Volume 185 - Issue 11
Clinical paradigms revisited
Author: Ami Schattner
Med J Aust 2006; 185 (11): 671-672. || doi: 10.5694/j.1326-5377.2006.tb00750.x
Published online: 4 December 2006
Published online: 4 December 2006
In reply: Wong writes eloquently, and seems utterly convinced of the merit of the “testing first” medicine that he preaches. Yet his arguments are flawed and his system, appalling.
Young physicians not wearing a white coat are a fairly common sight in hospitals these days. Without a coat, they no longer have a convenient means of carrying around essential tools such as a flashlight, reflex hammer or ophthalmoscope. Indeed, if all they have to do is automatically order computed tomography (CT) scans, they will not need such tools. It is exactly to oppose these negative trends in medicine that my article was written. What I was trying to say was not that history and examination should replace modern imaging, but rather, that the decision about whether and when to order a test, and what test to order, should more than ever be based on skilful verbal and physical contact with the patient. Careful interpretation of basic clinical data such as the proneness of the patient to develop certain conditions (“pre-test probability”), the behaviour of symptoms over time, and the results of very simple laboratory tests are also immensely valuable. Most of this information can only be gleaned from patient–physician communication.1
Would Wong’s approach to acute abdominal pain (do a CT scan first and then let the diagnosis sort itself out later) hold water in cases of acute gastroenteritis, renal colic, peptic ulcer, acute hepatic congestion, incarcerated hernia or Henoch–Schönlein purpura? All these not uncommon causes of acute abdominal pain can be confidently identified by their typical history and findings and successfully treated with no resort to imaging, which may be not only redundant but also costly and hazardous.2,3 An additional downside of imaging without forethought is that it is fraught with false negative findings (eg, early diverticulitis or pancreatitis) and false positive findings (eg, “incidentalomas”) that often result in diagnostic confusion, lost time and more unnecessary testing.4
When the indirect benefits of patient–physician communication and examination are also taken into account, the integral value of the clinical paradigm is even more strongly re-affirmed. Medicine is a humanistic profession. Patients experiencing pain, distress or uncertainty look up to the physician who talks to them, touches them, comforts them and is sensitive to their plight.5 Even the best, latest-generation CT scanner would never be able to do that.
References
- Silen W. Cope’s early diagnosis of the acute abdomen. 21st ed. Oxford: Oxford University Press, 2005.
- Weisbord SD, Palevsky PM. Radiocontrast-induced acute renal failure. J Intensive Care Med 2005; 20: 63-75. i1091787
- Markowitz GS, Nasr SH, Klein P, et al. Renal failure due to acute nephrocalcinosis following oral sodium phosphate bowel cleansing. Hum Pathol 2004; 35: 675-684.
- Kirch W, Schafii C. Misdiagnosis at a university hospital in 4 medical eras. Medicine (Baltimore) 1996; 75: 29-40. i1091791
- Tumulty PA. What is a clinician and what does he do? N Engl J Med 1970; 283: 20-24. i1091794