(First in a series of blog posts for BJS Academy - also available here)
I was at a national radiology conference four years ago when a consultant surgeon stood up and stated, “Clinical examination is dead”. There was a stunned silence for a few moments then hushed murmurs of discontent. She clearly believed it and stated it without embarrassment.
I think that in the context of her talk, she meant that CT for acute abdominal pain is more accurate than clinical examination and that clinical examination has a much lesser role these days. Which is undeniable. But she said what she said.
The shock was largely that she stated very publicly what most radiologists had been thinking for years - that surgeons don’t examine patients as thoroughly as they used to. If at all. But, in fairness, I think we are kidding ourselves if examination hasn’t always been truncated in some way.
In truth, partial clinical examination is often perfectly adequate. We don’t have the luxury of time to scrutinise vertex-to-hallux. Performing a rectal examination on every surgical patient used to be mandatory, the adage being “If you don’t put your finger in it, you put your foot in it”. Now it seems to be tantamount to assaulting the patient, such is the modern distain for using a rubber glove properly.
There is a great deal to be told from just looking at the patient from the end of the bed. Scottish surgeon Joseph Bell was duly celebrated for his visual deductions, being able to tell the occupation, recent activities and illnesses by mere observation. He was also Conan Doyle’s inspiration for Sherlock Holmes. Irrespective of observational skills, you can still diagnose peritonism by firmly kicking the end of the patient’s bed.
There are several other cheats. You will be no doubt aware of the so-called ‘orthopaedic triple point’ overlying the lower sternal body. This is where a strategically-placed stethoscope can hear lung, heart and bowel sounds without needing to move it one inch. But who are we kidding? Orthopods don’t use stethoscopes anymore. They don’t even know which end goes in their mouth.
I was told that there is an ultimate cheat. It is possible to complete a full physical examination in less than five seconds. If a patient can hop up and down on one foot with their eyes closed whilst singing ‘God Save the King’ then you can safely say that their all body systems are probably fine. Trouble is that I’m not sure I could do that. It isn’t my Republicanism but more a question of balance.
You may agree that doing away with clinical examination seems like madness. But apocryphal sporadic tales of surgeons sending patients for scans without clapping eyes nor hands on them are now neither apocryphal nor sporadic. ‘Straight-to-test’ pathways in prostate and bowel cancer are mainstream. As is telemedicine.
Tests can completely replace clinical assessment. I heard of a story of someone who broke their leg whilst skiing in the USA. The first doctor to touch her pre-op was the anaesthetist administering her general anaesthetic for her femoral nail. Hitherto, all had been x-ray, CT, bloods and an ECG. Probably safe but horrifying nonetheless.
Radiologists understand the frustrations of clinical examination. Examination of a patient is like a plain radiograph: specific but not sensitive. It is useful if abnormal but if normal or borderline, it is no use. That is, laying a hand on a patient’s abdomen is not as accurate as a CT but if they leap off the bed, you can be sure they will be encountering surgical steel sooner rather than later.
Yes, clinical examination lacks sensitivity but to omit it entirely is short-sighted. There are two major problems with this approach.
- Firstly, it makes modern surgical practice completely dependent on radiologists. It sometimes feels like that. Some surgeons, it would seem, can’t break wind without having a CT first for ‘?rectal gas’. We radiologists don’t want that; you lot don’t want that either. If every time the patient coughs, they have a CXR or CT abdo after every post-op temperature spike, the system would grind to a halt. Even more broken than it is at the minute.
- Second, radiological tests aren’t infallible. Sure, CT is better than a probing finger but it isn’t perfect. Particularly when reported by the modern breed of teleradiologist who seem curiously more fixated with covering themselves rather than giving a useful opinion. I’m astonished how even tentative reports are worshipped as gospel. Even a faint hint of a diagnosis is accepted as certain.
I don’t think we can turn back the modern tsunami of CT requests that floods every radiology department in the UK. The enthusiasm for CT amongst surgeons and ED doctors leads me to believe that they think ultra low-dose radiotherapy can heal abscesses, haematomata and even cancer itself. Perhaps the front doors to ED should be replaced with the Hoop of Truth (aka a CT scanner)? I joke, of course. But it gets dangerously closer to the truth every time I trot out this particularly tired joke.
But can I appeal to surgeons for at least a vague attempt at the old Clinical Method? You see, radiologists depend on a bit of clinical detail purely to estimate pre-test probability. Now I realise that most surgeons feel that Bayesian Reasoning is Devil-Speak, the sort of nonsense you’d expect from a physician. But radiologists find it useful if you say, “Nah, not really worried about this one”, so we can write off incidental blobs accordingly. However, if you say, “Paul, this patient has cancer written on their forehead”, I’m looking extra hard and not writing-off anything borderline.
If I promise not to mention post-test probability and likelihood ratios, will you promise me to resist this straight-to-test nonsense? Will you teach your resident doctors the words of Sir Lancelot Spratt (“Eyes first and most; hands next and last, and tongue, not at all”)? You can have as many CTs as you like if a surgical hand has touched the patient’s skin beyond a simple handshake.
