The NY Times has an article about how the latest crop of doctors has forgotten—or really, never learned—how to perform a physical exam.
Oh, they can take measurements, and they can order tests. But they have come to rely on those things to diagnose a patient, rather than their eyes and ears and hands. Traditionally, those were doctors’ primary tools, and their skills in using them needed to be sharply honed. Now much of the skill seems to belong to the MRI machine and the sonogram, which give doctors a false sense of security and protection from lawsuits.
I’m not knocking those diagnostic tests; they’re important. But they should be adjuncts to a proper examination, which can tell a doctor a great deal about health rather than body parts. With an MRI and other exquisitely sensitive imaging, you can get into the trap of Too Much Information. For example, the back MRI of a person over forty without back pain often looks almost as abnormal as an MRI of one who does. What does it all mean?
One of the most impressive bits of hands-on diagnosis I’ve ever seen was performed by a man I consider a medical genius, the shoulder and elbow orthopedist Dr. Frank Jobe. The patient was my seventeen-year-old son. He had experienced multiple and repetitive shoulder dislocations, and all the doctors he’d seen on the east coast had agreed that he needed shoulder surgery of the anterior (in the front of the shoulder) type.
Dr. Jobe is the famous surgeon who invented the Tommy John elbow surgery in 1974. He’s elderly and doesn’t operate any more, but back when he saw my son he still did. He’s a genial, low-key guy, despite his fame, and he laid his hands gently on my son’s shoulder and wiggled it a little.
“Oh, my,” he said in surprise. “He’s got anterior and posterior dislocations. That’s highly unusual.”
Almost all shoulder dislocations are anterior. A few are posterior. Only a tiny percentage of shoulder dislocation patients have both, and they usually are people who have hyper-flexible connective tissue, which does not describe my son. All the doctors had missed this, except Jobe.
He went on. “And it’s the posterior dislocation that’s done the most damage.” He explained that he would do two surgeries at once, an arthroscopic one for the anterior problem, and an open surgery for the posterior. And that’s what happened (successful so far; knock wood).
But at that appointment another thing impressed me. There was a younger doctor in the room at the same time, watching. He had done the initial workup of my son and had only felt the anterior dislocation. Jobe called him over and asked him to touch my son’s shoulder again, while he showed him what he had found, “Feel this?” he asked. “Feel that little movement underneath there when I go like that?” he said, jiggling the shoulder ever so slightly. “That’s it.”
The younger doctor tried and tried, but he shook his head. He couldn’t feel it.
I had my own experience with Dr. Jobe. By the time I had my elbow surgery for an ulnar nerve problem, about a decade ago, Dr. Jobe was phasing out the surgical part of his life. I had been to countless doctors, almost all of whom had pronounced my case impossible to diagnose, because the EMG findings (that’s an electrical test for nerve conduction) were ambiguous. So I went back to Los Angeles and Dr. Jobe.
He studied all the findings; I had about eight sets of EMGs to show him. He did his own exam. And in the end he said he thought I was a candidate for surgery. “I can’t give you a guarantee,” he said. “But despite what the EMGs say, I think that, from your symptoms and my examination, this surgery will help you.”
And so it did, rather dramatically, although it took a few years for me to recover. Jobe assisted at my surgery, and I was very glad he did, because it turned out that my case was unusually complex.
I still remember what Dr. Jobe said to me in the recovery room, “We were surprised at how much damage we saw when we opened you up. Your ulnar nerve was very inflamed, and it was pinned down by a large amount of scar tissue that we had to dissect off the nerve. Other nerves had been recruited into the mess, and we had to sever them. Then we moved the ulnar nerve the way we usually do. I can’t guarantee what will happen or how long it will take to heal, because your case is unusual, but I will tell you this: you needed this surgery. Without it, you were never going to get better.”
Without Jobe and his skills, I probably would never have been able to have had that surgery, and I wonder what would have happened to me. And I wonder whether he’s been able to pass those skills on to a significant number of doctors. And I wonder whether they are able to take the time and trouble to use them. I certainly hope so.