Nicholas Pimlott is an academic family physician at Women’s College Hospital and the Department of Family and Community Medicine at the University of Toronto. He is also the scientific editor of Canadian Family Physician.
When our middle son, Douglas, was in Cubs many years ago now, I was asked by his “Akela” to come and talk to the “pack” about my work as a doctor. This was for one of their career night sessions. I was intimidated by the thought of keeping a group of a dozen or so hyperactive eight-year-old boys entertained for 20 minutes. In what I thought was a stroke of genius, I decided to talk to them about the importance of the five senses in the work that doctors do.
I began by talking about the use of sight – all the things that we can see about a person and their state of health, to paraphrase Yogi Berra, just by looking. Moving from sight to hearing and the invention and use of the stethoscope, to touch, and smell, I ended with my master stroke – how medieval doctors used to taste the patient’s urine to make a diagnosis. And just to ensure the desired effect, I pulled an orange-topped plastic urine sample bottle filled with apple juice from my black doctor’s bag and proceeded to taste it. This had the desired effect, as laughter and cries of “Gross!” and “Disgusting!” filled the tiny church basement gymnasium, and I brought the house down. In a long medical career, I have probably never given a more well received presentation.
I’m a family doctor who teaches medical students and family practice residents. Over the pandemic, I have come to see how students’ inability to use their five senses in the practice of learning and mastering skills has seriously affected the development of clinical expertise. The use of our senses in examining patients is an indispensable extension of our clinical mind.
This notion of the physical senses being an extension of the human mind – a phenomenon called “embodied perception” or “embodied cognition” – has an academic theory and extensive literature behind it. In his brilliant 2015 book The World Beyond Your Head: Becoming an Individual in the Age of Distraction writer, philosopher, motorcycle mechanic and repair shop owner Matthew B. Crawford presents several case studies in human embodied perception, from short order cooks to pipe organ makers to elite professional hockey players.
In his chapter explaining embodied perception, he begins by describing the time a camera caught Pittsburgh Penguins centre Tyler Kennedy licking his hockey stick after a shift against the Florida Panthers. Mr. Crawfordrecognized the gesture as more than some strange and offputting ritual, but as an expression of the bond that athletes form with their equipment. The bond between a hockey player and their stick might be the most intimate, he argued. He further cites as evidence an article by sportswriter David Fleming called To Each His Own describing the bond between Washington Capitals player Alex Ovechkin and his stick during the 2007-08 season in which he led the league in scoring. Beyond passing and shooting, Mr. Ovechkin would use his stick:
“… as a crutch to get up after big hits. He wields it high and with two hands, like a nightstick, in scrums in front of the net. … He taps it against the boards to applaud a teammate after a fight or against the goaltender’s shinpads after a good save. He uses his stick to open and close the bench door. To calm his nerves, late in games, Ovechkin will sit on the boards with his back to the ice and his stick in his lap, like a baby blanket, and lovingly retape the blade.”
Perhaps the closest parallel in medicine between the practitioner and their equipment might be our relationship with our stethoscopes, though I have never licked my stethoscope (and, happily, have never witnessed a colleague doing so either). But these days most physicians while working wear their stethoscopes draped intimately around their necks and feel naked without it.
Unlike when I was a medical student in the late 1980s and stethoscopes, like the original Model T cars, came in one colour (black), they now come in a wide variety of colours, and the neckpieces and bell, which traditionally have been silver, are now also available in gold and flat black, allowing almost for customization and individual expression through this long-used tool. And just like hockey players have their names embossed on their sticks, so too can doctors have their names engraved on their stethoscopes.
Although my relationship with my stethoscope might not be as multifaceted as Mr. Ovechkin’s relationship with his hockey stick, in addition to the conventional uses to auscultate (a fancy medical word for “listen to”), for example, the lungs of a person with suspected pneumonia, or the heart of a patient in failure, I have used it, in a pinch, as an improvised reflex hammer, and when examining a hard-of-hearing patient unable to afford, or unwilling to wear, hearing aids, have placed it in their ears while speaking into the bell, a trick I learned from a skilled geriatrician during my internship.
In Mr. Crawford’s book, he quotes philosopher Michael Polanyi analyzing the moment when a person achieves competence with a probe such as a hockey stick or a stethoscope, “… and in doing so found that he had to use ‘attend’ in a new formulation: you are now ‘attending from’ the sensations in your hand [or ears, in the case of the stethoscope] to the objects at the probe’s tip; the sensations themselves you are only ‘subsidiarily aware of.’ In this way ‘an interpretive effort transposes meaningless feelings into meaningful ones, and places these at some distance from the original ones. We become aware of the feelings in our hands [or sounds in our ears] in terms of their meaning, to which we are attending.’”
Mr. Crawford has described this as the “mutual entanglement of action and perception.” During the pandemic, opportunities for young physicians learning their craft to discover this mutual entanglement of action and perception, which is so vital in becoming a skilled physician, have been markedly limited and come at a premium.
Throughout 2020 and at times during 2021, there were limited opportunities for undergraduate medical students to examine real patients in the courses where they would normally begin to learn these essential skills. Likewise, in our family practice clinics, there have been at times almost no opportunities for residents to build on examination skills learned during their undergraduate training.
How have we compensated for this? In my own teaching I have relied on two different but related approaches. The first is slow, deliberate practice and the second is visualization. Both treat opportunities to examine patients as a precious resource and a shift away from a teaching culture in which volume has been seen as the sine qua non of gaining sufficient clinical experience.
