscopes, the following method will detect gross differences without the use of fancy equipment: Place an earpiece of one stethoscope into your left ear, and place an earpiece of the second stethoscope into your right ear. Place the diaphragms of both stethoscopes on a solid surface, equidistant from a point 2 or 3 ft in front of you. Tap on the point, and in the manner of someone adjusting stereo speakers, notice whether the sound is louder in one ear than the other. To control for the possibility that your hearing is better in one ear, switch the earpieces and repeat the experiment. If the louder sound is now in the opposite ear, you have identified the stethoscope that is better for you. If you have an extra pair of hands, you might want to try this experiment with the unattached earpiece of each stethoscope occluded by a finger.
Question: What is the most important part of the stethoscope? (Appendix 1.1)
Amplifying stethoscopes are available. One study (Lukin et al., 1996) showed a significantly better detection of low-frequency sounds with an electronic stethoscope containing a sound amplifier and noise-filtering system (Medmax2) and suggested that such stethoscopes might have a role in bedside practice. One use of an electronic stethoscope is that the patient or a mentor may listen at the same time (Fig. 1-1). Note that the frequency distribution of sounds may be different from what is expected in the standard stethoscope. Always keep in mind the answer to the question above.
Clean the earpiece of your stethoscope from time to time with a cotton-tipped swab soaked in alcohol. A pipe cleaner might help clean out earwax that has migrated beyond the part that fits in the ear. Persons who produce copious quantities of earwax have on occasion noted it to be appearing at the chest piece. In former days, cardiologists regularly used compressed air to clean their stethoscopes.
Also clean the diaphragm of your stethoscope with isopropyl alcohol. Stethoscopes do harbor potential pathogens, especially on earpieces and diaphragm (Brook, 1997), and could be a source of nosocomial infections. Eighty percent of a sample of
200 stethoscopes were found to be contaminated; four harbored methicillin-resistant Staphylococcus aureus (Smith et al., 1996). Bacterial counts were significantly reduced with isopropyl alcohol, but not with soap and water (Breathnach et al., 1992; Marinella et al., 1997). In one study, cleaning of the stethoscope diaphragm immediately reduced bacterial count by 94% with alcohol swabs, 90% with nonionic detergent, and 75% with antiseptic soap (Jones et al., 1995). With patients who require contact precautions, dedicated stethoscopes left at the patient’s bedside are recommended (Wurtz and Weinstein, 1998).
200 stethoscopes were found to be contaminated; four harbored methicillin-resistant Staphylococcus aureus (Smith et al., 1996). Bacterial counts were significantly reduced with isopropyl alcohol, but not with soap and water (Breathnach et al., 1992; Marinella et al., 1997). In one study, cleaning of the stethoscope diaphragm immediately reduced bacterial count by 94% with alcohol swabs, 90% with nonionic detergent, and 75% with antiseptic soap (Jones et al., 1995). With patients who require contact precautions, dedicated stethoscopes left at the patient’s bedside are recommended (Wurtz and Weinstein, 1998).
 FIGURE 1-1 One use of the electronic stethoscope (A) is to permit the patient or student to listen at the same time as the physician or mentor (B). |
Reflex Hammers
Purchase any kind of reflex hammer that you wish to. The most popular type, currently, is the Taylor hammer, whose head is a rubber triangle (see Fig. 26-24). This is a good hammer for beginners because it has both a point (which is optimal for circumstances in which even the beginner knows the exact spot to be struck, such as the biceps tendon) and a broad surface (which can bolster one’s confidence when examining the ankle jerk). The head is usually mounted on a steel handle that ends in a point and may be used for producing a noxious stimulus (e.g., for the Babinski reflex) (see Chapter 26).
The Queen’s Square hammer (see Fig. 26-26) is popular in England. It has a round rubber ring for striking, mounted on a long wooden handle whose sharpened end can be used for producing noxious stimuli (e.g., for waking medical students during lectures).
