High-tech gadgets can’t replace this old-fashioned skill

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oT long ago, I was shocked to read an eminent GP colleague’s com - ments — in the British Medical Journal, no less — opining that training medical students in how to examine patients is a waste of time.

The suggestion was that it ’s a hangover from the long -distant past, since thanks to high-tech CT and MRI scans, ultrasound and echocardiography, no one needs to learn how to check a patient’s mouth and tongue with a depressor stick , or palpate their abdomen, for instance — let alone use a stethoscope to examine their heart.

For all our fascination with modern medical gadgetry, even at three score years and ten, I continue to believe that my most treasured skill is my training in medical diagnosis. A corner - stone of that is the craft of physical examination.

As medical students we learned to examine patients correctly, in lecture theatres and in hospital outpatient clinics. once the consultant had taken the history of a patient with a small team of students in attendance, there would be a demonstration of the clinical signs to look for and, one by one, the students all had a turn — to listen to the heart or lungs, or feel the pulse, or examine the abdomen, or a use a pinprick test or other methods (to check nerve sensitivity), or a ‘patella hammer’ for reflexes.

We learned how to examine the thyroid gland, from behind the patient using two hands, asking them to swallow to feel the gland move; to carefully check the skin for abnormalities — such as the stretch marks on the trunk and legs that may be a sign of Cush - ing’s syndrome — or any other of a whole range of other tests.

AND as part of our exams, we had to examine several patients, for 30 seconds each, before being asked for our opinion — followed by one ‘long case’: tak - ing a detailed history, conducting a full examination and then presenting the examiner with a diagnosis and treatment plan.

Invariably, the long case would involve a patient with aortic stenosis — a narrowed heart valve (see main story) or regurgitation (a leaky heart valve) or mitral stenosis (another type of narrowed heart valve, most often caused by rheumatic fever). Getting this wrong would result in failure. Aortic stenosis is common. And while it can cause breathlessness, at times it is a silent condition with perhaps only an occasional ‘drop attack’, i.e. sudden fainting, because not enough blood and oxygen is reaching the brain. A common complication is sudden death.

Using a stethoscope is a vital early step in diagnosis — to be frank, waiting for an echocardiogram (a type of ultrasound used to examine the structure of the heart) might be too late for too many patients.

A stethoscope is also vital for checking a patient with a cough and a high temperature to identify pneumonia, allowing prompt administration of potentially life-saving antibiotics.

THIS is especially important when you consider the time it can often take to access an ambulance, transfer a patient to hospital and then wait in the queue on arrival.

The sound of ‘ bronchial breathing’ of pneumonia through the stethoscope, unlike the soft and quiet sound of the air going in and out (as with healthy lungs), is very loud and clear.

Starting antibiotics at this point may avoid rapid deterioration into often-deadly sepsis. Yet some doctors merely call for the ambulance, a bit too keen to depend on the chest X -ray that will be organised once the patient gets to hospital. But that can involve a delay of hours before treatment is started.

In rejecting those examination skills for the sake of modern technology, my eminent colleague did not allow for the fact that scans can involve long waiting times.

Then there’s the chance they might be rationed by cost- cutting. And at a more banal level, what if the power is cut off for some reason?

These days, it is beginning to look as though most readers will see only a stethoscope on the photo of my esteemed Daily Mail columnist, psychiatrist Dr Max Pemberton — a reaffirmation of his status as a skilled medical doctor, both of mind and body.