Moving-on from Victorian Medicine (Still on the subject of Covid – a future direction for clinical assessment)

I had wanted to take a break from writing today; maybe after this one.

It has to do with the whole ‘thing’ of examining a patient.

You see, this is something central to what it is to be a doctor. It sits in the realm of things that can’t be challenged or questioned. If you don’t examine your patient, usually referred to as conducting, ‘a thorough clinical examination,’ and in particular if anything goes wrong, you are defenceless.

I’ll explain a little more.

If a patient asks me for advice and I listen to what they are saying, we call this, ‘taking a detailed clinical history’ and work-out a diagnosis that is correct, I am OK.

You tell me you have pain in your abdomen, your bowel habit has changed, maybe your blood count is low; I refer you for a colonoscopy and the result is that you have diverticular disease, all is fine.

If however you tell me that you have pain in your abdomen, your bowel habit has changed and your blood count is low and I say, ‘It’s probably diverticular disease’ and it turns out to be cancer, I am considered negligent (and rightly-so).

If, and here is the thing, you tell me you have pain, your bowel habit has changed and blood count is low and I examine you, and then decide, ‘It is probably diverticular disease,’ and it turns out that you have cancer, I might be found wanting, I might even be considered a bad doctor, but much less likely to be negligent.

I might document something like, ‘Impression – recurrence of known diverticular disease, reassure.’

If this turns out to be cancer, I will be considered a doctor who has examined a patient, made a mistake, and that is it.

This version is sort of iffy, as what I should say is, ‘Impression – recurrence of known diverticular disease, reassure; advise patient to inform me if pain does not settle in two weeks.’ (Or words to that effect) (we call this ‘safety-netting’).

The outcome of this would be the patient still has the pain and the doctor refers for the camera, the cancer is found and treated; two weeks doesn’t usually make a great deal of difference, particularly when in most cases it will be diverticular disease or something more benign and the two weeks will avoid many people having unnecessary tests and anxiety.

Now for the crux of this blog;

I don’t examine the patient who presents with what we call ‘signs and symptoms of cancer’.

That is no good.

How do we cope with Covid when we want to minimise clinical examination?

Well, one start would be to take a good history – by spending enough time talking with a patient, understanding what they are thinking, feeling and experiencing (often requires tone of voice, intonation, posture as well as facial expression), you can make a good stab at the correct diagnosis.

In medical school, they used to tell me that the history if 90% of the diagnosis.

I still agree.

We are going, in the days and weeks ahead to change the way we work as doctors, carrying this risk; you might call it the 10 per cent gap. When the risk of examining is felt to be too great or not justified and the diagnosis is made over the phone or by facetime or whatever form of telemedicine you have;

Doctors and nurses have been advised to write in the patient record, ‘Covid-19 – patient not examined’ or words to that effect in case of future litigation or investigation.

We will need more safety-nets.

We will need to understand risk and embrace the technology we have.

I have been using a hand-held ECG for the past year; it works fine and makes a reliable trace. No need to get undressed, it is quick and efficient, no stripping-off and spreading virus everywhere. We need more of this kind of thing.

We need people to check their oxygen saturations and heart rates at home; maybe people could learn (there is ample information of You Tube) how to check their pulse, count their husband or wife’s respiratory rate.

All of this is working in new and different ways to the old style.

Medicine has been deconstructing since the 1940’s – this will be the final push, the final step towards democratisation, levelling the playing-field, where doctor and patient partnership will become more important than ever.