The Clinical Eye: Mastering The Art Of Diagnosis
In ages past, before the time of ultrasounds and x-rays, CT scans and MRIs, the only thing that doctors had were their five senses. I never thought I would experience this kind of medicine, but going back to my home country proved otherwise. I had to find fetal backs with palpation alone, listening for the faint heartbeats of tiny babies with the bell of my stethoscope. I used mirror microscopes to view cuts of spinal cord and was taught to discern a diagnosis based off of my patient interview and physical examination alone. “Document or you didn’t do it” became a literal process as I spent time writing progress notes in paper charts. Our patients did not have the money for batteries of standard tests, they considered that a luxury and relied on us, on our clinical eye, instead.
Growing up in the United States and having worked in healthcare before my time in medicine, I was used to seeing standard orders but my time in a developing country for the duration of my medical education allowed me to find and experience an old and tried and true way of “doing medicine” and these are the things that I loved the most about the “old ways.”
#1: The patient is the one that knows their experience best.
Your greatest resource and best teacher is your patient. This is the truth of medicine and its practice, especially with patients that suffer from chronic disease. Oftentimes by the time they encounter us – the youngest and lowest on the totem pole, and with the least experience – they’re able to tell us everything from when they were diagnosed and how, to their symptoms, to the medications they take and any problems they’ve had as well as other issues that may or may not relate to their disease process. In instances where the patient is coming to the doctor for the first time, their experience is what leads us towards the diagnosis. Their history is more storytelling when we listen for the first time, a way for us to hear about all the characters and key players. If we pay attention, we can often discern that they are having difficulties just by the way they say something or illustrate something to us. These nuances are what create and build our clinical eye, and the better we pay attention, the more we know, thus leading to a quicker and more accurate diagnosis.
#2: Patients totally, absolutely lie
Dr. House’s favorite line became famous for a reason and that’s because it is, unfortunately, very true. Not all patients lie, but there are many that do – whether it be an omitted truth or vague response, the role of the physician often becomes an investigatory one! It is in these cases where our expertise is most needed; when a story does not match up with a physical examination finding or when a physical examination finding makes no sense when coupled with the patient’s history, our clinical eye blinks. Should the patient choose not to tell us the whole truth, our clinical eye helps us to still come to the correct diagnosis which then can be confirmed and validated by our diagnostic procedure of choice. The clinical eye sees all.
#3: Technology does not always translate to perfection, or even accuracy.
When I went to my internist for my yearly checkup, they attached me to leads for my electrocardiogram. I looked around the room for the machine and was surprised when they simply plugged the end into a computer with a USB. In less than five minutes, we had a six-second strip up on the monitor with my results read and entered into my chart. This kind of progress and innovation means that technology in medicine continues to evolve. We have gone from x-rays in two dimensions to three-dimensional ultrasounds. We can see the smallest occupants of our body moving along their protein links in electron microscopy and hunt for veins with a Doppler.
Even with all this technology, nothing can replace the human touch. I vividly remember one day in a crowded maternity ward where all the newborns needed blood draws for their newborn screenings. We had one newborn who was a hard stick, the residents had tried, the phlebotomists had tried and yet no one could draw his blood. His mother was distraught because they wouldn’t be able to go home until he was screened and so on a whim, they asked me (a clinical clerk at the time) to give it my best shot, as I had spent most of the day drawing blood from unwilling babies and mothers. He was too feisty to use a Doppler and even if we could, his limbs were teeny tiny. So with a deep breath and just the pads of my fingers, I located the artery and went in for the arterial stick and got it. After our two milliseconds of shock, the residents and my fellow clerks sprang into action as I held the catheter in place as the blood dripped into our collection tubes. That was a moment that humans won, for me. While we cannot deny the advantage that technology gives us, it is no replacement for practice, for human touch, for experience.
#4: Be confident in your skills and in yourself, but know that you can always ask!
A lot of having the clinical eye is believing that you have it. I distinctly remember interviewing patients on various occasions and after the first five minutes thinking to myself Oh my gosh. I have no idea what this could be. And I would sit there and panic internally while taking notes and nodding and smiling at my patient to continue! Oftentimes, we as medical learners are paralyzed by our fears – what if we look stupid? What if the question is dumb? What if we ask about something we should know already? We get so caught up in what asking the question will make us look like that we allow the question to remain unasked, and worse, unanswered. One of the best things that came from learning medicine in a setting where both resources and supplies were scarce I had to learn how to rely on myself – I had to believe in what I was seeing and hearing and what conclusions my mind came to based on its analysis of the facts backed up by both theoretical knowledge and clinical experience, albeit limited. Even more important than relying on myself was knowing that I could look to others, that the questions I was too afraid to ask were always the questions worth asking. No matter how “dumb” or ill-prepared it made me look in the moment, I needed to remember that I was asking for the future patients whose lives I would hold in my hands and I could set aside my fear (and pride) for them.
#5: It takes a lifetime.
A lifetime of learning. We hear it all the time as doctors. I first heard it when I was in medical school, a professor was warning us of what we had “signed up for,” which is a lifetime of education, a lifetime of learning, a lifetime of exams and evaluations and assessments, a lifetime of knowledge. As I’ve gotten older, I’ve learned that it’s not because we don’t know anything, but because we will never know everything. And so, with the same fire with which we chase our theoretical learning, we say yes to all the hours spent in outpatient clinics, yes to every interview, yes to every patient admission and yes to every case conference and presentation. We say yes to pursuing the lifelong commitment of honing our clinical eye.
Technology does make things much easier for us and many times, it helps us to illustrate our findings for our patients and our families. Though I do not discount its value, I truly believe that the clinical eye – the education we get from our patients and the skills that we learn through practice – is a treasure, an invaluable skill and beautiful experience. And in this world of beeping monitors, cool hard drives and brisk keystrokes, there is something to be said for a physician who warms their hands and listens, with a stethoscope and with their hearts.