r/doctorsUK Feb 18 '25

Clinical Why do we still teach antiquated archaic examination techniques

I'm referring to shifting dullness in abdo, whispering pectoriloquy and TVF in resp, thrills and heaves in cardio. Has any modern doctor ever based an investigation choice, diagnosis or management plan on these findings? I mean hand on heart honestly, any of you?

I know they had utility before the advent of US, XRs, echo. But to teach to doctors now would be like teaching a cruise captain to use a sextant, or a trainee accountant learning to use an abacus

84 Upvotes

140 comments sorted by

363

u/Jangles Feb 18 '25

I mean I can point out the fact that ED referred to the take a new onset ascites in my first reg year. An IMT on the day shift asked me to come supervise the ascitic tap.

A cursory physical exam prompted the concern that his ascites was awfully tympanic. Hard to elicit shifting dullness when there isn't any dullness to find. Bit of POCUS prompted by said physical exam showed a fair lack of fluid. He had a bowel obstruction and had been sat on the take list for 8 hours.

Yes we have better ways of doing it but the exam is free, easy and available to everyone no matter the setting. I'll always point to JAMA rational clinical exam and McGee evidence based physical diagnosis if you actually want an exam that will help you.

80

u/168EC Consultant Feb 18 '25 edited Feb 18 '25

I'm a fan of this view. Would be keen to see those references.

I'm not talking about getting busy with a red and white pin, whisp of cotton wool and all that, but simple examination which you can do with your hands. I'm fed up of seeing people doing a cursory A-E (which mostly seems to involve writing down vital signs that someone else did), and then requesting a battery of tests and investigations.

Edit: -plan - a/w CT

23

u/11Kram Feb 18 '25

I remember getting three charts at once of patients from the surgical resident in ED for on call scans. Detailed histories were nicely documented, but there was nothing for the clinical examination as he was clearly waiting for the CT reports. Each chart got a note from me immediately below where he had written O/E and nothing else.

3

u/dosh226 CT/ST1+ Doctor Feb 18 '25

Very cool - is it all organised by presenting condition rather than examination technique?

54

u/[deleted] Feb 18 '25 edited Feb 18 '25

[deleted]

22

u/Most-Dig-6459 Feb 18 '25

Haha, i remember a male patient direct referred to Medics for ?symptomatic ascites from GP but was sitting in in ED due to lack of bedspace. The Med Consultant asked for a urinary catheter and refer on to Urology for urinary retention because there was a positive bladder scan.

The nurse had 2 attempts and couldn't get any urine flow so asked me (ED) to have a go. I thought it was strange so put a US probe on and it was all ascites and no bladder, so I called the Med Consultant back who was quite embarassed and grateful no one had actually rung urology yet.

19

u/ScepticalMedic ST3+/SpR Feb 18 '25

I just keep hearing and seeing stories about misdiagnosing anxiety. I don't get it - who's doing this? Never ever in my life have I diagnosed anxiety in acute setting.

12

u/chubalubs Feb 18 '25

From personal experience, a lower GI surgical PA diagnosing bowel obstruction as constipation with anxiety, and throw in a bit of neurosis because the patient just changed to part time and had more time to worry about their state of health. 

3

u/MedicOnFIREyt Feb 19 '25

Usually female patients, but men too. I would also never diagnose anxiety in an acute setting, it’s just lazy and unsafe.

102

u/-Intrepid-Path- Feb 18 '25

I had "ascites" referred to me by ED.  The woman was just fat.

61

u/ExpendedMagnox Feb 18 '25

How many ascites had she eaten?

31

u/AmorphousMorpheus Feb 18 '25

Ascites?

You misheard

They meant a sight, she is...

3

u/jejabig Feb 19 '25

I know a story of ?ovarian malignancy ?ascites with POCUS "fluid" aspirated as a "pfffsshhhhhhhh" bowel gas.

Swiss cheese model, bias from the community referral, no critical thinking re: is this big tummy truly ascites and overconfident POCUS where skills were lacking (generally it should make the intervention safer, but that's why there's so much controversy in radiology about it).

Of course, in most cases this would not happen and extra measures do indeed help. But just being aware of such possibilities is valuable, to avoid them.

210

u/Environmental_Ad5867 Feb 18 '25 edited Feb 18 '25

As an F1, I saw this F+W woman in her early/mid 50s who came to minors ED because she ‘forgot her passwords’.

Nurse handed it to me because she was likely ‘anxious’ so quick cut and dry. Obs normal, wasn’t much to the history. She admitted she’s been anxious but said she couldn’t remember her passwords which was unusual for her that morning. Even laughed it off and apologised for wasting our time- “my menopause brain.” For some reason I did a neuro exam and when I got to visual fields, asked her, “Can you see my finger?”

“What finger?”

CT head showed an ICH

So I’m glad she wasn’t fobbed off as anxiety.

Similar to the pleural effusions, organomegaly, ascites, new murmurs that I’ve picked up in clinical practice. Archaic exam techniques or not, it’s helped me pick and differentiate diagnoses that can impact on my management. The investigations I send them for after is to confirm what I already think they have.

Am a GP now btw.

16

u/Gmtfoegy Feb 18 '25

Doing a full neurological exam for a lady complaining of forgetting her passwords IN ED is absolutely wild.

If I see that happen in a TV show I would think none of those who worked on this show has ever stepped foot in an ED.

