We are beside a gurney in the emergency department (ED), the medical student and me, looking down at Mrs. Jones who had sustained what appeared to be a straightforward cut to the webspace between the ring and little digit of her left hand. The student examined the wound and hoped to suture the laceration.
I greeted the patient and introduced myself as the emergency physician and the supervisor of the student. She was a pleasant, retired woman, though perhaps not that much older than me. I sensed she would be a willing participant in a teaching session for the student.
I asked the learner to show me how she examined the traumatized extremity. She began replaying the physical manoeuvres she had carried out. As she reached the end of her examination, I gently stopped her.
“Okay, what you say is entirely valid, but can you describe the attitude of the hand first?”
She looked at me as if scanning my face for the answer, “The attitude of the hand? What do you mean?”
“The attitude means the posture or the natural position. With a normal hand in a relaxed, palm-up position, how do the fingers reveal themselves?”
“They would be seen in a semi-flexed position,” she said.
“Yes, in a cascade of naturally increased flexion from the index to the fifth finger, agreed? So, why do you think I asked you to describe this?”
“Because it's part of the physical exam?”
“Well, yes, inspection is not only part of the examination, it is the starting point. OslerReference Osler1 tells us that we should not rush to palpate the abdomen, to percuss the lung fields, to auscultate the heart, and, I would add as a modern addendum, to place an ultrasound probe on the patient's body, before first using our eyes, our powers of observation. He was exceptionally observant, Osler. So, let us imagine a different patient—excuse us, Mrs. Jones,” I said, directing my comments to our patient, “for talking hypothetically here. I hope you don't mind my making a point with the student?”
“No, I don't,” she said. “Who would have thought hands have attitude, anyway?” I chuckle politely.
“Okay,” I said to the med student, “so a different individual presents to you with a wound on the volar surface of her left hand,” I say, pointing to the midpoint of the palm of the patient before us, “bleeding has been controlled with pressure, and you have the patient place her hand in a relaxed palm-up position. Take it from there.”
“Okay, so I will inspect the wound, the hand, and the fingers to assess the attitude, right? So, what do I see?”
“You observe that the middle digit is extended, unlike the others, which are in the natural position of flexion. What is your diagnosis?”
“Complete laceration of the flexor tendons, of course.”
“Yes, very good! Next you finish the examination, as you described in Mrs. Jones’ case, to confirm severance of both the flexor digitorum superficialis and flexor digitorum profundus, as well as to assess for nerve and arterial trauma. But you see how Osler was onto something? And, so, you must train yourself to look. To be observant. To pay attention to what you see.”
She nodded, but I detect a certain hesitation. “Do they still talk about William Osler in medical school these days?” I asked, though I am fairly certain I know the answer.
“Well, I think maybe he is mentioned from time to time, but…” she says, her voice trailing off.
I began to describe his contribution, my eyes grew wide, and I realized I am talking with large hand gestures: A McGill medical grad, a 25-year-old professor in Montreal, the chair of clinical medicine at the University of Pennsylvania in Philadelphia, a co-founder of Johns Hopkins Medical School in Baltimore, Oxford's Regius Professor of Medicine, sole contributor to his own textbook of medicine—I managed to stop myself before losing her attention. Patients were waiting, and there was much work to do.
“All right, you go ahead and stitch up the cut.” Having already demonstrated her competence, I left her to the task while I dashed off to see other patients.
I returned just as she was finishing the repair, and I bent over to inspect the suture placement. “Yeah, okay, looks good.”
“Yes, looks to me like she did a really neat job,” said Mrs. Jones. “So, thanks.” The student looks pleased.
Later, at the end of our shift, I sat down heavily and sighed. I then cleared my throat, as if to expel the momentary embarrassment of my display of fatigue. I looked to the medical student, “So,” I said, trying to look energetic, ”how did the work go for you today?”
She goes on to tell me that she enjoyed assessing patients, honing her skills in gathering histories, and performing physical examinations. “Inspection first,” she said, “yes, okay, but you know, it just seems so totally obvious.”
My thoughts fractured for a moment. I was adrift, thinking of how to respond. She was correct, I realized. My concrete example was not likely compelling to a keen, bright young student. In reaching for the profound, I had only uncovered the prosaic.
As for Osler, I often bring up medicine's Great One to students for the simple reason that he was the outstanding physician of his era, a member of one of the final generations of physicians to rely almost entirely on the human senses for diagnosis. The question is, does he have any relevance for students of the 21st century?
Scientific innovations have revolutionized health care, and we are all the better for it. However, as we focus on evidence-based decision-making and increasingly default to medical imaging techniques to facilitate diagnosis, discussions of the art of medicine seem to have fallen by the wayside. Yet, I am mindful that it is interpersonal dialogue and the beneficent human touch that separate the clinician from the technician. I fear for a future in which physicians fail to address this difference.
As I turn to the student, though, I choose to frame my words in a positive light, “You're right. It is obvious, I suppose, but Osler famously stated that the whole art of medicine is in the observation. All I want is to emphasize the importance of learning how to properly do a physical exam.”
I paused briefly and looked to see her nodding in agreement.
“May I suggest taking a few minutes to get the Wiki lowdown? Perhaps his life will inspire you as it has me.”
I briefly wondered what changes in practice she would see over the course of her career. What might she choose to teach her own students, when, like me today, she is more than 30 years from medical school? Unknowable, of course; I smile, shake her hand, thank her for her contribution to the day's work, and we go our separate ways.
