I was taught medicine like it was a religion. Indeed there were many similarities. A hierarchy with different dress codes, venerated objects, its own language of incantations, and an unshakeable belief in the infallibility of it all. I would often look around at my classmates as they read their spell books and wondered if they too thought this was all just hocus-pocus. My sense of absurd wonderment was greatest when I was being instructed in the dark art of clinical examination. I tried hard to learn the steps and rituals but it was difficult, because it made less sense than the rules of Quidditch. And there was always some jumped-up SHO prefect nerd telling you that you were doing it wrong!
The neurologists were dark wizarding masters, with their trademark bow tie, opening a magical briefcase full of obscure objects like tuning forks, dusters, and squeakers. All supercilious terms and ridiculous syndromes, demonstrating rare clinical signs that no one else could ever detect. But then came the cold winds of CT and MRI, and blew all this pomposity away. Technology has done the same to the cardiologist and chest physician who once proudly strutted and tutted on the wards, angrily chivvying the young warlocks and witches about their lack of clinical skills.
And the real concern about clinical examination is this. I know the predictive value of D-dimers, troponin, chest X-ray, MRI, sigmoidoscopy, and ultrasound. Clinical examination tests, however, are neither sensitive nor specific, with unacceptable rates of false positive and false negative results. Relying on clinical examination is dangerous. I have had many a duel on this topic.1–4 These articles questioning the legitimacy of examination met with vehement defensiveness but little by way of objective evidence of benefit.1–4
And the most common defence is that doctors need these ‘skills’ to work in low-income countries. But if you don’t have access to investigations then you are unlikely to have access to treatments! And what percentage of our graduates actually work in low-income countries? These clinical tests are redundant and usurped. Specifically, intimate and invasive examinations should stop for they are illogical.2–4 But the royal colleges have a belief system built on this mumbo jumbo,5 for much of medicine’s status is vested in clinical examination.
Most medical schools are as progressive as Hogwarts, trapped in the 19th century. There is no free thought, just relentlessly mindless dogma. Even questioning these doctrines gets you sent to Azkaban. I accept there are a few clinical signs like diamonds, but it is time to teach students about the huge limitations of clinical examinations and cull most of the traditional teaching. We should use our time and energy teaching appropriate investigations and history-taking, understanding uncertainty through the paradigm of probability, managing medically unexplained symptoms, and addressing health-seeking behaviours. For there is a new reality that we are spectacularly failing to prepare our students for. In the near future, there will be a total-body MRI at the door of all emergency departments.
Technology isn’t magic but it is magic, and it’s time to embrace it. Dear medical schools, Voldemort isn’t real, wands don’t work, and that’s just make-up on Harry’s forehead.
But no one seems to listen to a Muggle like me. Perhaps I need to start wearing a bow tie!
- © British Journal of General Practice 2017