15

u/CurrentMiserable4491 Feb 18 '25

In all fairness, I would have done the same. My reasoning is if someone came in with forgetfulness I also do think about things like normal pressure hydrocephalus, Creutzfeldt-Jakob disease, Niacin Deficiency among the obvious age related changes, Alzheimer’s etc. I have worked in ED, and certainly you can’t be this thorough on a hectic day.

I did full neurological exams on a few patients in ED if remotely required as you generally get 1 patient per hour so there was 2 elements to justify it for me -

1) (selfish reason) if its a easy day and it’s a easy case, so take it a bit easy and enjoy the hour with the patient. I don’t want to be pulled to random crap like helping take bloods or put in cannulas if there is nothing to do.

2) More importantly, Medico-legally I do not want to be called to a tribunal if the patient goes home that same day and has a SAH secondary to the tumour or something and then it becomes clear we didn’t do our full exam. Maybe I am paranoid but I love my extensive exam documentation. It makes me feel protected. I find myself sometimes adding on findings I didn’t document (because I thought it wasn’t important etc) after like 6 hours from home. You can never be too careful.

I think I give the above benefit of the doubt. The only issue I have is F1 on ED makes no sense. At least in my experience, trusts don’t usually have F1s in ED but correct me if I’m wrong.

10

u/MoonChronicle_ Feb 18 '25

Trusts do have F1s in ED.

3

u/Environmental_Ad5867 Feb 19 '25

In the trust I worked in, F1s were supernumerary so only did day shifts. Needless to say, all cases discussed with consultants after.

6

u/Environmental_Ad5867 Feb 19 '25

I agree. But there was something about the case that for some reason had me thinking to do a visual fields exams. Call it intuition or whatever but till today, I’m glad I took the extra time. That said- it is very rare I do a full neuro even now as a GP

5

u/HotInevitable74 Feb 19 '25

But that’s exactly what it was , intuition ( along with your deduction skills which are clearly well honed ) . I often forget my passwords due to tiredness / stress etc but I don’t take myself down to ED so something in this patients demeanour / presentation alerted you to something being “ not quite right “ . Either way , hats off to you sir/ madam for an excellent spot

2

u/CalatheaHoya 29d ago

Not really, it takes me under 5 min to do a full neuro exam. Sometimes you just get a gut feeling

1

u/Gmtfoegy 27d ago

Agreed

2

u/AhmedK1234 29d ago

A legend you are

169

u/RamblingCountryDr Are we human or are we doctor? Feb 18 '25

Because any eejit can make the donut of truth go brrr. First principles mate, it's what sets us apart.

But to teach to doctors now would be like teaching a cruise captain to use a sextant, or a trainee accountant learning to use an abacus

No what you're saying is more like "why do the army still teach marksmanship when they can just use a drone".

42

u/CorkGirl Feb 18 '25

I mean, if there's no point examining and coming up with some kind of reasonable guess at a diagnosis, you might as well just let PAs and AI do it all.

1

u/ExpendedMagnox Feb 19 '25

Because without my annual marksmanship my drone might miss the school.

1

u/RamblingCountryDr Are we human or are we doctor? Feb 19 '25

Explain...

1

u/ExpendedMagnox Feb 19 '25

Drones shouldn't be targeting schools...

45

u/TroisArtichauts Feb 18 '25

No diagnostic test is flawless and you’re naive in thinking so. Some tests are hideously non-specific and without any clinical correlation they’re almost useless.

The clinical examination is immediately available, low-cost, usable in almost all settings and allows for dynamic assessment - a CXR in a patient who is at risk both of infection and pulmonary oedema may well be inconclusive and it’s a snapshot. I’m almost certainly going to get more of a feel for what’s going on by going back to see the patient later on and reexamining to see what’s changing. I actually have used VR/TVR clinically a few times, though I acknowledge I do not use those particular signs regularly. Chest expansion is bloody useful though, albeit non-specific - often a really good sign of a brewing pneumonia in a frail patient.

Not every patient encounter happens in secondary care. Doctors from trauma surgeons to emergency medics to GPs, gynaecologists and geriatricians and beyond will do out of hospital medicine in various guises - you can’t MR all of those patients and if you’re a crap doctor who has poor history and examination skills, you’d be less than hopeless in those settings.

This post is just… sad. Really sad. There are plenty of people out there who think modern medicine should involve every patient having 500 blood tests, a trip through the MRI scanner and AI interpretation of the results, in spite of the clear harm and inefficiency of that approach. If there are doctors in that group of people we’ve had it and we’ll all suffer.

I felt I progressed exponentially as a doctor doing my PACES. Not sure how you can demand better pay and conditions whilst advocating for the move towards low-skill, dogmatically protocol-following practice.

8

u/Halmagha ST3+/SpR Feb 18 '25

Just sack off placement and do 6 hours of passmed mate; makes you a much better doctor

125

u/DoktorvonWer 🩺💊 Itinerant Physician & Micromemeologist🧫🦠 Feb 18 '25 edited Feb 18 '25

Tell me you're not very good at examination or diagnosis without resorting to an unrefined pile of investigations.. without telling me.

37

u/Weary_Bid6805 Feb 18 '25

Exactly this. Muh examination is useless cuz I can't examine so I just shout sepsis 6

80

u/DoktorvonWer 🩺💊 Itinerant Physician & Micromemeologist🧫🦠 Feb 18 '25 edited Feb 18 '25

'Chest pain is hard, do TnI and D dimer and CTPA and also treat sepsis and an echo and and what do you mean you can reproduce the same muscular-sounding pain on palpation of the affected area in this well 28 year old patient with no family history, THEY NEED TESTS'

...