My original reflex hammer from medical school was simply a round rubber ball about the diameter of a nickel, mounted on a handle. This illustrates the point that any hammer is satisfactory if the examiner knows where to strike the tendon. I have even used the diaphragm of a Sprague stethoscope, and a former resident, a Vanderbilt graduate, used her knuckle. Some physicians use the tips of their fingers, a tool that is always available.
Other Equipment
It is helpful to have a spring-loaded tape measure, calibrated in both inches and centimeters. It is cheaper to buy one from a fabric store than from a medical supply store.
Do not buy a single pin to use for sensory testing. Chopsticks and a pencil sharpener or a fresh safety pin for each patient may be used for this purpose (see Chapter 26). Or you can break a wooden swab in half and use the pointed end. Hollow needles are too sharp; they cause bleeding. For testing light touch, you need a supply of cotton-tipped swabs. For testing two-point discrimination, you may want to purchase an instrument called a Disk-Criminator, with blunt metal points various distances apart.
Calipers for measuring lymph nodes and other swellings are described in Chapter 8. A goniometer for measuring range of motion, which may be purchased or improvised, is described in Chapter 25.
Space-age Equipment
For those who think that low-tech equipment is obsolete in today’s high-tech society, the equipment used to monitor astronauts for the effects of microgravity includes: a penlight, a sphygmomanometer, an ophthalmoscope, an otoscope with disposable earpieces, a tuning fork, disposable tongue blades, a stethoscope, a neurologic pinwheel, cotton, a reflex hammer, and appropriate restraints (Harris et al., 1997).
The Science of Clinical Examination
Clinical diagnosis is currently the most neglected of the bases for the scientific practice of medicine. Yet, unlike the secondhand information with which the clinician often works, the clinical examination provides information obtained firsthand from the patient. Working with the primary source introduces in an almost effortless fashion the issues of level of certainty, normal variability, interrater reliability, intrarater reliability, and that unique, almost unconscious type of factor analysis used by the expert diagnostician. Experience with the clinical examination thus refines the techniques for handling information in general, and it develops the faculty for critical analysis that marks the scientist.
Unfortunately, the teaching of clinical examination is often marred by Olympian pronouncements sans references for specific statements. Providing references in areas that should be controversial
is one of the unique features of this book. Specific articles may be cited in the text where appropriate, and they will be listed at the end of a section or chapter. Where no article is mentioned, I have sometimes named the individual who taught me the sign. Unreferenced statements are usually based on the clinical experience of the author. (Clinical experience has been defined as “making the same mistake with increasing confidence for an impressive number of years,” in contrast to “evidence-based medicine” [vide infra], which involves “perpetuating other people’s mistakes instead of your own” [Lancet, 1997].)
is one of the unique features of this book. Specific articles may be cited in the text where appropriate, and they will be listed at the end of a section or chapter. Where no article is mentioned, I have sometimes named the individual who taught me the sign. Unreferenced statements are usually based on the clinical experience of the author. (Clinical experience has been defined as “making the same mistake with increasing confidence for an impressive number of years,” in contrast to “evidence-based medicine” [vide infra], which involves “perpetuating other people’s mistakes instead of your own” [Lancet, 1997].)
General references are critically reviewed in the annotated bibliography in the last chapter. Though not without faults, these books, which might be called “golden oldies,” have been helpful to me over the past 30 years, and the statements that I quote have been personally tested.
At bedside rounds at the University of Pittsburgh in the 1960s, Dr Eugene D. Robin always asked for the evidence for the data. His retinue of students and house officers felt that these carefully knotted strings of questions were but a requisite evil to be endured in passage to the nirvana of his 13 nostrums for the treatment of patients with chronic obstructive lung disease. Because there was a reason for each of the treatment orders (tea, supersaturated potassium iodide solution, ephedrine, etc.), it was clear to us that they were engraved on stone and would never change.
None of these nostrums are now used in the treatment of chronic obstructive lung disease, and atropine (which was then forbidden) is enjoying a renewed popularity. But the habit of asking “What is the evidence?” remains current.
