“What's Your Diagnosis?” at 17: Reflections on the Joy of Physical Diagnosis

Seventeen years ago, "What's Your Diagnosis?" was launched as a monthly service in CONSULTANT. The feature was developed with Dr Schneiderman to emphasize the skills involved in physical diagnosis-a field in which he is a nationally recognized authority.

Dr Schneiderman has coauthored a full-length textbook¹ and a handbook² of physical diagnosis, and is first author of an online bibliography of physical diagnosis. ³ He has also served as visiting professor and conducted bedside teaching rounds at universities and hospitals throughout the United States. At Hebrew Health Care in West Hartford, Conn, where he is vice-president of medical services and physician- in-chief, Dr Schneiderman continues to teach medical staff daily as well as to lead the clinical care of frail elderly patients with complex medical problems.

In recognition of his commitment to excellence in medical care, education, and research, and in service to the community and the medical profession, Dr Schneiderman was recently named Laureate of the Connecticut Chapter of the American College of Physicians.
-The Editors

I have kept writing monthly columns on physical diagnosis for all these 17 years principally because this work, and the habits of mind and behavior that it encourages, afford joy in the exercise and growth of my skills as a diagnostician and a teacher.

In my second year at Tufts Medical School, weary of basic science- not seeing how it related to clinical work as I have since learned-I found in the course in physical diagnosis affirmation of what I wanted to possess and to utilize, and how I wished to spend my time in the practice of medicine. I determined to become skilled at bedside evaluation. To that point I had not been distinguished in my medical student performance by any stretch of the imagination. Success breeds further effort. Two years of pathology residency included teaching physical diagnosis, and of course teaching always makes one a better learner. I also gained experience at autopsy that enhanced my understanding of physical signs.4 Upon return to internal medicine residency equipped with stronger understanding of pathologic anatomy and pathophysiology, I began to be complimented on some of my physicals.

The focus on physical diagnosis in the 28 years since then amounts to seeking further atolls of knowledge and skill in the ocean of my ignorance.⁵ Delight came when I would find that my interview, my examination, brought something new to the care of a patient who had already seen 10 consultants-and it need not have been a new diagnosis, it could also be a clearer sense of the interconnections between multiple problems, or of the gravity (or mildness) of an extant diagnosis. Any such realization bolstered the wish to expend more than the minimal effort on each bedside encounter. So did the feeling of connection and of achieving trust and confidence from patient and family.

A reputation as "that guy who knows all those physical findings" has provided a niche and has accorded with a self-image as a capable general internist with a broad and deep base of knowledge, and equally, a quirky individualist who swims upstream. Yet, to practice sound medicine, and incidentally to avoid becoming a caricature, one labors to learn as much therapeutics as diagnostics, and to utilize technology wisely and soundly. The taint of being antiquarian and of disliking technology instantly discredits: our capabilities have been extended in extraordinary ways.

Being a teacher and a practitioner of medicine, now at the start of my fourth decade with an MD degree, remains an immense privilege that carries responsibility not only to the individual patient but to the profession and its future. Acting on this, both locally in my own institutions, and through publication, offers a powerful counterweight to all the things that primary care clinicians rightly loathe: the intrusion of governmental and insurance bodies between doctor and patient, the often-hostile external oversight whereby our goodwill and competence are no longer assumed in the ways we believe we have earned, and the unending drain of paperwork of every description.

A dear friend long ago described a surgeon he admired as singing while he operated, and then paid me the compliment of saying he thought I was the counterpart in internal medicine. I submit that the gratification and immediacy and human connection in physical diagnosis, and the forum with which to share my knowledge of it, are intrinsic to the happiness in the daily exercise of my calling. The empowerment and communication of that pleasure is a central if implicit message of the columns.

References:

REFERENCES:1. Willms JL, Schneiderman H, Algranati PS. PhysicalDiagnosis: Bedside Evaluation of Diagnosis andFunction. Baltimore: Williams & Wilkins; 1994.
2. Willms JL, Schneiderman H. Pocket Guide to PhysicalDiagnosis. Baltimore: Williams & Wilkins; 1996.
3. Schneiderman H, Peixoto AJ. Bedside Diagnosis:An Annotated Bibliography of Literature on PhysicalExamination and Interviewing. 3rd ed. Philadelphia:American College of Physicians; 1997. Available at:http://www.acponline.org/public/bedside.Accessed November 16, 2006.
4. Schneiderman H. The morgue: a neglectedclassroom for physical diagnosis. Conn Med. 1983;47:8-12.
5. Schneiderman H. "What's Your Diagnosis?"at age 5: still learning together. Consultant. 1994;34:1231.