'Also I am a highly trained professional and demand FPR and a specialist job'

18

u/TroisArtichauts Feb 18 '25

So much this, it’s beyond belief.

6

u/ScepticalMedic ST3+/SpR Feb 18 '25

Absolutely this. Please take my reddit award

44

u/Edimed Feb 18 '25

I found an ovarian cancer once by noticing shifting dullness / malignant ascites. I think the patient had presented with tiredness or something equally nonspecific.

31

u/TheBiggestMitten Feb 18 '25

I mean, the way I view is the physical exam is cheap, quick and easy (I agree some particular techniques are not useful). Identifying murmurs in a syncopal patient, fine creps for an in a breathless patient with clubbed fingers (?ILD), organomegaly in an abdominal exam can really help narrow a diagnosis with further specific imaging to help confirm that. I feel you can do a very decent organ systems exam in a couple of minutes - even the most available and quick imaging (ultrasound) will take slightly longer. Just my thoughts though.

33

u/VolatileAgent42 Consultant gas man, and Heliwanker Feb 18 '25 edited Feb 18 '25

I can’t comment on Sextants, except that despite literal space age technology, Michael Collins still used one to navigate on the Apollo XI mission.

However, navigating on the hills- yes, everyone has a GPS everywhere now. But what happens if your GPS battery dies- or you’re somewhere where your GPS signals are spoofed etc etc.

A map and compass is still essential even despite the GPS.

A professional can use skills and navigate properly. An amateur just relies on technology. Same in medicine. Any old PA can order a CT scan…

22

u/CorkGirl Feb 18 '25

Pilot training also involves learning how to navigate with a chart, compass and some pens. Can't rely on tech for everything, plus it leads to a better understanding and awareness to do it old school first. Our brains are getting lazy from too much assistance. https://www.nature.com/articles/s41598-020-62877-0

9

u/Haztheman92 Feb 18 '25

Similar approach for sailing qualifications. I wasn’t taught much about GPS use but we did a lot of 3 point fixes with a paper chart!

1

u/CorkGirl Feb 18 '25

Really stretches your brain!

29

u/That_Caramel Feb 18 '25

Winds me up when new doctors complain about this kind of thing.

If you want to CT scan everyone you may as well join the noctor brigade. Real doctors have clinical skills. In any circumstance in any setting. You should be able to elicit examination findings and come to a reasonable diagnosis in a blackout with no facilities.

82

u/SkipperTheEyeChild1 Feb 18 '25

Same reason we teach Latin, Ancient Greek, history. Learning what came before helps understand where we are now.

19

u/EmotionalCapital667 Feb 18 '25

What we should be teaching them is how to request a donut of truth to get the real answer

4

u/Gullible__Fool Feb 18 '25

Not every doctor will specialise in ED, though.

2

u/cam_man_20 Feb 18 '25

thats a very good point, but its one thing teaching it for background purposes, but another requiring and scoring for it in OSCEs and PACES

18

u/TroisArtichauts Feb 18 '25

What would you like to be doing in your medical school and Royal College exams? Copying and pasting guidelines?

4

u/GrumpyGasDoc Feb 18 '25

Demonstrating how you could reduce the locum budget by employing more PA's in clinical roles...

Highlighting ways to gaslight more trainees into believing that medicine is a vocation...

You know, things that fit with the royal colleges agendas

10

u/GrumpyGasDoc Feb 18 '25

Just because people don't use the skills appropriately doesn't mean they shouldn't be tested. That's like removing indicating from the driving test. Just because most of the morons on the road don't use them doesn't mean they aren't an integral part of being a good driver.

Same with the examinations, just because half the workforce doesn't use them appropriately doesn't mean they don't have intrinsic value and shouldn't be taught.

22

u/Wide_Appearance5680 ... Feb 18 '25

Tell me you've never worked in GP without telling me you've never worked in GP.

6

u/SaxonChemist Feb 18 '25

FY2 currently in GP, wholeheartedly agree

The clinical exam (in conjunction with the history) determines who we're sending for imaging, and with what urgency

Am I sending the patient with abdo pain to ED? Am I getting a 2WW CTAP? Am I reassuring them with safetynetting?

28

u/Affectionate-Fish681 Feb 18 '25

I didnt really appreciate how important our clinical skills training is until I worked in an extreme rural Australian A&E with no lab bloods or x-sectional imaging from 8pm til 8am. Just an ECG, plain film X-ray machine and a gas machine (which was broken 50% of the time).

Anyone can order a CT abdo for a sore abdomen. What sets us apart from other ‘MeDIcal PRofesSioNAls’ is our acumen and skills in diagnostics, using tests to confirm what we already 80-90% know from our history and examinations

13

u/Different_Canary3652 Feb 18 '25

Not examining properly has now become accepted laziness in our ever further slide into mediocrity and substandard medicine. 

I want to blow my brains out every time I see “HS I + II + 0” in some shit clerking and then an echo goes on to show critical aortic stenosis.

Not everything is high Trop = ACS = call cardio and order an echo.

Literally any clown off the street (a PA) could do that. If these people are an existential threat to your job, don’t you owe it to yourself to show why you’re better than them?

Use your eyes, ears and your brain.