The Art of Clinical Examination
Because clinical examination remains a personal activity, historical and anecdotal approaches have a place, and many items in this text are based on experiences that actually occurred during bedside rounds. The occasional use of the first-person singular pronoun may be disturbing to some readers who are accustomed to the impersonal tone of most contemporary texts. The impersonal tone is an implication of universality, implying that the author, like the physicist, has embarked on the discovery of truly universal truths. Alas, there are not many universal truths in medicine, and when there are—when something becomes 100% perfect—that something usually moves into the field of public health or is assigned to a physician extender. On the other hand, the personal pronoun is a statement of limitation, nonuniversality, probability, and conditionality. This is not egotism, but the exact opposite: the plaint of Hippocrates about the difficulty of learning the art, the perils of secure prognosis in our techne (a Greek word meaning science, art, profession, and career, all wrapped up into one).
The use of the personal pronoun is also an exhortation to the student. A student who has made carefully controlled observations in an area where no others have done so not only makes a contribution to the body of knowledge but also shows that he has learned, at an early stage, the levers by which corrigible minds are moved. Such a student has learned the intellectual ground rules of science, the laws of scientific evidence, by which he can stand on the shoulders of his elders. But his observations are still quite personal. They are limited by the environment and circumstances in which they were collected. Another time and place might yield different results to some other person. Thus, the personal pronoun is meant as a reminder of limitation, not as a banner of grandiosity.
Additionally, the personal pronoun is a reminder of the individual responsibility borne by the physician. Despite the proliferation of committees, responsibility must, by nature, devolve upon the individual. It is fitting that observations dependent on a human observer—always a particular human observer—must be signed, unlike the graph of temperature readings. The same is true for the physician’s orders.
An individual may err or even dissemble; but the day that he relinquishes his individual authority and responsibility to an exterior authority is the day he renounces reason and conscience and opens the door to rampant error, pervasive deception, and the destruction of medicine as a profession (Read, 1949).
Ethical Foundations
The Oath of Hippocrates
Often referred to but seldom quoted, the Oath of Hippocrates embodies the assumptions underlying traditional medical ethics. The Oath reads
I swear by Apollo the physician, by Aesculapius, Hygeia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and judgment the following oath:
To consider dear to me as my parents him who taught me this art; to live in common with him and if necessary to share my goods with him; to look upon his children as my own brothers, to teach them this art if they so desire without fee or written promise; to impart to my sons and the sons of the master who taught me and to the disciples who have enrolled themselves and have agreed to the rules of the profession, but to these alone, the precepts and the instruction. I will prescribe regimen for the good of my patients according to my ability and my judgment and never do harm to anyone. To please no one will I prescribe a deadly drug, nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion. But I will preserve the purity of my life and my art. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by specialists in this art. In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction, and especially from the pleasures of love with women or with men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or outside of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and never reveal. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.
Modern Ethics
In modern times, a revolution in ethical thinking is reflected in the various oaths and declarations that many institutions have proposed to supplant the “archaic” Oath of Hippocrates, beginning as early as 1948 with the Declaration of Geneva (Orient, 1994). The underlying assumptions are radically different.
In the Hippocratic tradition, ethics is founded on discoverable but unalterable universal law. The physician is responsible to each individual patient—and to the Lawgiver. The new ethics, in contrast, is based on man-made or positive law, and the needs and goals of individuals are subservient to those of society. Population health takes priority, raising the question of “Who is the patient?” (Jonsen, 1990).
The utilitarian concept of doing the “greatest good for the greatest number”—with Society or Humanity or even the Planet as the patient—is in irreconcilable conflict with the Hippocratic tradition of dedication to the individual patient (Baker et al., 1999). The Oath of Hippocrates is compatible with the Judeo-Christian ethic, the belief that humankind has inherent flaws, and the view that government should be constitutionally limited (Orient, 1981), and is incompatible with totalitarianism. The Oath of Hippocrates was in fact outlawed in the Soviet Union because it might have interfered with the physician’s loyalty to the state (Field, 1957). Utilitarian modernist codes are compatible with an expansive, even totalitarian state, and reflect the utopian view that humankind is perfectible.
