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Art of diagnosis: There's a reason it's called a 'physical'

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By Sid Schwab
Published:
  • Using the most recognizable and iconic medical technology -- the stethoscope -- Owen Rung, 7, of East Aurora, N.Y., listens to his heartbeat during a ...

    Associated Press

    Using the most recognizable and iconic medical technology -- the stethoscope -- Owen Rung, 7, of East Aurora, N.Y., listens to his heartbeat during a project in the "All About Me" summer discovery camp at the Buffalo Museum of Science on Wednesday.

In medical school we were told that the diagnosticians of old could thump on a chest and detect a lung tumor as small as a centimeter. I'm not sure I believed it, but I've always had a love for the art of physical diagnosis -- of touching and listening, following the clues, learned and taught. As technology pervades, that art is becoming almost (not quite) superfluous and antiquated, an amusing throwback. Look at that old guy, touching his patient. Sweet, really, if a little creepy. Hasn't he heard of imaging? Sure I have. A realist, I've ordered a ton of 'em. Still, I'd propose that what makes a doctor a physician is the ability to use all senses, not just technology, to figure out what's going on. It's a satisfying combination of book-learning and experience, of sensory attunement to another person.
In those school days, revelations came in bunches, and each discovery seemed like a little miracle. I remember sitting across from my roommates in our apartment, getting the hang of an ophthalmoscope, using -- as required -- my left eye to see into their left, my right into their right. Frustrated by the photo-ruining red reflex we all know, finally getting past it to see the eye grounds: the retina, with its tale-telling vessels and their disease-revealing crossings of each other. And then that retinal full moon: the optic nerve. Thumb the wheel of lenses to get focus, get the depth right, and there it is. Breathtaking. Now I must be a doctor. Did I hear the split heart sounds? (It's actually la-lub, la-dub.) Who cares? I chose surgery.
If you strum a plastic comb next to your ear, the sound it makes is similar to that of obstructed bowel. When examining for appendicitis, it's best to use one finger: point tenderness -- pain in one spot and much less right next to it -- is a tipoff. If a person has localized pneumonia, if you ask her to whisper while you listen with a stethoscope, you can hear (theoretically) the whisper more loudly over the area of infection. It's called "whispered pectoriloquy." Other findings with cool names: fremitus, crepitus, borborygmi, rhonchi, rales (rhymes with "pals.") Those are textbook stuff, teachable. Gauging the tension of an abdominal wall by touch and percussion, interpreting the sound of the thump -- that's art, based on assimilated input over lots of encounters. To assess perfusion in shock, feel the warmth of the knees. Looking for subtle differences in circulation to the feet? Place each hand on a foot, hold them there, then switch: differences in temperature will be doubled.
No matter how much data I'd checked ahead of time -- labs, X-rays, chart notes -- I never felt I knew much until I saw the person I was asked to evaluate, touched him or her, observed their faces, listened to their words and the sounds of their bodies. Smelled the air in the room, sensed the level of "sickness." Sometimes, yes: poked my finger you-know-where. To the patient -- who knows? -- perhaps it seems like posing. Going through some showy ritual, a pretense. Or maybe it's mysterious and awesome, like a conjurer, a mystic, a whole-body palmist.
After hearing the words (probably the most important of all) and doing the exam, I've taken out appendices without ordering scans. Same with gallbladders. Nowadays it feels like insanity, out-necking too far. Know what? It is. Back then I'd explain why I thought it wasn't needed; today I'd just give up and order it.
Sometimes I'd catch myself, still with my hand on a belly while sitting on the bed talking to patient and family about my impression and recommendations. Long since having garnered the information to be had from the examination, subconsciously I guess I liked to maintain that touch. As inspiring as it is to be allowed to operate, literally to enter into a bond and to breach boundaries of flesh that only a few are privileged to do, the physical exam has a special intimacy of its own. A unique interaction with a fellow being, heightened by practical knowledge and distilled experience, it's way more than ritual and I hope it's never fully supplanted by magnets and beams. Drawing on all the senses and the ability to synthesize them, bringing together knowledge, skill, and instinct, as human as it gets, learning by touching another person depends on who we are and what we're made of. There's really nothing else like it.

Sid Schwab lives in Everett. Send emails to columnsid@gmail.com.

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