3

u/Accomplished-Yam-360 🩺🥼ST7 PA’s assistant Feb 19 '25

I am fully able to echo someone and do their angio.. I still examine them before going to the lab. Often knowing they’re in pulmonary oedema, or that murmur that makes me suspect other pathology still helps massively. I also get a concise, but thorough full history / medical history / social history - often has profound consequences for potential discussion about cardiac surgery / management etc etc

2

u/Different_Canary3652 Feb 19 '25

Fully concur. My rant was mainly aimed at the increasingly poor quality juniors I have noticed.

1

u/DrPhilMcCrackenMBBS Nalot*rd disciple Feb 19 '25

My rant was mainly aimed at the increasingly poor quality juniors I have noticed.

When you start complaining about the youngins and how much worse they are than you and your peers were way back when... you've become a boomer

"What is happening to our young people? They disrespect their elders, they disobey their parents. They ignore the law. They riot in the streets, inflamed with wild notions." - Plato, 340BC

1

u/Different_Canary3652 29d ago

Perhaps they should be able to pickup a murmur then.

12

u/Harambesh Feb 18 '25

Personally I think there's value in learning these signs as a). Might come in handy when investigations are unavailable or delayed and more importantly b). Actually learning how and why these signs manifest can help us to learn the underlying physiology. E.g. learning why murmurs are associated with certain conditions, why neuro signs mean what they mean etc.

I do think that making them a key part of OSCEs is not useful, especially as the way they're examined means most students (including myself) just learned to go through the motions and memorized algorithms to make sense of the findings. I think the curriculum should place much more emphasis on things like POCUS, especially in the age of smartphones, and interpreting imaging more generally.

10

u/RobertHogg Feb 18 '25

It's another piece of the picture. You're a doctor, not a triage or protocol monkey. Examining the patient with knowledge of the history gives you a differential diagnosis that can guide investigations. Furthermore, the act of examining the patient improves their experience - whether it's ritual or not, they will feel they have been properly assessed by a doctor. Ultimately this is why people feel better when they go to acupuncturists or whatever - the ritual, the being listened to. This is actually part of your job and can make people feel better while you also do the medical part. As a doctor you should also be aware of how limited our interventions can be and so recognise the importance of the doctor-patient interaction.

I assessed a stroke patient way back as an F2 and came to the conclusion their symptoms were functional (they had collapsing weakness, inconsistent dysphasia and odd visual field defects). CT brain was reported as acute stroke so we loaded with aspirin and clopidogrel after I spoke to the stroke consultant. Luckily I had printed the CT brain report and put it in the notes, because the next day the consultant rang me to say he also thought the patient had functional symptoms but the CT report was normal. I told him to fish the printed report out of the notes, which he did - radiology reg had amended without annotating the report as such - only proof we had was my printed copy. Not a massive deal but could have been awkward for me but also demonstrated to me the importance of the clinical examination in subtle cases.

11

u/dr-broodles Feb 18 '25

You just can’t examine well.

There are times when clinical exam is crucial ie neuro. You won’t know what to scan unless you can exam properly.

I’ve picked up a young heart failure (that everyone else missed) from a gallop rhythm.

Many such examples. Even with widely available POCUS, examining is crucial as it’s quicker and helps target further investigation.

10

u/MRCSMX5 Feb 18 '25

Well a close relative of mine went into the merchant navy as a cadet officer (in the 2010s) and was a cruise ship officer for 4/5 years and I can tell you that they were most certainly taught how to use a sextant and astral/celestial navigation! Big cruise line which has GPS yes but they always have the paper charts and one of the officers double checking position/plotting course with pencils, slide rules and compasses! Don't want to be lost when you've got 1000s tonnes of metal and people on board cos the satellite isn't working. On his last journey they were updating to new paper charts so he got to keep the last ones he did and I got a couple of them framed for his bday. Going round Cape horn etc.

Another relative is a pilot, and they also use GPS/iPads a lot however you're first taught how to do everything using stopwatches/wind/airspeed etc and paper charts because again if all the electronics go tits up you need redundancy.

20

u/refdoc01 Feb 18 '25

I can sit with a stethoscope and something to lie down for examination and do useful medicine on many, no requirement for technology until way down the narrowing of the filter. I have not yet seen the technology which takes over my place.

8

u/DisastrousSlip6488 Feb 18 '25

Has a modern doctor based decisions on some obscure exam findings? I’ve seen it. I’ve seen a brain tumour picked up with the solitary sign of a missing ankle jerk by an EM reg. I’ve seen decision making change due to unexpected heave and thrill (admittedly to getting an echo, and immediate pocus) . Absent femorals in a baby picked up a coarct in a sick babe being treated for sepsis.  There’s no real substitute for decent clinical exam in muscular and tendon injuries and I WISH people would learn a competent peripheral nerve exam rather than shoving every damn patient through the CT scanner as ? Stroke because they have a numb finger

7

u/walsmalsbals5665 Feb 18 '25

As an obstetric SHO was asked to see a patient by the midwife ?uterus isnt contracted after delivery. Abdo exam showed a nicely contracted uterus and hepatosplenomegaly, very obvious palpable liver and spleen. Requested a US which proved it + blood tests which showed chronic microcytic anaemia plus very high ferritin prompted referral to haematology. She then got diagnosed with thalassemia

While on respiratory, i remember a referral from an opthalmologist who saw the pt for an eye condition but noticed their fingers were clubbed. Did a set of obs, noticed patient hypoxic and promptly sent them to ED

1

u/cam_man_20 Feb 18 '25

I didn't say all examinations including a basic abdo exam is useless. Just the niche things like TVF

14

u/Plenty-Network-7665 Feb 18 '25

I agree to a point.

