Consultant Cardiac Surgeon
Director of the Faculty of Surgical Trainers of the Royal College of Surgeons of Edinburgh
Arthur Ignatius Conan Doyle was born in Edinburgh in 1859 and decided to study medicine at Edinburgh University. It was one of his teachers, Dr Joseph Bell, a Fellow of the College of Surgeons, who most impressed him and influenced his career. Dr Bell was a master of observation, logic deductive reasoning and diagnosis. These attributes were to stimulate him to create that character
of Sherlock Holmes. The back pages of the Oxford handbook of medicine are filled with syndromes eponymous to the clinicians who demonstrated similar skills. Almost all the syndromes described are a collection of observations using the all the senses during inspection, palpation, percussion, and auscultation. Perceived lack of time in clinical practice and the advent of tick box clerking forms are eroding clinical skills, costing money and removing the joys and nuances of history and examination. Inspection of the patient in bed and the surroundings will tell you of the patient is well or unwell – lipstick, glasses and a cup of tea are usually signing well-being. Observation of the patient getting out of a chair and walking into the outpatient room offers indication of frailty and mobility. The handshake is good measure of grip strength and nutritional status 1 . A welcoming smile and a proper address reflect respect.
Few people can talk without hesitation or deviation for more than a minute, but it is recognised that doctors have a bad habit of interrupting 2 . ‘In your own words. please tell me what is bothering you today…’ and listen while observing the ninety five percent communication that is non-verbal. It is what matters to the patient that counts. Verbal and visual cues are important. It was sad to hear a seventy six year old lady presenting for coronary artery bypass surgery telling us that her husband has dementia and falls and that she does not want surgery but wants help with her husband who is asking for a divorce after fifty five years of marriage because she believes he needs to be in care’; it is what matters to the patient that counts. We should not encourage disease conveyor belts – not operating with reassurance is all that is required. Finding a fungating penile cancer inserting a urinary catheter in a patient requiring acute revascularisation is indicative of silo thinking and failure to enquire or look; systems enquiry is a diagnostic sieve predicated with open questions and followed through with direct deductive questioning.
Examination is a privilege. Inspection takes in every detail – a faeculent burp of patient four days post cardiac surgery was the clue to a strangulated umbilical hernia on a late Friday afternoon ward round; this did not need CT confirmation. Palpation is done with the lightest of touches with the extended fingers of steady hand at the level of the elbow whilst cognisant of a knowledge of surface anatomy. The patient is often too polite to tell you if it is uncomfortable, but their facial expression will tell you all. Percussion and tactile vocal fremitus are akin clinical ultrasound. Auscultation should be able to detect the whisper of a murmur and the tinkle of obstruction – what happened to Korotkoff sounds? All patients all the time deserve a full examination no matter how or where they present. A proper examination in our clinic has removed the need for follow up chest X rays and realised a saving of £24 000.00 a year, improved the flow and reduced the waiting times. Investigations should supplement and not replace clinical acumen – ‘routine’ preop tests 3 and post op ‘bloodletting’ 4 costs and caused distress.
The social history not only gives the clinician the sense of value and utility of the decision making for the patient, but it also enhances the clinical contact. How many people have met the designers of the Spitfire or soldiers that have paraded the colour for our Queen? People bring stories – attention to the ‘name of the dog’ 5 and the last holiday recorded in the notes adds to the 5/5 patient experience. It is a simple trick understood by many in the service industry but rarely in the NHS were the operative word should be SERVICE. Ignatius, the editor of Harvard Business Review stated that health care is complex. The CEO of Starbucks said that his business is simple – one customer, one barista and one cup of coffee at a time. Health care is the same – one patient one need and one clinician at a time. The best hospitals in the world have learnt that to fail in that interaction just once is more than enough. A good history and examination is fulfilling for the clinician and ‘transformational’ for the patient 6 . It delivers what matters to the patient, improves flow, reduces costs / litigation 7 and is an enjoyable experience for the clinician and patient.