The value of clinical medicine cannot be denied even in this modern era of medicine where most sophisticated tests and investigations are available in many teaching hospitals and medical centres. During the last three decades, numerous sensitive, specific and complicated laboratory investigations have been in fashion to reach and confirm a diagnosis and every day their number is increasing and the methodology continues to change. However, these are very expensive tests and the affordability is sometimes beyond the capacity of a common man. Therefore, it is very important to emphasize on clinical acumen so that common illnesses are diagnosed and treated promptly, rather waiting for the laboratory tests. This does not mean that the importance of these tests is denied. They are of course a great help in this context.
The laboratory investigations cannot supersede a good clinical acumen and these are required to establish or exclude a diagnosis. This point has to be emphasized on young doctors during their training. A sound knowledge of clinical examination skills can make these young doctors super clinicians of the future. It is better to realize this earlier than later.
It is rightly said that medical knowledge is a science but on the contrary medical practice is an art. We have seen many doctors over the years who had blooming knowledge of medicine but ultimately they were not successful as a good practitioners which ultimately matters.
There is no doubt that a sound basic knowledge in a particular field makes a strong foundation but its application in a right way is most important. Above all, a good practitioner should be a good human too. The doctor-patient relationship is very pious and taking a detailed history and a physical examination assures the patient that the doctor has done his best to diagnose his 3ailment and this further builds the confidence of the patient and he becomes more co-operative. It is very well-said that clinical medicine blossoms human medicine into humane medicine. Clinical diagnosis and assessment of severity of disease are based on history, thorough clinical examination and investigations and the importance of these three sources is well known to every good clinician.
It is also worth noting that when medical students enter from the basic sciences of anatomy and physiology to the clinical years, they are in a different environment because there they were learning with frogs, dogs, rabbits and dead human bodies (cadavers), but now they will learn on living humans with various diseases. There will be both male and female patients and understanding and respecting their feelings is most important. This leads us to say that good mannerism, kindness and politeness do matter a lot. This approach makes the patient realize that this particular doctor is kind, friendly and is interested to treat him or her. To learn on the living human patients one needs their co-operation and one should be grateful to them that they have co-operated with their full effort in spite of infirm health. Otherwise, if the patient does not co-operate then learning clinical medicine and mastering clinical examination skills may become very difficult and not less than a major problem.
Clinical methods are the skills which every doctor should achieve before they enter in real independent clinical practice. As it is obvious, this skill is acquired during a life time of practice. No doubt the methods in clinical examination keep on evolving and changing but not to such an extent as laboratory investigations. Clinical skills are learnt by a combination of mutual study and experience.4
It is also important to know that various teachers have their own way of examination of different systems but all of them have some basics in common which is a healthy exercise. Sometimes students experience difficulty from this while in actual examination. It is therefore advised that all the doctors should follow a well-known standard text book of clinical examination and can quote reference from that book to the examiner rather than naming a particular person, which the examiner may not like. But undue argumentations should not be done with the examiner on these points of controversy as the candidates should not take any “risks” at all during examination.
DC Corrigan (1802–1880) a renowned clinician said, The trouble with doctors is not that they don't know enough, but they don't see enough.
The skills required for a competent clinical examination can only be learnt and mastered by practice at the bed side of a patient. Each patient is like a book and unless you open it and explore, you would not get enough knowledge about the disease. It is also worth noting that few patients have multiple pathologies and one can come across these problems very often and should be able to tackle them with confidence. A thorough basic knowledge of anatomy, physiology and pathology adds towards “perfection.”
It is also important to note that most medical problems can be solved by a careful history and clinical examination without subjecting the patient to many unwanted, expensive, undesired and painful investigations.
The author has tried to put his experiences as a student, teacher, examiner and a practitioner in this book. A lot of care has been taken to design this book to create interest in the medical students, both undergraduate and post-graduate to understand importance of clinical examination skills.5
This book will not only enhance the clinical knowledge of already practicing clinicians but will also help tremendously to undergraduate and postgraduate medical students to get through their examinations, i.e. MBBS (final), MCPS (Medicine), MD (Medicine), FCPS (Medicine), MRCP (UK) and other medical examinations.