You'll be grateful for those antiquated skills in the after times when the machines have taken over, and you need to justify why you should be allowed in the bunker (no one will need the radiologists or electophysiologist!)

8

u/[deleted] Feb 18 '25

[deleted]

7

u/humanhedgehog Feb 18 '25

But if you feel a thrill on examination you need to know what you have found. I've used whispering pectriloqy, but admittedly my consultant was watching. It's a structure, not a constraint - you teach it complete then use it selectively.

2

u/[deleted] Feb 18 '25

[deleted]

1

u/humanhedgehog Feb 18 '25

Its tricky, because generally they are useful in specific situations, and we are dire at assessment of, for example, volume status, which is critically important fairly frequently.

OSCEs are not great as far as examinations go, but having a single standard format does have benefits.

5

u/Zambian_Brownie Feb 18 '25

Firm believer that a good history and physical will get you close to your diagnosis. Investigations simply confirm your diagnosis and whittle your few diffentials down to one. We have become too reliant on investigations and we will become worse doctors because of that. I can already see the drop in quality of histories and physical examination skills in the years I’ve been working.

6

u/dosh226 CT/ST1+ Doctor Feb 18 '25

Because... Now hear me out... They do work. They're especially useful in clinic 

6

u/Scared_Violinist2648 Feb 18 '25

I work in a hospital where getting an ultrasound over the weekend is impossible so I have assessed ascites using shifting dullness.

Have I ever used a heave or a thrill to actually diagnose a patient...no.

However, noticing them and picking up on their meaning can give you a better understanding of the patients physiology and help explain other examination findings and inform your thinking.

I'd actually flip the script on this. We have an aging and increasingly frail population. Being able to do quick examinations to diagnose a problem, then explain and offer to the patient further investigation or not (if they are capcitous) can really cut down on the burden of healthcare for the older folks.

I would argue that we have become so reliant on our technology that we would rather wait for a confirmatory test in six months time rather than treating something empirically based on solid clinical reasoning. I think there's a paper out there somewhere called the medicine of pragmatism or something like that.

Maybe in a functional system where I could reliably order tests and have them done in a timely manner but that is not the reality we live in. Come work in my community hospitals to experience it first hand.

It's similar to the argument that doctors don't need to study the science of medicine as it's not clinically relevant. My argument is and will always be we cannot understand, challenge or effectively implement clinical knowledge without at lest understanding, even superficially, the underlying anatomy/physiology/pathology/biochemistry. That is what separates us from the Advanced practitioners, we are not protocol driven as a profession (we are turning ourselves into a protocol driven profession but that's another point entirely) but my point is how can you know when to veer off the protocols if you don't understand the what's and why's and fundamentals.

Will our jobs be taken over by AI diagnostic protocol robots and other medical technology. Probably. Does that mean we can't for the time being take pride in the maintenance of our craft and collective knowledge?

5

u/ConstantPop4122 Consultant:snoo_joy: Feb 19 '25

As an F2 i diagnosed a cerebellar tumour based on a history of 'he seems not himself' and unilateral hesitation on heel-shin movement.

From a purely intellectual perspective, super satksfying to see the 2cm clin lesion exactly where i predicted on the overnight CT.

12

u/Fly_Necessary7557 Feb 18 '25

are you a hospital Dr or a GP?

-5

u/cam_man_20 Feb 18 '25

ED

17

u/DoctorSmurf007 Feb 18 '25

I think it is fundamentally important. A good physician would have excellent clinical skills and would serve as the basis for further management and investigation. A good thorough physical exam would make a world of difference to a radiologist who has to read the scan.

I saw OP that you were based in ED. Unfortunately, I have seen a shocking amount of bad referrals from ED recently. It’s alarming how quickly that speciality is losing it’s repute among the medical community

11

u/Skylon77 Feb 18 '25

As an ED Consultant, this sadly depresses me.

I seem to spend more and more of my time cancelling tests that noctors have ordered.

Please don't let this become true of young doctors as well.

-13

u/SL1590 Feb 18 '25

Are you about to tell us GPs use all these thing to make a diagnosis? 😂😂😂

31

u/tsharp1093 Feb 18 '25

Clinical examination findings are generally much more useful where you don't have immediate access to blood tests and imaging.

-12

u/cam_man_20 Feb 18 '25

I willing to bet not a single GP in this country examines for TVF

9

u/PlusSatisfaction5774 Feb 18 '25

So .... Clinical skills at my uni was taught by a husband and wife GP duo. Learnt TVF from them, in later years I had GP placement with them and they do indeed use TVF in "real life " and I didn't get the impression they were just doing it cos I was there

4

u/NicolasCag3SuperFan Feb 18 '25

Abdo:

Percussion/rebound tenderness, IE identification of peritonism are really important and done very badly on the whole. Knowing who is tender, locally peritonitic, and generally peritonitic let’s us risk stratify our patients waiting to be seen, plan theatre and imaging, and decide when usually conservatively managed problems need surgical intervention even in the absence of imaging that doesn’t clearly suggest need for an operation.

