The Vanishing Art of Clinical Science – Hyposkilia

This has been written by Dr. Anisha Sawkar Tandon, a consultant radiologist at the St. John’s Medical College, Bengaluru. You can reach her at anisha.sawkar at gmail.com

I am a practicing radiologist. Over the past few years I have noticed a disturbing trend that threatens to destroy the very nature of medicine. I have been witnessing increasing referrals for radiological investigations even before a clinical history has been taken. We radiologists are familiar with the experience of having to report radiological studies with absolutely the bare minimum clinical history or the complete lack of it. But what has begun to shake me to the core is the fact that even when I have gotten back to the referring clinician for more information, there have been innumerable instances where they simply do not know more just because they have not really talked to the patient in detail, leave alone examined the patient.

Here is an example of one of the situations that I was confronted with when reporting an MRI of the brain of a 58-years old lady who was sent from the emergency department. The referral form mentioned, “Rule out cerebral venous thrombosis (CVT)”. These were the only words of “history” provided. The MRI brain not only had no signs of CVT, but there were some symmetric basal ganglia changes that favored a metabolic encephalopathy, likely related to chronic liver disease. Since the Emergency department is easily accessible with a phone call, I could immediately contact them and ask for more details.

At first, since their question was “rule out CVT”, I attempted to elicit some history related to CVT. The disturbing answer that I got was, “The patient basically has altered sensorium and since CVT is one of the conditions that could cause CVT, we just wanted to rule it out!” I tried to find out more about the altered sensorium and the information I got in response was, “She basically looks like a psychiatric case and also has diabetes and hypertension”. After obtaining this invaluable information, I explained my findings and requested them to assess whether the patient had some form of liver dysfunction since the findings were definitely “metabolic” and not “psychiatric”.

These events had occurred at 6 pm in the evening. The next day, when I decided to follow up on what had happened to my patient, I found this sequence of events that had unfolded after my MRI brain report. The patient, had, at 7 pm undergone an ultrasound of the abdomen, which showed cirrhosis of liver with portal hypertension and ascites and suspicious nodules in the liver. At 8 pm, the patient had undergone a CT scan of the abdomen that confirmed the cirrhosis with regenerative nodules, portal hypertension and ascites. Meanwhile the results of the liver function tests showed findings consistent with chronic liver disease and the patient was known to be HbsAg positive for 5 years. The next morning, a clinical examination by a gastroenterologist and neurologist concluded that the patient was, in fact, in hepatic encephalopathy.

If you analyze this case, it worked out beautifully for the radiologist. What else could a radiologist ask for? An MRI brain, an ultrasound abdomen and a triple phase CT scan of the abdomen in one patient in one evening! What about the patient though? It’s scary to think that not one, but all of the above investigations could have been avoided by just basic history taking and an adequate clinical examination.

I understand that in a busy ER, not every patient with altered sensorium is going to undergo a 30 minutes detailed neurological exam, but a 30 minutes exam wouldn’t be needed if the simple task of talking to the patient had been accomplished which would have brought out the known Hepatitis B status. Whenever I see this kind of situation, I am appalled at what medicine has come to. There are so many more such instances in which an ultrasound of the abdomen is the first time that a large laparotomy scar has been noticed, or an MRI brain study is the first time when a craniotomy has been discovered and the referring clinician has had no knowledge of the same. It’s a different situation when such cases have been directly referred by some remote village primary health center “(PHC) and then perhaps the lack of knowledge by the referring physician can be overlooked. But it’s acutely disturbing when these cases are referred by our own colleagues, specialists in their fields and the first person to touch the patient’s hurting abdomen is a radiologist.

As a radiologist who wishes her field to thrive, I should have no cause for complaint. But as a doctor and a clinical radiologist, I am concerned about the kind of medicine we practice today, where the end result is unnecessary investigations and ultimately a burden on the patient and the system.

I would like to end by quoting Sir Robert Hutchison who said the following words, which sadly are very pertinent today

“From inability to leave well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art, and cleverness before common sense, from treating patients as cases, and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.”

Comments

  1. Dr.O.P.Srivastava says:

    Absolutely right.I agree to you 100%.Clinical evaluation definitely plays an important role.I am an old timer(Graduated in 1967).I remember a case of our time where by tapping the sternum to find it tender in a severely anaemic lady,we could suspect Leukemia,which got confirmed by lab test.

  2. Anisha Sawkar Tandon says:

    Dr. Srivastava, thank you for your feedback. We enjoy interacting with old-timers, as you refer yourself, but i’ve noticed that with the senior generation of Physicians, the clinical skills are so good, that there are very few radiology referrals unless absolutely required. That makes the interaction even more satisfying as there is always a strong clinical backing for requesting the imaging study.

  3. priyank says:

    so true.. but i guess rather than lamenting about the deteriorating interest of clinicians in taking adequate clinical details. the time has come wherein the ER departments should implement clinical criteria and algorithms which rely on few minimal basic questions that guide further line of investigation…

    • anisha sawkar tandon says:

      @priyank – With this new branch of Emergency Medicine as a PG specialty, I think there are some questions about training. I feel that an MD medicine resident, an MS general surgery resident, an MS OBGY resident and an MD pediatrics Resident need to be around to guide the ER resident at least in the first year so that they can take informed decisions about imaging. The problem in some ERs is that the physicians of different fields refuse to get involved unless the case has been first proved by an imaging modality to belong to them. Something needs to be done to fix this…

  4. girish kulkarni says:

    inevitable,with advancement in diagnostic techniques.

  5. Very true mam. Myself being a radiology resident, i have faced similar situations in last 2 years. Sometimes, explanation given is ‘work load that you ll not understand being radiologist’.

  6. a situation where i found a patient with pain lower limb was ordered for investigations,mri,,emg
    nerve conduction tests but missed to exam peripheral pulses & missed the diagnosis

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