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- Page navigation anchor for Bad medicine - the young onesBad medicine - the young onesMany a time I have been amused by the sharp and witty critique of Des Spence about life in general and in the world of general practice, being able to identify with many of the difficulties faced and seeing the funny side of his cynicism. There has also been a hope that someone out there has been listening and has the power to change things for the better. My interest has been particularly spiced by the fact that I live not far from his stomping ground and I stomp right past the new Maryhill practice on my way to the swimming pool!However, his latest rant in the BJGP left me wondering if his grand old age of 50 has left him bereft of hope and whether he has any therapeutic capability left to help his patients. He recounts a very destructive student life, devoid of any virtue. This negative attitude seems to have matured into solving care crises by doing the opposite and promoting assisted dying. The economic utilitarian argument has taken toll on his sense of duty of care. I hope I have missed his humour, if there was any!Competing Interests: None declared.
- Page navigation anchor for Clinical examination as a "dark art"Clinical examination as a "dark art"
Des Spence’s article regarding clinical examination in my opinion, described a poorly considered viewpoint. In fact in the same edition, a letter was published1 which reflected my own view that clinical examination is paramount, especially in the isolated setting.
Working in the military environment, resources and investigative tests are limited. Purely on the basis of a history and clinical examination, I have to make a decision regarding whether my patient is fit to remain deployed in an austere environment or must return to the UK. Occasionally, this decision can impact on the ability of the military unit to carry out their tasking, which has impact beyond the individual patient. Without a firm grounding in clinical examination, I would not be able to adequately perform my job role, both caring for my patients and provide medical advice to the Command team and support my unit on operations.
Yes, relying purely on clinical examination is dangerous, but so is relying on technology – it can break, can be unavailable and is expensive! A doctor should have the knowledge and skills to formulate a differential diagnosis based on history and examination alone, and utilise focused investigations where possible to prove the diagnosis and/or direct the management of the case. Patients expect this and respect our abilities as doctors. In this increasing time of stretched resources, the “dark art” of clinical examination, while not...
Show MoreCompeting Interests: None declared. - Page navigation anchor for Bad Medicine - Spence and his spellsBad Medicine - Spence and his spells
Des Spence has no doubt learned his craft the hard way. If his intention is to make the business of diagnosis and treatment easier for his younger muggles, he could do no better than direct his students to refer to Primary Care Diagnositics by Nick Summerton (CRC press 2011). The answer to his spells is to be found in the library, not the clinical imaging department.
Competing Interests: None declared. - Page navigation anchor for Bad medicine: Clinical examination - response from the authorBad medicine: Clinical examination - response from the authorThanks you for your response. Writing is sometimes about trying to engage the reader even if you have serious point to make ! In fact I do not suggest that examination has no value , merely that this value is over stated. For clinical examination has huge potential for false positive and false negative results, so as a diagnostic tool has only limited value. I suggest that we teach students a cut back version of examination and impression on the them the limitations of clinical examinations . Much of what I was taught should be cast down.As respect to vaginal examinations . Bimanual examinations misses more than one in three masses and this is in hospital patients under GA. Therefore the error rate is likely much higher in low risk GP populations.1 The clinical value of all Bimanual examinations in any setting is highly questionable. Speculum examination clearly do have value but not routinely as was the practice in the past. For example, there is no indication to do speculum when taking diagnostic swabs which is still common practice. Also a normal examination in a symptomatic patient does not exclude malignancy of the cervix or the uterus.The research you quote is interesting if retrospective observational data.2 I agree that if patients are referred they should be examined (speculum and inspection) but there is no evidence that short delays by GPs adversely effect outcome. The delays...Show MoreCompeting Interests: None declared.
- Page navigation anchor for Bad medicine; clinical examinationBad medicine; clinical examinationThe article Bad Medicine: Clinical Examination might have made me chuckle at the imaginative use of Harry Potter references but it did not persuade me to change my clinical practice.1 The author seems to equate disdain for the perceived hierarchical teaching and comment from medical schools and royal colleges as proof that clinical examination has no relevance.He suggests that we ‘embrace technology’ and cites how CT and MRI have blown away the pom-posity of consultants; both these things may have merit but they do not mean that examination is without value. He is right that it is dangerous to rely on clinical examination; but a good clinician will take a full history and enhance that with appropriate examination, there is no absolute reliance. As a GP, I don't have access to investigations during a consultation; examination helps to determine whether an illness can be managed in primary care or needs to be referred for further investigation or secondary care consultation and whether such referral should be routine or urgent.He again highlights intimate examination such as pelvic examination (bimanual examination +/- visualisation of the cervix).2 .The evidence that this examination is of no benefit to asymptomatic women is clear, but to suggest that pelvic examination has no place in the management of symp-tomatic women is cause for concern. There has been little resear...Show MoreCompeting Interests: None declared.
- Page navigation anchor for Better management of medically unexplained symptomsBetter management of medically unexplained symptomsAs ever - great article.Can I draw your attention please to this piece that was recently published by GP View? It also relates to your other writings about antidepressants.Competing Interests: None declared.
- Page navigation anchor for Clinical examinationClinical examinationA recent article1 questions the value of clinical examination and claims that the “most common defence is that doctors need these skills to work in low income countries”.This is untrue. Practitioners, when making a clinical decision with patients, need to incorporate all the tools available to them. Such tools in primary care may be few but they are crucial. They include the patient’s background, a focused history and a clinical examination. Additionally, consideration needs to be paid to medical ethics and the patient’s values. The thought processes of many junior hospital doctors are echoed by Dr Spence. As a result departments become saturated, tests begat tests and decisions are spiraled ever upwards. One of the first lessons of a new GP registrar is to “unlearn” this mindset.It cannot be denied that evidence based medicine has been a crucial determinant for medical development over the last 25 years. It drives many public health policies and saves lives. Conversely, it is used by primary care bodies to scrutinise practitioner at times excluding common sense. In the uncertain world evolving illness there cannot be evidence for everything. Any objective change – however “soft” can be helpful.A reassuring history and negative examination allows us to use time. Conversely a worrying history especially with demon...Show MoreCompeting Interests: None declared.