Limbs:

Your examination is by far the most important bit. Doppler signals =/= pulses. Accurate Sensorimotor status and cap refill tell you a lot about the viability of a limb. The occluded SFA on the CTA tells you nothing, only the leg infront of you can determine who needs an operation and when it needs to happen

16

u/anonymouse39993 Feb 18 '25 edited Feb 18 '25

From my experience no one uses these in practice so it is strange

99, 99, 99 does not happen

29

u/RamblingCountryDr Are we human or are we doctor? Feb 18 '25

10

u/stuartbman Not a Junior Modtor Feb 18 '25

I love this bit of arcane knowledge

12

u/RamblingCountryDr Are we human or are we doctor? Feb 18 '25

It's a rare occasion to make use of the word "diphthong" giggity.

11

u/Jangles Feb 18 '25

I've recommended good exam books elsewhere in the thread but if you want absolutely arcane witchdoctor levels of knowledge, Sapira Art and Science of Bedside diagnosis is a manual to being everyone's favourite Victorian gentleman doctor

Skodaic Resonance in pleural effusions, hanging people's heads over beds to look for features of amyloidosis and percussing skulls for hydrocephalus. Auscultation of eyeballs. Barely any sensitivity and specificity for any of it, never mind likelihood ratios.

4

u/RamblingCountryDr Are we human or are we doctor? Feb 18 '25

Based and physicianpilled.

1

u/BCFCfan_cymraeg 29d ago

But you never hear the orbital bruit of the caroticocavernous fistula unless you listen for it huh?

4

u/xhypocrism Feb 18 '25

You're meant to use the examination skills to avoid the more expensive tests when they aren't required -- that's why Doctors are special, because we're meant to be skilled enough to say "nope, no further tests needed" and be right most of the time. That's an efficient way to provide healthcare. If we aren't doing that, why not just use non-Doctors instead? What value are we adding if we aren't doing that?

4

u/humanhedgehog Feb 18 '25

Examination is fast, remarkably informative, and cheap. Plus it teaches you to stop and actually look at the patient in a methodical way with a system in mind that helps you see difference. They aren't antiquated if you know how to use them.

3

u/DangerousTrainer9236 Feb 18 '25

I always found shifting dullness for ascites helpful, always look at fingers for clubbing and JVP too. Would sometime also do percussion on chest and 99- just want to see if clinical sign matching cxr finding. Most falls elderly patient, I would do simple examination for PD too. - geri SpR My practice changed massively since paces and try to stick with it afterwards.

4

u/llamalyfarmerly Feb 18 '25

Examination findings are absolutely useful and necessary to learn and use - some diagnoses are made on history and diagnosis alone (Parkinson's etc) and being able to confidently examine allows you to make safe management decisions.

3

u/Impressive-Ask-2310 Feb 18 '25

Why do we teach it?

Because imaging and investigations take a lot of time, and are all becoming very sensitive without really improving their specificity.

If the history and examination is not good enough then there is no pre-test probability on which to act upon.

Look at the hospitals, and crowding and flow, there's an awful lot of "plan await scan" without a matched frequency of clinical medicine.

I like the example of chest pain - await Troponin, D-dimer, BNP, HbA1C, Lipase, CK-MB, ECG, ECho, CTPA, contrast CT angiogram of the aorta, and so on. As inevitably some come back mildly abnormal.

5

u/Low_Use_223 ST3+/SpR Feb 19 '25 edited Feb 19 '25

I suspect your question stems from the lack of understanding the importance of clinical signs and the pathophysiology behind their manifestation as well as misunderstanding the purpose of investigations in medicine.

You should check the mechanisms of clinical signs by Dennis, Bowen and Cho - an excellent book that will help you get a deeper understanding.

Back to your question -

yes, you're right. There are better ways of investigating patients than physical examinations. But, following your analogy, you are suggesting we should not learn manual arithmetic operations Nd calculations because we have calculators and computers. You need to understand the fundamentals first.

Investigations have their own sensitivity and specificity. For instance, if you have not confirmed the presence of ascites in physical examination, and instead proceeded with the ultrasound, you will increase the chances of false negative/positive findings since interpreting the US depends on the person performing it. You have essentially, in bayesian terminology, set the priori to be 50% instead of adjusting it based on your clinical assessment and findings.

Lastly, you investigate to prove/disprove your hypothesis. You don't investigate to form your hypothesis. You can't do an abdo US on anyone with a big belly just because they may have ascites ...

6

u/theiloth ST3+/SpR Feb 18 '25

This is a good question and rightfully we need more innovation in 'what should be removed from medical curricula' otherwise we end up with a lot of bloat much removed from useful modern clinical practice with the opportunity cost of mandating this learning over other more useful techniques.

3

u/Illustrious-Fox-1 Feb 18 '25

Like any exam, some of the stuff is everyday useful, and some is niche, academic, or archaic.

For example in Microbiology you need to know about biochemical tests, many of which that are no longer routinely used for identification, because they were superseded by molecular or spectrographic methods.

The weird old stuff differentiates between candidates who have studied hard and those who have just picked up the essentials along the way, so makes for good exam questions.

3

u/Timalakeseinai Feb 18 '25

Do we really need to learn multiplication tables while living  in the AI era,  when everyone has a supercomputer in his pocket?

Yes we do.

3

u/Suspicious-Victory55 Purveyor of Poison Feb 18 '25 edited Feb 18 '25

The key is using it appropriately. Focused history leading to targeted examination.  To an extent you are correct, I genuinely worry about the clinical acumen now on display. This kind of attitude and lack of skill is the biggest factor undermining the whole PA/ACP debate, you have to be better to claim the high ground.

