“Treat the patient, not the CT scan”

Abraham Verghese  has a fantastic op-ed in the Times discussing the growing, Asimov-esque presence of technology in hospitals at the expense of the physical exam. Not only is physical exam diagnostically important, but it also serves as a timeless ritual in the physician-patient relationship.

IN my experience, being skilled at examining the body has a salutary effect beyond finding important clues that lead to an early diagnosis. It is a ritual that remains important to the patient. Recently my ward team admitted an elderly woman who had been transferred from her nursing home in the night because of a change in her mental status. A CT of the head and all other tests were determined to be normal; the problem had been dehydration, and she was better, ready to go back. But as our team was about to enter the room, my intern warned me that the patient’s lawyer daughter was unhappy with the plan to return her mother to the nursing home, and was waiting impatiently to see me and contest the transfer.

After introducing myself to the patient and to her daughter, I did a thorough but quick neurologic exam. I put the patient through her paces: mental status, cranial nerves, motor and sensory function, used my reflex hammer and pointed out interesting things along the way to my interns and students. I then said to the daughter that her mother seemed back to normal. To our surprise, the daughter seemed comforted, and now had no objection to her mother’s return to the nursing home.

Later, our team discussed what had just happened. We all felt that the daughter witnessing the examination of the patient, that ritual, was the key to earning both their trusts.

In fact, just today in first-year physical exam class, a professor noted that no matter the ailment, patients almost always expect to have their hearts listened to. This desire doesn’t seem to be a sign of an overzealous patient, but rather, a sign of a person seeking a comforting, even sacred, ritual.

Dr. Verghese closes with a poignant analogy:

An answer that might have been posed on “Jeopardy!” is, “An emergency treatment that is administered by ear.” I wonder if Watson would have known the question (though he will now, cybertroller that he is), which is, “What are words of comfort?”

Amen.

Image from mypatraining.com

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