A few days back in one of our social networking groups there was this discussion on “clinical examination in Medicine” – recovering a lost art. There were discussions regarding the importance of the same, at the same time the challenges of doing a full examination in the midst of very busy OPD with each doctor seeing 40 to 50 patients in an hour or so. One of the senior consultants remarked about the 6th sense we need to develop if are to work in busy set ups, where one develops a sense of recognising patients who need full examination and evaluation. As I was participating in the discussions, I was taken back in memory to my early experiences in the art of clinical medicine under a very astute clinician.
I remember, one evening as a Junior Medical officer, working up a patient for about 2 to 3 hours, and coming to a possible diagnosis of “Malabsorption Syndrome” after a full history, clinical examination and investigations. I was quite satisfied with myself, having been able to make such a diagnosis myself and was waiting for the next day rounds to present the patient to the senior consultant. The senior consultant walked with me to the bed side, looked at the patient, and as I was getting ready to present the case with all details, he remarked – He has a Malabsorption look, does not he? I was taken aback. I had spent a few hours working up and coming to a diagnosis and here is this senior consultant walking in, looking at the patient and coming to a diagnosis with no details known to him! I asked him with awe – can you explain, what do you mean by “Malabsorption look”. I had never read this in any text books. He smiled, I remember that smile even now, I do not remember what he said, but it was something of a very humble statement – I cannot explain, one develops a sense over time.
I remember the same day as I was sharing this with awe to some other friends there, they telling stories of such experiences they had too. One shared about a patient with Nephrotic Syndrome, who had been the best hospitals in Mumbai and after renal biopsy coming up with a diagnosis of “Renal Amyloidosis”. And this consultant looking at the patient without knowing any details, gently touched the ear lobes, felt the same, and asked, does this patient have Amyloidosis, secondary to Hansen’s? The subtle clinical sign of ear lobe thickening due to Hansen’s was missed even at the best hospital in Mumbai, though they had taken the patient through all the possible investigations and come to a partial diagnosis.
The question is – how does one develop this sixth sense? Or do we need it at all today, in the context of “technologically driven” “Investigation focussed” science of Medicine than the art of medicine of yester years. Maybe it is my age, I still strongly feel the art cannot be lost to science and technology. The skill of practice of Medicine should be, how to practice Medicine as an art and use science and technology to supplement the art and not the other way around. If so (for those minority who still feel art cannot be lost), we need to champion against the rapid extinction of this aspect of Medicine.
But sixth sense comes out of utilization of the available 5 senses. The issue which we realize today is that, we are not training people to use their five sense well. If one uses the five senses well, the 6th sense will develop overtime. But an undeveloped five senses will stunt the development of 6th sense too. And this will lead to undue dependence on investigations.
The Eye - Vision – observation, The Hands - Touch – the clinical examination, The Ears – to listen and not hear alone, The Smell – to smell some fetors (and not much The Taste), are given to us to engage with people who carry the image of God. Giving up these senses and leaving them under the mechanical evaluation by laboratories and radiological centres is negating the “humanity” of humans. Humans need to be observed, listened to, touched, and even smelt at times, if we are to treat them as people with “imago dei….”
Today morning we had a question put to us, by a consultant – a 16 year old girl walks in with a waddling gait (walking like a duck) – what would you think….?
I leave it for you to guess. But the issue raised was – do we observe, do we listen, do we touch and use our God given senses to relate well to the person who has been brought to us….