By Paul Goldfinger, MD, FACC.  Editor @Blogfinger.net.

In a NY Times piece recently a young physician argued that experience in medicine is overrated and that smart young physicians, armed with technology, can do a better job in diagnosis and treatment than silver haired professors steeped in Hippocratic values.

In 2016, I posted a piece called “The Case of the Hypokalemic High Jumper.”  (link below)  It was a difficult situation where all the technology available could not produce a diagnosis, but a careful history taken at the bedside by a physician was all that was necessary.

The case of the hypokalemic high jumper

In the New Yorker cartoon above, an alert doctor took a good look and made the diagnosis.

In medical school, in the second year, we all took a course called “Physical Diagnosis.”  It taught us how to take a proper history—very detailed, but customized to suit the needs of an individual patient.  We also learned how to conduct a sensitive physical examination—how to feel a spleen, palpate a liver and listen to the heart and lungs—in fact how to accurately assess the whole body.  We were taught that such skills  have been used by physicians going  back to the Greeks  and that we could learn so much using those basic tools.

During my cardiology residency, we were trained to be meticulous in auscultating the heart  (ie listening with a stethoscope.) We used stethoscopes with 3 heads to help sort it all out.  We made recordings of heart sounds where we could measure intervals down to fractions of a second in order to figure out how narrow a heart valve might be.  It was a source of great pride to be able to use just our ears and minds to determine if someone needed heart surgery or not and then to help a medical student who couldn’t appreciate the subtleties of the cardiac examination.

But now, I am afraid that doctors are becoming too complacent in using technology to replace the traditional tools. These skills are still helpful in assembling all the pieces of a puzzle and then following the progress of the patient at the bedside or long term in the office.  I see doctors doing a poor job in taking a history, a process which has been replaced in large part by computer check lists.  Garbage in, garbage out.  And the same concern exists for the physical examination.

I was present when a patient went to a local ER with a painful, swollen knee. The Physician Assistant took a cursory history  (he had no idea that a real doctor was observing) and ordered an X Ray.  He did not properly examine the knee.   And he never bothered to review the patient’s medication list. He was functioning like a robot via an algorithm.  If he had done a proper history, he would have learned that the patient was on a blood thinner and might have a hemarthrosis  (bleeding into the knee.)  The problem was diagnosed with a proper history and physical exam by a careful physician and corrected by aspirating the joint with a needle and adjusting the medication.

Yes, the new technologies are remarkable, but each patient is different, and the physician must use all the tools available at his disposal including his eyes, head, ears and hands.  And, experience is perhaps the best tool of all.

RUFUS WAINWRIGHT   “Heartburn.”   This is a peculiar song, but it makes the point that doctors need to remember that psychological factors can mimic heart burn or something much more serious—like a derailed roller coaster.  A doctor must take a good history to pick up on this situation.

“Is this heartbreak or is this heartburn?
Can I be spared from being so dramatic?
Gotta learn the difference when I love ya
The difference when I love ya and that derailed roller-coaster”