The medical ethics of “prehistory”—prior to about 1947—is being supplanted by bioethics (Irving, 2002). Moral absolutes are swept aside in favor of rules and mathematical risk-benefit ratios. Behavior directly forbidden by the Oath of Hippocrates is now defined as ethical, especially when it involves nonpersons or those deemed to be “nonsentient” or otherwise unworthy of life. Replacing the firm, immutable, timeless principles derived from natural law is a dialectic of internally contradictory demands (Arnett, 2002): the primacy of patient welfare, patient autonomy, and social justice. These are the three fundamental principles of the Charter on Medical Professionalism, put forth in response to “unprecedented challenges” of the new millennium, and “intended to be applicable to different cultures and political systems” (Medical Professionalism Project, 2002).
Discussion of the raging ethical conflicts that the American medical student will unavoidably confront is beyond the scope of this book. The reader should be aware, however, of the implications of the Hippocratic assumptions made by this author: the physician’s calling is to serve each patient. An illness is important if it affects the patient, even if rare or politically disfavored. The physician’s purpose is not to classify patients into categories defined by numerical codes, to calculate quality-adjusted worthiness to live, to determine the allocation of a common pool of “resources,” or to achieve bureaucratically determined societal goals and objectives.
Definitions
Semantics has a profound effect on our thinking (Sapira, 1980a, 1981a, 1982). Conversely, the way in which I will use certain terms reflects the philosophy that underlies the approach to interviewing and diagnosis that will be taught in this book. The terms are listed alphabetically to facilitate future reference, but should be skimmed now for purposes of orientation. Mathematical terms related to the analysis of diagnostic tests are defined later in this chapter.
Academic medicine: That practice of medicine in which the practitioner is mainly concerned with the development of new knowledge.
Basic science: The parochially impractical but clinically useful sciences concerned with discipline-bound language and the general rules of scientific evidence.
Compliance: (i) change in volume per unit change in pressure (dV/dP)—a measure of the ease with which a structure may be deformed; (ii) a tendency to give in to others; (iii) obedience to a dictate given by an authority; (iv) (vulgar medical parlance) doing what the doctor wants.
The issue of “compliance” was “discovered” in the 1960s, and a professional discourse was created around this subject in the 1970s by Sackett and Haynes. Thousands of studies have sought to identify causes and design “corrective” interventions on the basis of the assumption that in the age of “evidence-based medicine” (vide infra), patients always ought to follow their doctor’s orders and that those who do not are “deviant” (Lerner, 1997).
I have never had a patient who was completely noncompliant. As a rule, the bones are noncompliant, but the muscles and subcutaneous tissues are almost always compliant (myositis ossificans and calcinosis being the exceptions that prove the rule). I have had a number of patients who chose not to follow my advice. It is quite likely that the problem was with me, not with the patient. I had failed to spend enough time to persuade the patient of the presumed wisdom of my advice; or perhaps I had not got to know the patient well enough to understand why the advice would not be attractive. That failure on my part does not justify appropriating a word from the physical sciences to hide behind while blaming the patient.
These days, government and third parties demand that physicians and institutions be in “compliance” with volumes of regulations; “noncompliance” may be the cause for punitive sanctions. When the term “compliance” is used, it denotes that the subject is in a subordinate position and is very likely to have signed an agreement in which he is called a “provider.”
Conversion: (i) To turn all together: as in, “the patient with atrial fibrillation and a high degree of atrioventricular dissociation underwent direct current conversion to normal sinus rhythm”; (ii) certain neurologic events of psychogenic origin such as paralyses and somatosensory impairments. The Freudian belief is that the unconscious conflict would be unbearable if it became conscious, so instead it manifests itself symbolically in a conversion reaction. (This is a glib summary of a very large body of work that I find quite convincing.)
Delivery system: Something that connects “providers” with “consumers” (Orvell, 1995). Examples include vending machines, Federal Express, and managed-care companies. “Health care delivery” is to be distinguished from the practice of medicine by physicians.
Diagnosis: (i) The process of identifying the patient’s disease; (ii) a thorough understanding.
Disease: A particular destructive process or morbid change in an organism with a specific cause and characteristic manifestations; see Illness.
Education: Teaching the selection of contexts within which acts are performed; see Training.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
