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Why I have not stopped examining patients
  1. Charles Warlow
  1. Correspondence to C Warlow, Emeritus Professor of Medical Neurology, Department of Clinical Neurosciences, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK; charles.warlow{at}ed.ac.uk

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“O my! O my! O my!” exclaimed Mole to the water Rat when he saw the beauties of the river in early spring in the first chapter of Wind in the Willows, a book that many children in the UK were, and are still, brought up on. “O my! O my! O my!” I thought as the letters of concern and complaint came flooding in after Chris Hawkes's editorial ‘I’ve stopped examining patients!'.1 More letters than after almost all previous articles combined (look at them after his article on line). Why? I think essentially because he struck at the heart of a neurologist's prowess—the ability to elegantly, accurately and quickly elicit physical signs which lesser mortals (ie, general internal physicians) have missed or never heard of. And then to use the signs, along with the history, to direct appropriate investigations, if any at all are required, and so make a diagnosis. Examining the nervous system is what we are trained to do, over and over again. And in our turn we relentlessly teach the students to ‘examine the nervous system!’. Indeed we endlessly debate among ourselves the best way to reinforce the reflexes, look for nystagmus and so on.

Professor Hawkes exaggerates for effect but even he still admits to examining some patients under some circumstances. I agree. In every single case we should ask ourselves the question “exactly why am I trying to elicit this particular physical sign in this particular patient?” After all, there is an opportunity cost in a busy clinic where time spent talking to the patient could be compromised by too much fiddling with their toes. I well recall being reprimanded by a senior neurosurgeon in an x-ray meeting when I remarked that it was pointless doing the plantar responses because I already …

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