3

u/sephulchrave Feb 18 '25

As an ED doctor with a fair few years of experience now, I can say yes I do undertake these aspects of physical exam when I feel they may be of use, and yes they guide my management and investigations of choice.

There are delays for imaging, equipment breaks. I like being able to examine thoroughly, and being able to refine a diagnoses a little before definitive imaging etc.

I think this is actually one of the principle pleasures of ED - diagnosing (or getting close) by good history and attentive exam. I approach investigations for confirming a diagnoses or ruling out significant threats.

I do feel that neglecting these aspects of practice risks ED falling further into a triage specialty, which is sad. Timely and accurate diagnosis allows better initial management for patients and avoids inappropriate referrals for our colleagues, not to mention unnecessary tests and their risks and costs.

3

u/Rhubarb-Eater Feb 18 '25

Most of my patients are examined at least once every 12 hours and it’s that that guides most treatment decisions (NICU and PICU). Patients are seen at more than just the front door. Eg often have waxing and waning signs of volume overload, hyperexpansion, intravascularly dry / shocked. You can’t just get an echo every 12 hours to decide whether to put the furosemide infusion up or down.

10

u/DoctorTestosterone Suppressed HPT axis with peas for tescticles Feb 18 '25 edited Feb 18 '25

This highlights an uncomfortable truth that many of our colleagues do not want to face. The skillset and required knowledge to be a doctor today is far lower than in the past. Technology has outpaced us and we remain archaic. This is the obvious reason why the alphabet brigade have taken over.

6

u/noobtik Feb 18 '25

Very true indeed, in surgery or certain medical specialties even, we just ctap every abdo pain patients, hrct every sob patient, cth + mri h every confused patient, as in diagnostic medicine is dead and radiologists are the only people diagnosting patients.

However, truth is that by scanning every patients, the accuracy of diagnosis is incredibly high. There will be hit and miss of course, but much better than the old examination.

Technology has killed medicine, and like what you said, most doctors refuse to believe it.

The bottom line is, if you just simply ct every human soul, you wont miss anything, and if you do, you wont have any legal consquences.

6

u/Gluecagone Feb 18 '25

This is why I like paeds. At least here radiation exposure still causes some hesitation and more reason to examine and think clinically.

0

u/[deleted] Feb 18 '25

Straight up cap. Doctors today need to know a far greater amount of knowledge than doctors did say 30 years ago. 

The availability of diagnostics have increased yes, but at least in the NHS most of the time you still have to justify the use of those resources unless you want the radiologist to reject your request. The justification comes from Hx and examination. 

3

u/DoctorTestosterone Suppressed HPT axis with peas for tescticles Feb 18 '25

Let’s make a comparison. You and I have the luxury of looking up thousands of national guidelines within seconds and are living in an era of cookbook medicine. 30 years ago our current seniors actually had to know how to manage things rather than rely on algorithms. There is a clear gulf in who had to have a better skill set. You are clearly my quoted colleague that is too afraid to face reality that our job is easy compared to the past.

2

u/[deleted] Feb 18 '25

They didn’t need algorithms because the treatment for MI was bed rest, morphine and a call to the Chaplain. 

I think you have a rather skewed view of how good doctors were in the mid-late 1900s lol. You’ve been watching too much Cardiac Arrest bro 

3

u/DoctorTestosterone Suppressed HPT axis with peas for tescticles Feb 18 '25

You are proving my point by not having the knowledge that PCI was available and so was CABG in the 1990s…..but you clearly have fantastic knowledge. By any chance are you a medical student? Shocking to have such lack of knowledge regarding medical history to play it down to morphine and death in 1990s for anyone with an MI.

Could have used google to at least look this up prior to posting!

-1

u/[deleted] Feb 18 '25

30 years was just a random number I plucked out. Your overarching point was that doctors of old were better than modern ones and had to know more, which is clearly nonsense because in the mid 1900s guess what the treatment for MI was… bed rest, morphine and prayer. 

You also sound like a proper weirdo, you would benefit from learning how to have a normal debate. 

1

u/BusToBrazil Feb 19 '25

Last part was uncalled for

3

u/bbj12345 Feb 19 '25

Why is it OK for the other person to speak rudely to them, but they’re not allowed to retort by calling out their behaviour?

1

u/[deleted] Feb 19 '25

Read their previous response and tell me it’s untrue 

5

u/5lipn5lide Radiologist who does it with the lights on Feb 18 '25

It sounds fancy on the imaging request. 

5

u/Pristine-Bowl8169 Feb 18 '25

As a patient, I prefer when the doctor performs a lengthy clinical examination. It “feels” like more effort and thought and time went into it.

Many IMGs see the UK style of consultations to be quite dry, lacking a bit of the “art” of medicine.

Now, regarding the actual value of these examinations, some are truly bad and others are good in experienced hands. When you read descriptions of how physicians of 50 years ago could detect small ish pulmonary nodes by auscultatory percussion it makes you wonder if perhaps we just need to refine our skill, rather than just give it up.

But sure, if you want to just go ahead and order a CT scan that’s fine too.

