“The plethora of tests available to the young clinician has significantly eroded the skills necessary to obtain adequate histories and careful physical examinations. Day in and day out, I encounter egregious examples of misdiagnosis engendered by inadequacies in these skills.” ~William Silen, M.D. “The Case for Paying Closer Attention to Our Patients” (1996)
“Treat the Patient, Not the CT Scan,” adjures Abraham Verghese in a New York Times op-ed piece of February 26, 2011. Verghese targets American medicine’s overreliance on imaging tests, but, like others before him, he is really addressing the mindset that fosters such overreliance. Preclinical medical students, he reminds us, all learn physical examination and diagnosis, but their introduction to the art dissipates under the weight of diagnostic tests and specialist procedures during their clinical years. “Then,” he writes, “they discover that the currency on the ward seems to be ‘throughput’ – getting tests ordered and getting results, having procedures like colonoscopies done expeditiously, calling in specialists, arranging discharge.” In the early 90s, William Silen, Harvard’s Johnson and Johnson Distinguished Professor of Surgery, made the same point with greater verve. In one of his wonderful unpublished pieces, “Lumps and Bumps,” he remarked that “the modern medical student, and most physicians, have been so far removed from physical diagnosis, that they simply do not accept that a mass is a mass is a mass unless the CT scan or ultrasound tells them it is there.”
Verghese and Silen get no argument from me on the clinical limitations and human failings associated with technology-driven medicine. But these concerns are hardly unique to an era of CT scans and MRIs. There is a long history of concern about overreliance on new technologies; Silen has a delightfully pithy, unpublished piece on the topic that is simply titled, “New Toys.”
One limitation of such critiques is the failure to recognize that all “toys” are not created equal. Some new toys become old toys, at which point they cease being toys altogether and simply become part of the armamentarium that the physician brings to the task of physical examination and diagnosis. For example, we have long since stopped thinking of x-ray units, EKG machines, blood pressure meters (i.e., sphygmomanometers), and stethoscopes as “new toys” that militate against the acquisition of hands-on clinical skill.
But it was not always so. When x-rays became available in 1896, clinical surgeons were aghast. What kind of images were these? Surely not photographic images in the reliably objectivistic late-nineteenth century sense of the term. The images were wavy, blurry, and imprecise, vulnerable to changes in the relative location of the camera, the x-ray tube, and the object under investigation. That such monstrously opaque images might count as illustrative evidence in courts of law, that they might actually be turned against the surgeon and his “expert opinion” – what was the world coming to? Military surgeons quickly saw the usefulness of x-rays for locating bullets and shrapnel, but their civilian colleagues remained suspicious of the new technology for a decade or more after its invention. No fools, they resorted to x-rays only when they felt threatened by malpractice suits.
Well before the unsettling advent of x-ray photography, post-Civil War physician-educators were greatly concerned about the use of mechanical pulse-reading instruments. These ingenious devices, so they held, would discourage young physicians from learning to appreciate the subtle diagnostic indicators embedded in the pulse. And absent such appreciation, which came only from prolonged training of their fingertips, they could never acquire the diagnostic acumen of their seniors, much less the great pulse readers of the day.
Thus they cautioned students and young colleagues to avoid the instruments. It was only through “the habit of discriminating pulses instinctively” that the physician acquired “valuable truths . . . which he can apply to practice.” So inveighed the pioneering British physiologist John Burdon-Sanderson in 1867. His judgment was shared by a generation of senior British and American clinicians for whom the trained finger remained a more reliable measure of radial pulse than the sphygmograph’s arcane tracings. In The Pulse, his manual of 1890, William Broadbent cautioned his readers to avoid the sphygmograph, since interpretation of its tracings could “twist facts in the desired direction.” Physicians should “eschew instrumental aids and educate the finger,” echoed Graham Steell in The Use of the Sphygmograph in Medicine at the century’s close.
