Volume 186 - Issue 7
Clinical paradigms revisited
Author: James L Mallows
Med J Aust 2007; 186 (7): 381-383. || doi: 10.5694/j.1326-5377.2007.tb00951.x
Published online: 2 April 2007
Published online: 2 April 2007
To the Editor: It is clear Dr Wong1 has a practice rather different from mine. He is not used to the truly undifferentiated patients that present in their thousands to emergency departments and general practices every day. There, the art of history and examination is truly alive.
No one questions the value of complex imaging. It has its place after a detailed history has been taken and focused examination and relevant investigations have been carried out, leading to a risk assessment and management plan. One does not order computed tomography (CT) scans willy-nilly. For example, the Canadian CT Head Rule2 for patients with minor head injury sets out which patients should have a head CT scan, based on a simple set of historical and examination findings. Moreover, CT scans are wasted on conditions for which CT imaging is inappropriate — it is rare that I order a CT scan for a child with abdominal pain.
When I ask surgical registrars for their opinion, I am actually asking for their consultant’s opinion. Nothing guides like an experienced hand, whether it be feeling a belly or writing a CT request form. On many occasions, I have concluded that all the imaging performed on a patient with abdominal pain did not contribute to the diagnosis and the patient simply needed a laparotomy. At my insistence, the consultant is called, appropriate treatment commences, and the patient boards the experience express on the track to recovery. As Shem quips, in his satirical book on medical training and hospital life — nothing heals like cold steel.3
CT is not the be-all and end-all of medicine. Hopefully, by the end of his training, Wong will have developed the hand of experience and be able to continue the art of medicine through the ages. In the words of William Osler:
The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.4
References
- Wong K. Clinical paradigms revisited [letter]. Med J Aust 2006; 185: 671-672. 0_CBBCDFDH
- Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001; 357: 1391-1396. 0_CBBDHJBC
- Shem S. The house of God. London: Transworld Publishers, 1995. 0_CBBCADFI
- Osler W. Aequanimitas, with other addresses to medical students, nurses and practitioners of medicine. 2nd ed. Philadelphia: P. Blackiston’s Son & Co, 1925. 0_i1091795