Doctors need to do more than see, they must observe

Not in any way that I agree with her necessarily (I often don’t, and often particularly don’t like the way she expresses opinions), but Terry Prone writes in the Examiner today about doctors‘ powers of observation >>>

NOT reading X-rays is bad enough.

Not reading patients is a hell of a lot worse. It’s also more widely distributed than the X-ray issue and undoubtedly causes commensurate failure to accurately diagnose.

If I had the money, I’d sponsor a study into the gaze patterns of doctors. All doctors. GPs, consultants, A&E registrars, psychiatrists. The methodology would rely on filming the medics in their normal setting, as they meet new or returning patients. At least some of the filmed clips, and probably a majority of them, would show the doctor paying more attention to the records on their computer screen than to the patient. Of course, they’d be listening while reading the most recent prescriptions issued to the patient or (in A&E) the notes taken by the triage nurse. But they would not necessarily be LOOKING at the patient.

The notion that you can learn a great deal about somebody has gone so out of fashion in medical circles that the exceptions are interesting. Here’s an example of an exception. A consultant examining a woman patient, post-surgery, surrounded by student doctors, completes the examination and straightens up to leave the room. As he turns, he comes face to face with the woman’s partner.

“Have you had your cholesterol checked recently?” he asks. The man shakes his head. He’s never had his cholesterol checked. Dammit to hell, his expression says, I’m a non-smoking reasonably fit guy who’s not overweight. Cholesterol? The doctor turns the non-patient around so the students can see his face and points out a couple of bumps like cottage cheese under the skin beneath his eyes. They, he says, and a couple of other features he also points out, might indicate raised cholesterol levels. He then departs, leaving the patient’s partner floored and the patient in the bed looking mad that the spotlight has been taken off her miseries.

I witnessed that incident some time back. Significantly, I’ve never witnessed another example of that kind of acute observation. That’s because, according to Dr Joseph Bell, “Most people see, but they do not OBSERVE. Look at a man, and in his face you will find clues to where he comes from. His hands will show what work he does. The rest of the story is told by the clothes – even by a piece of cotton sticking to his coat”.

Dr Bell was a surgeon who taught at the University of Edinburgh in the late 19th century. He constantly stressed that anyone planning to become a doctor must learn to use their eyes intelligently. His work with students was a constant illustration of this core proposition. He would, for example, deliberately avoid learning anything about a patient before they arrived in his consulting rooms, thereby forcing him to watch them with intense attention. In one case, he told a male patient he was a cobbler by trade, because Bell had copped on that the man’s trousers were worn smooth on the inside of the knee, where, typically, a cobbler would hold the shoe on which he was working.

One of Bell’s students was a young man named Arthur Conan Doyle, who, when he left the university in the 1880s, found it difficult to make a living as a GP and began to supplement his sparse earnings by publishing detective stories based on what he had seen Joseph Bell do on his rounds. He transformed Bell into Sherlock Holmes, and made a fortune.

In some cases, Conan Doyle actually lifted real encounters between Bell and patients and inserted them into his books, because Bell, like Holmes, didn’t just observe, analyse and make a judgment, but, because he was a gifted teacher, would also explain the steps of the process, as did Holmes.

It can be argued that watching patients closely is not as important as it was in Bell’s time, because of the ready availability of tests. It can be counter-argued, however, that healthcare would be considerably less expensive if doctors did not so readily reach for the testing option, and that each time they do – particularly in the case of GPs – they are contributing to their own de-skilling and becoming little more than gateways to a multiplicity of mechanical interrogation processes.

Of course Bell was working at a time when more people worked in trades or crafts that carried direct, explicit threats to their health. Coal-miners could be expected to suffer specific lung problems. Hatters, because of their use of mercury, had a greater tendency to become somewhat unhinged. (Hence Lewis Carroll’s Mad Hatter in Alice in Wonderland.) Soldiers returning from overseas theatres of war were likely to be sickened by malaria or other tropical diseases. It was, accordingly, important that a man’s trade be taken into account when assessing what ailed him, whereas today’s office workers and electronic engineers tend not to develop profession-specific illnesses or disabilities other than obesity or backache from sitting too long.

I would have thought, nevertheless, that for doctors and nurses, it’s vital to develop the capacity to hoover up at least some of the myriad clues to health and illness manifest in someone’s appearance. Yet, although commercial firms spend a fortune training their salespeople to use their eyes to pick up relevant clues about their prospects, the emphasis placed in medical training on the same skills seems to be minimal. Every now and again – usually after medical scandal – someone remarks that communication skills should play a greater part in the education of medical professionals, but this tends to be interpreted as either referring to the development of a better bedside manner (which is always a good thing) or the inculcation of an understanding of media, so the doctor or nurse can acquit themselves creditably on a radio or TV programme (which is also useful.) The less flamboyant skills of listening and watching are core to good communication, but rarely figure in discussions of improving doctor/patient interactions, perhaps because their results are unmeasurable.

Conan Doyle’s observation of his mentor persuaded him otherwise. He realised that what Bell did was forensic examination, using his eyes and ears and applying critical thinking to the product. He further realised that one of the great benefits of this approach was that it could disprove patients who chose to lie to their doctor, having watched Bell tell a patient that the patient had been an army man, probably playing a musical instrument, only to have the patient deny any musical knowledge or army experience.

Bell quietly asked him to remove his shirt, which action revealed the letter “D” in scar tissue on his chest, the result of having been branded as a deserter. When Bell silently pointed to the brand, the man admitted that he had once been a bandsman in a Highland regiment. It was at that point that Bell used a sentence close to the one always associated with Sherlock Homes, although Holmes aficionados swear it never appeared in any of Conan Doyle’s books.

“It was elementary, gentleman,” was the surgeon/teacher’s summation of his observation and analysis.

This story appeared in the printed version of the Irish Examiner Monday, March 15, 2010