Volume 186 - Issue 7
Clinical paradigms revisited
Authors: Sandeep Chauhan, Ruth D’Cruz, Sanjay D’Cruz, Ram Singh and Atul Sachdev
Med J Aust 2007; 186 (7): 381-383. || doi: 10.5694/j.1326-5377.2007.tb00952.x
Published online: 2 April 2007
Published online: 2 April 2007
To the Editor: Apropos the letter by Wong entitled “Clinical paradigms revisited” in the Christmas issue,1 declaring fossilisation of the very pillars on which medicine stands, we would like to express a contrary opinion.
To be adept physicians, clinicians must hone their skills at taking a lucid and informative history and conducting a thorough physical examination. It would be a crying shame if young doctors, having slaved for 5 or more years to obtain a medical degree, had to rely solely on expensive investigations when they have the God-given tools of the five senses. To confirm a clinical diagnosis and assess the extent of disease, doctors should order specific and appropriate investigations, rather than ordering tests that may be irrelevant and financially bleeding the patient. The issues of cost, radiation hazard, availability of trained personnel, and need for expensive equipment have been trivialised.
In a country like India, where the majority of the population cannot afford even minimal hospital fees, to even contemplate using a computed tomography scan as a first-line diagnostic tool for something as basic as abdominal pain is absurd.
Moreover, the use of advanced technology does not guarantee a correct diagnosis. A recent case of aortic dissection was misdiagnosed as acute coronary syndrome on the basis of electrocardiography.2 If due emphasis had been given to pulse and blood pressures in both limbs, this mistake could have been avoided. In another case, involving recurrent loss of consciousness, investigations were non-contributory, but a history of substance misuse at home pointed to the correct diagnosis.3 In another study, clinical judgement regarding the severity of pneumonia was found to be a more reliable predictor than a standardised scoring system based on clinical signs and laboratory findings.4
Doctors ought to be able to make a clinical judgement in the first instance, rather than resorting blindly to expensive investigatory tools. We do not deny the usefulness of modern technological devices for confirming or ruling out clinical possibilities, but they must be used judiciously. Such investigations cannot take precedence over physicians’ reliance on their clinical skills, lest we become helpless without technology.
References
- Wong K. Clinical paradigms revisited [letter]. Med J Aust 2006; 185: 671-672. 0_CBBJEEGA
- Jauhar S. The demise of the physical exam. N Engl J Med 2006; 354: 548-551. 0_CBBJFCDE
- Rubin D, McGovern B, Kopelman RI. Back to basics. Am J Med 2006; 119: 482-483. 0_i1091797
- Siegel RE. Clinical opinion prevails over the pneumonia severity index. Am J Med 2005; 118: 1312-1313. 0_i1091799