The set up of this book is simple and effort has been made to discuss part of the examination step-wise thus the name “step by step in clinical examination skills”. Various commands given by the examiners to the examinee from various systems have been described. Help of photographic material is also provided to the student in the book. A few examples of various commonly asked commands are quoted below:
“Examine this patient's pulse”
“Examine the fundus of this patient”
“Look at this patient's face and do the relevant examination”
“Listen to the pre-cordium.”
It is therefore of utmost importance to listen carefully what the examiner says about the command or read carefully if the command is written on a piece of paper at the patient's bedside and proceed accordingly, rather than going into more details of those aspects which are not asked at all. Time factor is very vital in these examinations and you have to satisfy the examiner that you know the art of doing clinical examination perfectly under examination environment and under the specified time limit. It may be difficult but by no means impossible. The answer to this difficulty is to do more practice of clinical examination even on normal human subjects, e.g. your brother, friend or colleague etc. It is an old but well said saying “practice makes one perfect” therefore get yourself awake, tighten up all your strengths, straighten your aim, 6spend your time honestly with the patients and practice day and night and I can assure you that you will feel that you have achieved confidence in examining the patients correctly.
Also remember that for a good clinical examination, besides basic working knowledge you should also be well equipped with your instruments of basic needs which should be kept in order in a small brief case. At times I have seen students searching their pockets for needles, measuring tape, ophthalmoscope or a tongue depressor which wastes a lot of important and vital time which can be spent in a more useful and fruitful way on the patient.
In the end a well-dressed, groomed, well and soft spoken clinician adds to the beauty of the all this drill. You should have nails and beard (if you have it) trimmed, or clean shaved with polished shoes. But this does not mean that you should think that by examining the patients you will get dirty rather it is impressive to the examiner and the patient.
When I appeared for my membership examination (MRCP) in London in 1986, I was told by my teachers that even if you are wearing a three piece brand new suit and if you have to examine abdomen at the level of the bed, kneel down on the ground! This further adds to the confidence of the patient and gives impression to the examiner that how dedicated you are in conducting a thorough clinical examination. I was told by a very eminent teacher that in the examination it is not only the knowledge we test but we also take notice of the overall appearance of the examinee and his mannerisms. The examinee may be very good in knowledge but if the bed side manners are bad then the chances of that candidate to pass are very grim.
I must also stress that the history and a thorough physical examination are two important pillars in patient's 7management to follow later. If you want to become an accomplished physician or clinician, you have to polish your clinical skills and should continue polishing it for the rest of your life. The experience grows and expands identifying the symptoms, problems and abnormal findings, listing them to an underlying process of pathophysiology and establishing a set of most relevant laboratory investigations more easily.
Bern and Lown said that today's physicians seem at times more interested in laying on tests than laying on hands. Sir William Osler, another renowned clinician once said medicine is an art of probabilities and a science of uncertainties and that these aspects are inseparable very much like Siamese twins for whom trying to separate one from the other would only kill them both.
Sir William Osler encouraged students of medicine in almost all his books. In one of his books, he has written learn to see, learn to hear, learn to feel, learn to smell and to know that by practice alone you can become an expert. It still applies in this modern era of science and technology. We need to listen to our patients very patiently; we need to understand their complaints or symptoms and we need to observe them with critical sense to elicit physical signs. These skills can be achieved by every doctor but require sincere and strenuous effort and perpetual practice.
I would request the readers that having passed their examinations; they should continue following the best of clinical examination skills in future and pass on their knowledge to their students and juniors.
In the end, I must thank all my students and colleagues who continuously hammered me to write a book in a simple and easy way to learn the clinical skills in physical examination. I have tried to write very simple language and hope that this will be another useful addition to a treasure of books on this subject.