Part One: In Defense of Medicine
Chapter XIII. Farewell to Clinical Medicine?
My Left Kidney. I recently complained of pain in my left side; it appeared during a urinary infection, and recurred four months later. I examined myself as well as I could, and told my HMO internist that I had palpated the lower pole of my left kidney, that it was tender, and that squeezing the organ reproduced my complaint. I was not really worried, that is, didn't think of a tumor; if the pain were due to a tumor, why should it appear during a urinary infection, or disappear for several months? I rather thought of a cyst, or an impairment of the outflow of urine with, as a result, hydronephrosis, that is, overfilling of the kidney's urine-collecting spaces, distending the organ. I asked the doctor if he would consider examining the kidney with ultrasound. I told him that I duly identified the kidney by its rounded, slightly flattened shape, resiliency, "ballottement" between the two palpating hands, and typical mobility with respiration.
The doctor gave me a long look, as if I were telling him I was seeing ghosts. Then he patiently explained to me that "palpation of kidneys was a method of low sensitivity"; that what I had felt could have been the colon, or anything else; and that the kidney, being situated outside the peritoneal cavity, could not move with respiration.
All these explanations were complete rubbish. When a positive finding is claimed, the sensitivity of the method is not in question. Colon, being felt as an oblong soft wad without palpable lower end, cannot be mistaken for a kidney. The site of organs within or outside of the peritoneal cavity has nothing to do with their respiratory mobility. Organs move with respiration if they are attached to the diaphragm, as is the liver, or if they are loose in their bedding as are the spleen and kidneys, and the movement of the diaphragm pushes them down when the subject is breathing in. It is respiratory mobility that enables us to palpate the kidney. Thus, each of us knew for sure that the other was talking nonsense.
Having denied the value of kidney palpation, the doctor nevertheless tried to do it. He told me not to breathe deeply, and several times poked the left side of my belly with the tips of his outstretched fingers. The maneuver could not serve any purpose, either in medical examination or otherwise. It certainly could not be used to palpate a kidney. Finding nothing, the doctor said: "No ultrasound is needed, but since you are a physician, and ask for it, I'll order it for you." The ultrasound revealed a hydronephrosis.
The ineptitude of my HMO internist in his attempt to examine my kidney is, alas, no exception; it is now the rule. It is the sad consequence of the fact that medical men and women no longer learn the art of medicine from experienced physicians. (102)
A master would show them how to position the patient and how to teach the patient diaphragmatic breathing; how to warm up the examining hand and place it flat on the patient's skin; how to exert delicate pressure, avoid eliciting muscular defense, run the hand first cursorily around the abdomen, check the points that give clue to disease of the appendix, of the gall bladder, of the colon; how to slip the hand off to check for peritoneal irritation, and then set about examining each particular organ. He will explain to the student what he feels under his fingers, will verify his findings, confirming that this round shape, moving with respiration, is the distended gallbladder, and the soft touch he's felt, yes, is the spleen.
Nowadays, this kind of instruction is rarely given and even less frequently requested. Since I moved to the United States I've had the opportunity to watch more than a dozen American doctors trying to examine the abdomens of their patients. It was a sad picture every time. They exerted rather brutal pressure with one or both hands, here and there, without a slightest chance to identify any of the abdominal organs; determine their size, shape, or tenderness; reproduce the patient's complaint; or check the classical signs of disease.
I would respect these colleagues more if they refused altogether to touch a patient's abdomen and relied exclusively on CT scan, etc. Such a decision can be criticized, but it can also be defended. But no, they tried to do the examination of the abdomen, so, they recognized its importance, yet had not the slightest idea how to do it.
There have been in mankind's history arts and skills that fell into neglect and oblivion, but clinical medicine has been the first one to be jeered at, scientifically refuted, and buried with relief. Studies have been published showing that history taking did not contribute to diagnosis and was a source of errors, and that palpation of the abdomen was devoid of diagnostic value and misleading. These studies were initiated in the new era, when clinical methods had already fallen into neglect. The subject of these studies was history taking and palpation of the abdomen as performed by "modern" doctors who had never learned how to do it. What they studied was their own ineptitude.
Which Test Shall We Order? Some years ago in Leiden, at Holland's most venerable university, at the weekly conference of the department of cardiology, one of the residents presented a patient as a candidate for coronary angiography. The patient, a man of 35, "complained of chest pain," said the resident. The routine electrocardiogram was normal, the lab findings were unremarkable, and the exercise test gave ambiguous results. Coronary angiography, introducing a catheter to the aorta and injecting dye to the patient's coronary arteries, was necessary to determine the cause of the pain.
"Wait a minute," somebody said. "I talked to this patient, and his complaint is not in the least suggestive of coronary heart disease. The man never felt any pain or discomfort behind the breastbone, never had any symptoms while walking or riding his bike, never had to stand still in the street. He complains of sharp 'stings' of a very short duration, just one second or less, localized somewhere at the left side of his chest, and occurring at rest, mostly when he is in bed. I would think of painful premature ventricular contractions. There is no reason to do coronary angiography. Give him a Holter" (a portable device for round-the-clock registration of heart rhythm).
That resident was simply a fool. Still, he had gone through medical studies, successfully passed all exams, started a specialist training; and in all those years of intense, science-oriented schooling it was never impressed on him that one could talk to the patient, ask him questions, and try to get the gist of the matter. Thus, he catches--not even a complaint, but what he mistakes for the patient's complaint--and rushes to do invasive tests.
Who Has Read Your Ultrasound? A few years ago in Boston, someone in my family noticed a growth in his mouth, on the upper jawbone, and consulted an ear-and-throat specialist. The doctor ordered an ultrasound, and said that the tumor could be malignant, and that the extent of surgery would depend on intra-operative pathology findings. Perhaps the right halves of the jawbone and palate will have to be removed.
I looked into the patient's mouth. There was a growth the size of a large plum. It was as hard as a stone. My heart sank. Was this honest, hardworking man, in his early forties, flesh in the new country where his child...