In the spring of 2021, a 75-year-old woman came to see me for a persistent cough. She arrived during a clinic in which I had been assigned to teach a third-year medical student. She was the only in-person visit on a list of otherwise virtual telephone visits. How to make the most of this limited opportunity for the student to perform a physical examination?
I sent the student in to see the patient, advising her to spend as much time as she needed to take a thorough history and physical examination. About 20 minutes later the student came out to review the patient with me, which seemed a surprisingly efficient use of time for a learner at that stage of training. After presenting the history I asked her:
“What did you find on examination? What do you think is the diagnosis?
“I didn’t examine the patient, Dr. Pimlott. I wasn’t sure what to do or what to look for. I am not sure what is normal and what is abnormal. I’m not sure of the diagnosis,” she replied.
What to do in such a situation?
It was the perfect opportunity to engage in a practice that music teachers have known for years. Teaching slowly and deliberately, with immediate feedback and correction of technique, is a highly effective tool for acquiring complex skills. This idea can be summed up in the aphorism “Practice does not make perfect. Perfect practice makes perfect.”
Slow and deliberate practice in examining a patient with possible pneumonia requires a series of steps that include looking, listening and then feeling by percussion over the chest. First, making sure that the patient is properly undressed and wearing a gown, we look carefully to see if they are having any difficulty breathing at rest, when speaking and when moving to the examination table. We count the numbers of breaths in a minute and observe whether they are using accessory muscles of the neck to assist them in breathing. Listening means both with and without the stethoscope – often the sound of wheezing in an ill asthmatic patient, for example, can be heard without using the stethoscope, typically a sign of more severe illness. Using the stethoscope requires the systematic application first of the diaphragm (to hear higher pitched sounds, such as wheezing) and the bell (to hear lower-pitched or coarse breath sounds, like the ones audible with some forms of pneumonia) across the entire back and front of the chest, being careful not to miss the “cupolas,” those areas of lung above the collarbones.
At first the student seemed awkward and uncomfortable going through this process, especially in front of the patient, but normalizing this method of teaching as well as acknowledging that even experienced physicians like me occasionally need a refresher to tidy up bad habits, can make help make this a safe and constructive exercise.
This past winter, as the Omicron variant caused a fourth wave, opportunities for learners to examine patients in person became scarce once again. In a teaching clinic in February, all patients were virtual, with one older male in his late 70s calling in with a six-month history of worsening knee pain. I asked my third-year student, “Have you examined knees before?”
He replied that he had not, but he and his classmates had watched a video of someone doing a knee exam. There is value in watching another clinician perform a physical examination. But the act of watching someone else perform a physical examination compared with the act of carrying it out yourself is akin to watching a sex-ed video and thinking you know how to make love.
The student called the patient, taking a thorough and careful history. When asked for potential diagnoses, the student was able to generate a very short list, mainly based on what might be most common in an older man.
I then drew a knee on a piece of paper, highlighting all the relevant bony, cartilaginous and soft-tissue structures.
This diagram was the basis for an exercise in together visualizing performing the examination – look, move (first actively, then passively with assistance from the examiner) and, lastly, feel the various structures, looking for warmth and fluid in the joint, tenderness along the joint lines and in any of the soft tissues, and stability or laxity of any of the ligaments that hold the entire structure together.
Through this exercise, we could also imagine what the physical examination findings might be in an older man with such long-standing knee pain – he may have a limp, and/or atrophy of the muscles above and below the knee from impaired use, and/or laxity of the collateral ligaments from degeneration of the cartilaginous cushions of the menisci seen in osteoarthritis, the most common cause of knee pain in older patients. In this way, the connection between the exam findings and the likely diagnosis can be clearly linked.
Drawing for teaching purposes is a habit I acquired beginning in first year in medical school. It was a way for me to memorize anatomical structures but using a printed a picture of the knee with all its structures or using a plastic model is every bit as effective.
One of the most famous studies on the effectiveness of visualization comes from a 1950s study by Dr. Judd Biassoto and his colleagues from the University of Chicago. In it, the researchers randomized college students into three experimental groups. First, the ability of all three groups to take basketball free throws was measured. Following this baseline assessment, one group went to the gym to practise their free-throw skills, the second group used visualization as practice and the third group did nothing. When tested in the gym later the first two groups had improved in their shooting accuracy substantially, and about equally. Not surprisingly, the third group did not improve at all. I learned this trick of visualization from a clinical teacher more than 30 years ago and have been using it ever since.
One thing that has been clear to me as a clinical teacher during the pandemic is that whether due to lack of opportunity to examine patients or due to lack of skill in interpreting examination findings when those opportunities have arisen, learners are having trouble developing reasonable or even rudimentary diagnoses without those physical examination findings. In medicine there is an old saying – “the history gets you 70 per cent towards a diagnosis, the physical exam adds 20 per cent and laboratory tests the rest of the way.” But, in my view, teaching in the pandemic has revealed that the physical examination and its findings are much more integral to clinical reasoning. Or, as Matthew Crawford puts it: “… when you go deep into some particular skill or art, it trains your powers of concentration and perception. You become more discerning about the objects you are dealing with and, if all goes well begin to care viscerally about quality, because you have been initiated into an ethic of caring about what you are doing.”
The pandemic has forced physicians to be creative and adapt in unexpected ways, whether in looking after our patients, or in teaching our students. Using forgotten tools, such as visualization or borrowing from other expert teachers the concept of deliberate practice, has allowed us to help learners attain the essential clinical skill of embodied perception. This will stand us in good stead as we continue to train tomorrow’s doctors as this pandemic still unfolds, and in future pandemics certain to come.
Keep your Opinions sharp and informed. Get the Opinion newsletter. Sign up today.