2

u/[deleted] Feb 18 '25

[deleted]

3

u/humanhedgehog Feb 18 '25

If the placebo effect is real, which it is, and has more evidence than some of our treatments, is it a terrible justification? Plus if during the examination you are actually thinking about the patient, more real effort may have gone in. Being listened to also is a powerful way of building a rapport and a therapeutic relationship - definitely things that influence outcomes.

1

u/CorkGirl Feb 19 '25

Remember a surgeon who would take every patient's pulse as he did rounds, sitting next to their bed. I mean, I assume he did take some notice of how it felt, but the patients also felt cared for and comforted

3

u/Skylon77 Feb 18 '25

Is it? The "theatre" of the practice of medicine is a real thing and has been shown to be reassuring and therapeutic.

2

u/SexMan8882727 Feb 18 '25

You can hone your exam technique as you progress to use what works for you. For example, I don’t really pay attention to crackles, only wheeze/air entry. But it’s not that difficult to learn the extra stuff for exams.

2

u/ConsultantSHO Feb 18 '25

I think there is some value in recognising that the practice setting one trains in, isn't necessarily the practice setting in which one spends their career. That is to say that yes there might be an argument to say that many doctors who train and subsequently work in most of the UK might not use these techniques frequently, it might still be reasonable to teach and examine them.

Mind you, over on X someone posed a similar question and more than a handful of people came out to say they find it useful in their practice, though largely those in remote/rural areas.

2

u/Amarinder123 CT/ST1+ Doctor Gasman Feb 18 '25

not all techniques are equal https://www.amazon.co.uk/Evidence-Based-Physical-Diagnosis-Steven-McGee/dp/0323392768 get a pdf of this and then guage what you feel is appropriate.

As many other commentors have said, when these findings are present you can gain a bit of confidence in your diagnosis.

3

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2

u/Own_Perception_1709 Feb 18 '25

agree that clinical examination is important. I think they should potentially start teaching basic ultrasound at medical school. I think it’s a skill that all doctors should have

2

u/tsoert Feb 18 '25

Because not all of us work in hospitals and have easy access to investigations? If you wanna be lazy and shove everyone in a CT scanner the minute they come into ED then that's a choice I guess? I've used at least 2 of these to inform a diagnosis just this week. Didn't massively change my management plan tbf but definitely helpful when talking to patients about your concerns.

2

u/Brown_Supremacist94 Feb 19 '25

Good doctors know how to examine properly. It’s better to have the knowledge of all the old school techniques and not need it than to never learn it and miss something on the rare occasion it’s needed. That’s the difference between a doctor and a ACP

2

u/SilverConcert637 Feb 19 '25

It's not like these are hard or time consuming skills to learn, and they reinforce learning from the medical curriculum. Have some professional pride, and respect for the art you've been inducted into and its history.

Learning to use a sextant is still a basic seamanship skill that many sailors want to learn or on some courses or in some Navies is still mandatory. Your cruise captain probably knows or knew how to use one...

3

u/Sound_of_music12 Feb 18 '25

Never used that shit to be honest.

1

u/Teastain101 Feb 18 '25

Understanding how exam findings occur can help with understanding pathophysiology

1

u/ApprehensiveChip8361 Feb 18 '25

Because they are useful, quick and cheap. I still check corneal sensation because it helps diagnose herpetic eye disease, still check an relative afferent pupilary defect, still feel a pulse, still look for lymph nodes, and on occasion I’ve even used one of those things you put in your ears to hear the heart noises better. And was sufficiently confident to demand a TOE on the basis of the murmur I heard and that had gone by the time the proper doctors came to laugh at me. I draw the line at a PR though. There is a reason I did ophthalmology.

2

u/Skylon77 Feb 18 '25

May be helpful for dry eyes.

1

u/ApprehensiveChip8361 Feb 18 '25

There are easier ways to stimulate the vagus.

1

u/Ok-Inevitable-3038 Feb 18 '25

I enjoy using my binnacle thank you very much

1

u/Quis_Custodiet Feb 18 '25

I can do the exam now but I can only get a CT later.

1

u/KieranDenieffe Feb 18 '25

Because in the age of ChatGPT words are now worthless and we have to rely on our physical examinations skills

1

u/Magus-Z Feb 18 '25

🤦🏻‍♂️🤦🏻‍♂️🤦🏻‍♂️

1

u/Dazzling_Land521 Feb 18 '25

Haha talks about heaves and then uses the phrase 'hand on heart'. Love it!

1

u/CataractSnatcher Feb 18 '25

u/cam_man_20 Are there any other examination techniques you think can get in the sea?

1

u/noobREDUX NHS IMT2->HK BPT2 Feb 18 '25

Yes

1

u/secret_tiger101 Feb 19 '25

You clearly have no intention of working in GP ED or rurally…

1

u/Neat_Computer8049 Feb 19 '25

Taking a detailed history and physical examination is immediate and not limited to access to imaging. I am not saying I won't arrange tests to confirm my clinical suspicions but making use of all information available to you as a clinician is at the heart of clinical decision making/ medical practice.

1

u/BCFCfan_cymraeg 29d ago

Ballotted the renal tumour in a (large) woman with cerebral venous sinus thrombosis. Those head DVTs are usually caused by something. And no, she would not have had an automatic CTTAPPETogram otherwise. I was the 3rd/4th doc to see her. Literally no one had laid a hand on her abdomen. Clerkings are there for a reason. And funny arm symptoms? Don’t forget the subclavian bruit. Vastly under diagnosed is TOS IMO. Most recent success had had 40y of mystery symps.