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I’ve stopped examining patients!
  1. Christopher H Hawkes
  1. Honorary Professor of Neurology, Queen Mary University London, Neuroscience Centre, Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, 4 Newark Street, London E1 2AT, UK;

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    When I was a medical student in Edinburgh, back in the 1960s, we were all taught on fear of death to undress patients down to their underwear and examine them from head to toe. Scare stories abounded with statements like “if you don’t put your finger in it, you’ll put your foot in it” or “he would have got the diagnosis if he had bothered to examine the abdomen”. Patients were accustomed to this type of thoroughness. But over the years we have modified our approach—many patients now object to undressing routinely in the clinic unless you can give them a really good reason, and they may respond that “my general practitioner (GP) has already done that”.

    It is true that for a neurologist, the yield from general medical examination is fairly small, in proportion to the time taken. Why use a stethoscope when carotid duplex or an echocardiogram will give infinitely superior information? When did you last diagnose mitral stenosis with a stethoscope? I guess not for many years. And what about an atrial myxoma? I have diagnosed this twice (by chance) but only after an echocardiogram. A carotid bruit is nice to pick up but it is sometimes due to turbulence without serious stenosis, or it is on the “wrong” side, and it cannot measure reliably the degree of stenosis which when very severe may not generate a bruit at all.

    Increasingly, I find myself examining patients with their clothes on and while they are sitting in the chair, and even more alarmingly (perhaps) I am not examining them at all! Well yes, I do in a sense, as all clinicians do indirectly, by watching patients as they enter the room, by the way they sit, talk, give the history and by observing any involuntary movement. The ability to take a history and examine simultaneously is a technique that takes a few years to acquire, but what I really mean by “examining” is going as far as putting the patient on a couch and undertaking a formal examination—selective or otherwise—and that is what I have found myself doing less and less over the past 10 years or so. On the odd occasion when unannounced I have visited a colleague’s room, I have usually found they are adopting the same approach.

    This realisation prompted me to undertake a small survey of my last 350 new referrals in various district general hospitals over the preceding 4 months or so (okay, this was retrospective and liable to all sorts of bias but the clinics were all typical without being full to bursting). What it showed (table) was that the patients I usually did not examine had in the main: seizure disorder (88% not examined); syncope (82%); transient ischaemic attack (60%); dementia (60%); and head or face ache (72%). Those who were examined—at least in the chair if not on the couch as well—had: mono- or polyneuropathy; radiculopathy; demyelination; myelopathy or stroke (all 100% examined); movement disorder (97%); fatigue or depression (73%).

    Table Proportion of 350 new patients who I examined neurologically

    So why should this be? Simply because most of the tests we now have available are infinitely superior to physical examination in diagnosing or excluding disease. If your patient has a headache, he or she is going to need a brain scan—nowadays patients expect it. No matter how much you exert your charm, and even going as far as a thorough examination, explain that it’s not a serious form of headache, they will thank you, but just before they leave will say “but just for reassurance doctor could I have a brain scan please”. Others will nag their GP or pay for it in the private sector. Similarly for transient ischaemic attacks—the examination is unnecessary (the clinic nurse does the blood pressure I trust) because inevitably you will be ordering a brain scan, imaging the neck vessels and requesting a full cardiac workup. Do you really get out your stethoscope and listen to the heart, neck, and the femoral arteries; perhaps if medical students are watching, or certainly to fill up the time for a private patient, but otherwise let’s be brutally honest—never! Do not delude yourself by writing in the letter to the GP that “brief neurological examination was normal”. No-one will believe you.

    When you undertake ward consultations, do you regularly carry around a set of instruments and, if so, actually use them, or do you compromise with other peoples’ examination findings and rely increasingly on multiple investigations? Some argue (and I agree) that good neurological examination technique is essential; it has to be learnt and then applied but only when the correct moment arises. Well yes, maybe, but how many medical students do you find who, for example, can test joint position sense properly, or even light touch? When examining fourth year medical students recently I had to fail two of them for testing vibration sense by holding the vibrating end of the tuning fork. That was after they had spent much of the time working out how to make it vibrate. As a neurology tutor, I used to watch neurology registrars in training perform a neurological examination, usually during grand rounds. It could drive one to despair—a significant minority examine badly, even those at hallowed institutions of excellence.

    Unquestionably, if we did not have MRI, neurophysiology and cardiac screening facilities, the traditional approach would need to be drummed in just as thoroughly as in the old days, but things have changed and neurological examination is practised less and less. I do not regret it. I can spend more time talking to and reassuring my patients, backed up by investigations which I know are many times more reliable than the most fastidious bedside examination. Those of us working in large conurbations will doubtless agree that examining someone with poor English is unreliable and so in general I over-investigate these patients (to preserve my registration if nothing else).

    So, do we just sit back and let things change? Well yes, actually, I think we should, and take this even one step further. If there is no need to examine everyone, just to talk to them, why are we not organising video conferences direct to GP surgeries—a “video clinic”? Nothing new about this but it is very rarely undertaken. For the commoner complaints, you could make a good start this way, cut down drastically on hospital clinic resources and become the darling of your business manager. Given that even the basic emailing of letters to and from GPs has not yet started, video clinics will probably be some time off, but for the moment I’ve stopped examining patients—well, almost!