In the USA the issue of indiscriminate use of expensive, sophisticated, and time consuming test in lieu of, rather than in addition to, the clinical exam is being much discussed. The cause of this problem is of course multifactorial. One of the factors is the decline of the teaching of clinical skills to our medical students and trainees.
Such problems seem to have taken hold in developing countries as well. Two personal anecdotes will illustrate this.
In the early nineties I worked for two years as a faculty member in the department of ob & gyn at the Aga Khan University Medical School in Karachi, Pakistan. One day, I received a call from the resident in the emergency room about a woman who had come in because of some abdominal pain and vaginal bleeding. While the resident told me these two symptoms her next sentence was: “… and the pelvic ultrasound showed…” I stopped her right in her tracks before she could tell me the result of the ultrasound scan. I told her: “First tell me more about this patient. Does she look ill? Is she bleeding heavily? Is she in a lot of pain and where is the pain? What are her blood pressure and pulse rate? How long has she been having these symptoms? When was her last menstrual period? What are your findings when you examined her ? What is the result of the pregnancy test?”. The resident could not answer most of these basic clinical questions and findings. She had proceeded straight to a test which might or might not have been necessary or even indicated and she was not using her clinical skills or judgment.
In another example, the resident, also in Karachi, called me to the emergency room about a patient with a ruptured ectopic pregnancy. He told me that the patient was pale, and obviously bleeding inside her abdomen and on the verge of going into shock. The resident had accurately made the diagnosis, based on the patient’s history, examination, and a few basic laboratory tests. But when I ran down to see the patient, he was wheeling the patient into the radiology department for an ultrasound. "Why an ultrasound?" I asked. “You already have made the correct diagnosis and she needs an urgent operation not another diagnostic procedure that will take up precious time before we can stop the internal bleeding.” Instead of having the needless ultrasound, the patient was wheeled into the operating room.
What I am trying to emphasize is that advances in technology are great but they need to be used judiciously and young medical students and trainees need to be taught to use their clinical skills first and then apply new technologies, if needed, to help them to come to the right diagnosis and treatment. And of course we, practicing physicians need to set the example. Or am I old fashioned and not with it?
Medico legal and other issues may come to play here and I am fully aware of these. However the basic issue of clinical exam is still important.
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