By Dr. Anonymous. So true. Doctors dislike the uncertainty of trying to put together the pieces from a patients history and the old fashioned physical exam. I was talking to a colleague about this issue last night. It was lamentable the way that emergency medicine had fallen to the state of ordering a whole series of tests, including CT scan, before the doc even saw the patient. Then the doc would go in and see the patient armed with the concrete and certain results of the tests. In this article a doc describes all the tests the doctor got looking at the wrong part of the body. The ultimate problem was a disc in the neck. But note that the patient did not have any pain, his only complaint was numbness in the arm. In the old days, we docs were trained to think about the problem starting at the site of the complaint and then working toward the rest of the body. Simple anatomy: Arm numbness > local nerves > Brachial plexus in area between neck and arm > neck > spinal cord > brain stem > brain. And we were taught to think about problems that affect either the nerves and/or the blood supply to the nerves. It is obvious from this report that two neurologists had become so entrapped by the technologic wonders of the diagnostic realm that he/she lost site of the underlying patient complaints, and the underlying pathophysiology! The problem is amplified for people with back or neck problems. I dare say, it is a rare doctor who even thinks about laying his hands on the patients back, poking and pushing to try to elicit the source location of the pain. They will NEVER see the muscle spasm, the swollen soft tissues, the skin discoloration, the reflex withdrawal of a single spinous process as compression from the examiners thumb triggers focal muscle spasm. The docs do cursory reflex testing, never getting the legs or arms to fully relax so they never see the hyperactive reflexes that are so characteristic of those in pain. They never see, or worse, totally disreagard the abnormal crossed adductor reflex that so often accompanies chronic pain. (The crossed adductor reflex involves the knee reflex. Normally the hammer stretches the tendon below the knee and this stretch triggers a reflex contraction of the quadriceps muscle in the thigh, tending to straighten the leg. In the crossed adductor reflex the contraction of thw quadriceps musle on the same side of the hammer tap triggers a simultaneous contraction of the adductor muscle in the opposite leg. For example, testing the knee reflex on the right leg will produce a simultaneous reflex that extends the right knee and also pulls the LEFT leg over toward the right leg. The best way to see this reflex is to test the reflexes while the patient is sitting with the feet flat on the floor and the knees slightly extended, that is with the feet about a foot in front of the knee. Back to the jist of the linked article, doctors today are too enamored with established technology and resistant to both old fashioned physical exam AND newer technology that can shed new light. The problem is that old fashioned physical exam and new technology require a lot of thought as to how they are integrated to cause the problem. Too often the docs of today want a simple visual picture that they can point to and say that is the problem......too many still dont seem to know what to do when all their pictures are normal. As too many pain patients know, the worst step occurs when the docs, and the insurance companies, turn around and blame the patient for making it up or faking it. In medical terms they say it is psychogenic when it is most often a matter of inadequate knowledge of the doctor. psmag/navigation/health-and-behavior/decline-physical-exam-modern-medicine-84906/
Posted on: Tue, 08 Jul 2014 14:03:40 +0000
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