Lower still on the totem pole of medical technology, indeed about as low down as one can get – is the stethoscope, “invented” by René Laennec in 1816 and first employed by him in the wards of Paris’s Hôpital Necker (see sidebar). In 1898, James Mackenzie, the founder of modern cardiology, relied on the stethoscope, used in conjunction with his own refinement of the Dudgeon sphygmograph of 1881 (i.e., the Mackenzie polygraph of 1892), to identify what we now term atrial fibrillation. In the years to follow, Mackenzie, a master of instrumentation, became the principal exponent of what historians refer to as the “new cardiology.” His “New Methods of Studying Affections of the Heart,” a series of articles published in the British Medical Journal in 1905, signaled a revolution in understanding cardiac function. “No man,” remarked his first biographer, R. McNair Wilson, in 1926, “ever used a stethoscope with a higher degree of expertness.” And yet this same Mackenzie lambasted the stethoscope as the instrument that had “not only for one hundred years hampered the progress of knowledge of heart affections, but had done more harm than good, in that many people had had the tenor of their lives altered, had been forbidden to undertake duties for which they were perfectly competent, and had been subject to unnecessary treatment because of its findings’.”
Why did Mackenzie come to feel this way? The problem with the stethoscope was that the auscultatory sounds it “discovered,” while diagnostically illuminating, could cloud clinical judgment and lead to unnecessary treatments, including draconian restrictions of lifestyle. For Mackenzie, sphygmomanometers were essentially educational aids that would corroborate what medical students were learning to discern through their senses. And, of course, he allowed for the importance of such gadgetry in research. His final refinment of pulse-reading instrumentation, the ink jet polygraph of 1902 (see sidebar), was just such a tool. But it was never intended for generalists, whose education of the senses was expected to be adequate to the meaning of heart sounds. Nor was Mackenzie a fan of the EKG, when it found its way into hospitals after 1905. He perceived it as yet another “new toy” that provided no more diagnostic information than the stethoscope and ink jet polygraph. And for at least the first 15 years of the machine’s use, he was right.
Now, of course, the stethoscope, the sphygmomanometer, and, for adults of a certain age, the EKG machine are integral to the devalued art of physical examination. Critics who bemoan the overuse of CT scans and MRIs, of echocardiography and angiography, would be happy indeed if medical students and residents spent more time examining patients and learning all that can be learned from stethoscopes, blood pressure monitoring, and baseline EKGs. But more than a century ago these instrumental prerequisites of physical examination and diagnosis were themselves new toys, and educators were wary of what medical students would lose by relying on them at the expense of educating their senses. Now educators worry about what students lose by not relying on them.
Toys aside, I too hope that those elements of physical diagnosis that fall back on one tool of exquisite sensitivity – the human hand – will not be lost among reams of lab results and diagnostic studies. One shudders at the thought of a clinical medicine utterly bereft of the laying on of hands, which is not only an instrument of diagnosis but also an amplifier of therapy. The great pulse readers of the late nineteenth century are long gone and of interest only to a handful of medical historians. Will the same be true, a century hence, of the great palpators of the late twentieth?
 I worked as Dr. Silen’s editor in 2000-2001, during which time I was privileged to read his unpublished lectures, addresses, and general-interest medical essays as preparation for helping him organize his memoirs. Sadly, the memoirs project never materialized.
 In this paragraph, I am guided especially by two exemplary studies, Christopher Lawrence, “Incommunicable Knowledge: Science, Technology and the Clinical Art in Britain, 1850-1914,” J. Contemp. Hist., 20:503-520, 1985 and Hughes Evans, “Losing Touch: The Controversy Over the Introduction of Blood Pressure Instruments in Medicine, “ Tech. Cult., 34:784-807, 1993. Broadbent and Steell are quoted from Lawrence, p. 516.
 R. McNair Wilson, The Beloved Physician: Sir James Mackenzie (New York: Macmillan, 1926), pp. 103-104. A more recent, detailed account of Mackenzie’s life and career is Alex Mair, Sir James Mackenzie, M.D., 1853-1925 – General Practitioner (London: Royal College of General Practitioners, 1986).
Copyright © 2012 by Paul E. Stepansky. All rights reserved.
I stumbled upon your piece googling Dr. Silen. I was privileged to be part of his 8 student anatomy discussion group in my first class at HMS in 1997. As was our routine we had group discussions about a case of a middle aged person coming to the hospital for abdominal pain. At some point in our discussions I naively blurted out something like ‘why can’t we just get an ultrasound to see’ and was subsequently lambasted by Dr. Silen in regards to junior medical students and our reliance on these newfangled tests or toys. Now 15 years later I perform ultrasounds multiple times daily during my shifts as an attending ER physician… I only wish I had an ultrasound dongle I could plug into my iPad. 😉