You have
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We are beside a gurney in the emergency department (ED), the medical student and me, looking down at Mrs. Jones who had sustained what appeared to be a straightforward cut to the webspace between the ring and little digit of her left hand. The student examined the wound and hoped to suture the laceration.
I greeted the patient and introduced myself as the emergency physician and the supervisor of the student. She was a pleasant, retired woman, though perhaps not that much older than me. I sensed she would be a willing participant in a teaching session for the student.
I asked the learner to show me how she examined the traumatized extremity. She began replaying the physical manoeuvres she had carried out. As she reached the end of her examination, I gently stopped her.
“Okay, what you say is entirely valid, but can you describe the attitude of the hand first?”
She looked at me as if scanning my face for the answer, “The attitude of the hand? What do you mean?”
“The attitude means the posture or the natural position. With a normal hand in a relaxed, palm-up position, how do the fingers reveal themselves?”
“They would be seen in a semi-flexed position,” she said.
“Yes, in a cascade of naturally increased flexion from the index to the fifth finger, agreed? So, why do you think I asked you to describe this?”
“Because it's part of the physical exam?”
“Well, yes, inspection is not only part of the examination, it is the starting point. OslerReference Osler1 tells us that we should not rush to palpate the abdomen, to percuss the lung fields, to auscultate the heart, and, I would add as a modern addendum, to place an ultrasound probe on the patient's body, before first using our eyes, our powers of observation. He was exceptionally observant, Osler. So, let us imagine a different patient—excuse us, Mrs. Jones,” I said, directing my comments to our patient, “for talking hypothetically here. I hope you don't mind my making a point with the student?”
“No, I don't,” she said. “Who would have thought hands have attitude, anyway?” I chuckle politely.
“Okay,” I said to the med student, “so a different individual presents to you with a wound on the volar surface of her left hand,” I say, pointing to the midpoint of the palm of the patient before us, “bleeding has been controlled with pressure, and you have the patient place her hand in a relaxed palm-up position. Take it from there.”
“Okay, so I will inspect the wound, the hand, and the fingers to assess the attitude, right? So, what do I see?”
“You observe that the middle digit is extended, unlike the others, which are in the natural position of flexion. What is your diagnosis?”
“Complete laceration of the flexor tendons, of course.”
“Yes, very good! Next you finish the examination, as you described in Mrs. Jones’ case, to confirm severance of both the flexor digitorum superficialis and flexor digitorum profundus, as well as to assess for nerve and arterial trauma. But you see how Osler was onto something? And, so, you must train yourself to look. To be observant. To pay attention to what you see.”
She nodded, but I detect a certain hesitation. “Do they still talk about William Osler in medical school these days?” I asked, though I am fairly certain I know the answer.
“Well, I think maybe he is mentioned from time to time, but…” she says, her voice trailing off.
I began to describe his contribution, my eyes grew wide, and I realized I am talking with large hand gestures: A McGill medical grad, a 25-year-old professor in Montreal, the chair of clinical medicine at the University of Pennsylvania in Philadelphia, a co-founder of Johns Hopkins Medical School in Baltimore, Oxford's Regius Professor of Medicine, sole contributor to his own textbook of medicine—I managed to stop myself before losing her attention. Patients were waiting, and there was much work to do.
“All right, you go ahead and stitch up the cut.” Having already demonstrated her competence, I left her to the task while I dashed off to see other patients.
I returned just as she was finishing the repair, and I bent over to inspect the suture placement. “Yeah, okay, looks good.”
“Yes, looks to me like she did a really neat job,” said Mrs. Jones. “So, thanks.” The student looks pleased.
Later, at the end of our shift, I sat down heavily and sighed. I then cleared my throat, as if to expel the momentary embarrassment of my display of fatigue. I looked to the medical student, “So,” I said, trying to look energetic, ”how did the work go for you today?”
She goes on to tell me that she enjoyed assessing patients, honing her skills in gathering histories, and performing physical examinations. “Inspection first,” she said, “yes, okay, but you know, it just seems so totally obvious.”
My thoughts fractured for a moment. I was adrift, thinking of how to respond. She was correct, I realized. My concrete example was not likely compelling to a keen, bright young student. In reaching for the profound, I had only uncovered the prosaic.
As for Osler, I often bring up medicine's Great One to students for the simple reason that he was the outstanding physician of his era, a member of one of the final generations of physicians to rely almost entirely on the human senses for diagnosis. The question is, does he have any relevance for students of the 21st century?
Scientific innovations have revolutionized health care, and we are all the better for it. However, as we focus on evidence-based decision-making and increasingly default to medical imaging techniques to facilitate diagnosis, discussions of the art of medicine seem to have fallen by the wayside. Yet, I am mindful that it is interpersonal dialogue and the beneficent human touch that separate the clinician from the technician. I fear for a future in which physicians fail to address this difference.
As I turn to the student, though, I choose to frame my words in a positive light, “You're right. It is obvious, I suppose, but Osler famously stated that the whole art of medicine is in the observation. All I want is to emphasize the importance of learning how to properly do a physical exam.”
I paused briefly and looked to see her nodding in agreement.
“May I suggest taking a few minutes to get the Wiki lowdown? Perhaps his life will inspire you as it has me.”
I briefly wondered what changes in practice she would see over the course of her career. What might she choose to teach her own students, when, like me today, she is more than 30 years from medical school? Unknowable, of course; I smile, shake her hand, thank her for her contribution to the day's work, and we go our separate ways.
Acknowledgement
The author would like to recognize the student, Ms. E. R., medical class of 2019, University of British Columbia.
Competing interests
None declared.