Physicians

Laying on of the Hands

It appears that except for physical therapists, masseuses, and priests no one lays on the hands anymore. Certainly contemporarily trained physicians do not.

Recently I went to my local ER because a 2-day old pain in my back “due to a strained muscle” from a gym work-out was now, at 11:00 PM, causing me to be quite short of breath and unable to lie down. The ER reception desk was empty and, as the sign instructed, we picked up the phone and announced our presence. An ER nurse came out, signed me in, registering me as a new patient, escorted me back to a cubicle, recorded my vital signs, took a short history, listened to my chest (“A few crackles there in your back”), started an IV, ordered an EKG and a chest x-ray, and drew a whole bunch of bloods, one tube of which revealed that I was probably having pulmonary emboli (clots to my lungs). The CT scan confirmed the diagnosis of “multiple bilateral pulmonary emboli”.

Then I saw my first doctor. While standing at the bottom of the bed juggling a clipboard that was barely controlling various colored sheets of paper, she took a short history, listened to my chest (“A few crackles there in your right posterior chest”), told me that the CT scan was positive, and that the admitting hospitalist would come to see me soon. The nurse explained that the ER doc was busy with a very sick patient being transferred into town.

The admitting hospitalist was a true gentleman. He even sounded like a gentleman with his clipped British accent and Eastern Indian last name. He took a longer history, listened to my heart and lungs (“A few crackles on the right side there”) and outlined what was to happen next; a stay in hospital for three days at least, immediate anticoagulation, and tomorrow an ultrasound of the legs and an echocardiogram looking for a source of the clots. He explained things very clearly, was reassuring, and answered my questions succinctly and thoroughly. I felt that I was in good hands, …but I was a little uneasy that no one had done a complete, or even a semi-complete, physical exam.

What has happened to all that we were taught in second year Physical Diagnosis?

No one stretched my calf looking for a positive Homan’s sign. No left lateral decubitus positioning to listen for that subtle, easy to miss heart murmur. No confirmation that my extraocular movements were normal. No listening intently for a carotid artery bruit. Forget looking for splinter hemorrhages on my retinas or even under my fingernails. My abdomen could have been hiding an enlarged liver or spleen, but no one would have discovered it that night. Come to think of it, I do remember the admitting hospitalist briefly pushing two fingers against my shins and commenting, “trace edema”.

After a day shadowing a physician in a program sponsored by our local medical society, a banker summed up his impression with, “A physician’s job is a day-long quest for credible data”. I agree, and it is clear to me that the physicians caring for me that night were doing just that as efficiently as possible. Why bother checking for Homan’s sign when an ultrasound tech the next morning will tell you if there is a clot in the leg, its location and how big it is? The echocardiogram will give so much more information about my heart dynamics than an application of a stethoscope for a minute or two. With a dramatic CT scan showing all the clots and some pleural fluid, and with me having significant pain every time I took a breath, why spend a lot of time percussing my chest, feeling for vocal fremitus, or switching back and forth from bell to diaphragm on the stethoscope?

As technology has advanced, objective test results have replaced many physical findings as the foundation of a correct diagnosis. The job of the physician has become in large part that of deciding which test will give the best information. That is not bad, but I remember that our Physical Diagnosis professor won more “Best Teacher” awards than any other faculty member, … or any imaging machine. He not only provided us with our first glance into the real magic of clinical medicine, but he imprinted us with the appreciation that “laying on of the hands” was a vital part of a respectful relation with the patient.

I received excellent, efficient care. I was diagnosed quickly and treated appropriately, courteously, and was fully informed. But, in remembering Eliot Hochstein, MD I have to say that as a patient I sure do miss some parts of the “good old days”.

One part of the “good old days” hasn’t changed. At about 1:30 AM after all the tests that night were done and I was being prepared to be moved upstairs to a bed, I was still really uncomfortable because  I had not yet received any pain medication. I asked for some, and got my first dose at 2:00 AM.

References:
1.Physical Diagnosis, a textbook and workbook in methods of clinical examination 
by Elliot Hochstein and Albert L. Rubin. Published 1964 by Blakiston Division, McGraw-Hill in New York .

Herbert Mathewson, MD, blogs at HUB’s LIST, a compilation of medical fun facts gleaned from a variety of medical journals, newspapers, other public and professional sources, and an occasional private communication.

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Francoisfeed hammermillGraham ChiuLouise Denton, MDTaylor Walsh Recent comment authors
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Francois
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Francois

Dear Dr. Mathewson,
I share your regret for the lost art (and the mostly unpursued science) of the physical exam; however, I respectfully submit that according to all available evidence, Homan’s sign is neither a sensitive nor a specific sign, and that it’s use should be discouraged.

feed hammermill
Guest

nice post
hammermill thanks for your sharing

Graham Chiu
Guest

I remember reading a study that showed that listening for carotid bruits is a waste of time. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1496909/ and the take home message is, don’t waste time looking for things in asymptomatic patients.
On the other hand .. what was the result of the lupus anti-coagulant? Why do you have multiple PE? I take it you’re not on estrogens! 🙂

Louise Denton, MD
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Louise Denton, MD

Comparing people to cars! Now that is a brilliant idea! Just what the politicians do, comparing toxic CPOE devices to typewriters. Gag me.

Taylor Walsh
Guest

Eerily reminiscent of how another “body” is treated these days: the automobile. Technicians read computer output and do the fixing. I had a bad catalytic converter “fixed” that way, and was back two months later with the same problem. In first instance the computer didn’t record the leaking oil that caused the bad converter in the first place — and the second. An honest to goodness mechanic would have had his face and hands in there and made the full diagnosis. These guys just said, “the computer didn’t say anything.” In both these cases, the technologies are geared to locate… Read more »

propensity
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propensity

http://www.nytimes.com/2010/10/12/health/12profile.html
I bet they each billed the highest level E and M code, while cutting corners. This has now become the standard of care. If there is an EMR involved, the computer gets more time than the patient.

HMathewson, MD, www.hubslist.org
Guest

Actually from a previous hospital experience I knew that the hospital would charge about $4000 for the CT scan and Medicare would actually pay $600. How could I have used that information that night? Should I ask what the hosptial in the next town charges for their CT scan? What would I do with that information? The real question to ask is how the difference between $4000 and $600 should be negotiated. Who should make the decision as to how much it is worth? Of course to me as the patient with shortness of breath and chest pain, the CT… Read more »

Jason Bohmann
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Jason Bohmann

What is more scary is that you have no idea of the cost of the services you’ve been provided or an expectation of the future cost of your treatment. Only in healthcare to be go in and submit ourseleves to blank checks written on our behalf. I think this is partly because many of us have health insurance, but also due in large part because our physicians and hospitals have a huge incentive to act like price is not open to discussion. Upon entering the facility you should have been presented a menu of costs so you know exactly what… Read more »