Some of my fondest memories from my days as a UCSF Internal Medicine Resident are of Dr. Kanu Chatterjee, Professor of Cardiology, who passed away on March 4, 2015, a few days after his 81st birthday. Dr. Chatterjee was renowned in the field of cardiology, but he was also a superb teacher of young doctors in training.
He was born in Bangladesh and later moved to Kolkata (Calcutta), India where he completed medical school. He then moved to the UK to complete his training in Internal Medicine and Cardiology. There, he learned what British physicians were trained to do:
- First, observe the patient,
- Then talk to him, ask questions, and listen carefully to the answers
- Finally, do a physical examination
Dr. Chatterjee insisted that we do the same.
Observe, listen, examine
We were taught to observe the patient, watch him intently; are his pupils constricted, or are they dilated? Does he “look” sick, in acute distress, or depressed? Then ask the patient to tell you his story—what are his symptoms? How did they start? What makes it better and what makes it worse? We were encouraged to keep on asking questions until we had a good understanding of what was going on.
Then, we proceeded to the physical examination, guided by what we learned by taking the history. Touch the patient; is the skin clammy? Is it dry? Touch the radial artery pulse with just the right amount of pressure and you can feel the subtlest wavelet of pulse following the main one. Listen intently to the heart sounds: Many conditions have their own distinctive rhythm, notes, whoosh sounds, and hushed murmurs. Crowded around the patient’s bed in the Cardiac Care Unit (CCU), we watched Dr. Chatterjee in reverential awe—even if we were exhausted after a long night of call. Here was a craftsman, nay an artist, performing what may have become a long lost art.
The history and physical guide the rest of the work-up
By approaching the clinical evaluation in this manner, you can make a quick presumptive diagnosis. And you can use that information to guide your further evaluation with blood tests, X-rays, CT scans, MRI, and so forth. We never failed to be impressed when days later and after many thousands of dollars in blood tests and imaging studies, Dr. Chatterjee’s bedside diagnoses came back confirmed.
But, alas, things have changed…
Since those days, much has changed in medicine…cost skyrocketed, managed care dominated, and time constraints escalated. Now, it seems, imaging studies have, all too often, replaced the methodical “observe, listen, examine” approach I was taught.
Here’s an example. A few years ago, I had to go to the ER as a patient myself. As I was waiting, I watched a harried physician as he listened to a nurse presenting a new case—an elderly patient who had been transferred from his nursing home with chief complaint of abdominal pain.
Without missing a beat, the doctor ordered a CT scan of the abdomen. I was shocked. He hadn’t even laid his eyes on the patient, let alone taken a history or performed a physical exam. What was his working diagnosis? Did the patient have an incipient appendicitis? A gallbladder attack? A bowel obstruction? Or was he simply constipated?
I wondered to myself: why not ask the patient a few questions about the nature of the pain and exacerbating factors? Why not at least find out when the patient had had his last bowel movement? And, why not examine the abdomen and do a rectal exam before rushing him off for a CT scan?
After a few hours, I learned that final diagnosis turned out to be constipation of 4 days duration as well as dehydration. The patient was discharged back to his nursing home after some IV fluids and an enema.
One of my favorite medical texts
I still cherish my 13th edition (1960) of the British classic, Physical Signs in Clinical Surgery, by Hamilton Bailey. Ironically, I got it from the UCSF library, with a big stamp on the title page: “Discard.” As somebody famously said a long time ago, “Forgive them O Lord, for they know not what they are doing.”
To get an idea how the Brits taught their surgeons in those days, here is a short snippet from this discarded treasure trove:
“The Location of Pain.
Whenever pain is a feature of the case, it is an excellent practice to instruct the patient to point to the site of the pain…Ask him to place one finger on the spot where the pain is felt most. …Only after the patient has concluded his examination do you commence yours.”
Why am I waxing nostalgic?
The good old days? Not quite. When memories fade, we tend to remember the good and forget the not so good. The missing appendix until it ruptured, the high mortality rates of preemies, the awful effects of chemotherapy on children with leukemia, the sense of futility in treating stroke patients and so on.
You’ve got to be an inveterate optimist with a sense of mission to keep going day in and day out. And yet, something has been lost. Is it that there is less and less need to have any sort of relationship with the patient? Or, is it that the art is being replaced by technology rather than augmented by it? Either way, I have to wonder, has medicine lost its soul?