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.
My stethoscope has lain idle on my desk for the past 12 weeks. It is my third stethoscope since I was a second-year medical student at the University of Toronto first entering the wards. I reckon that in a 28-year career as a family doctor I have used my stethoscope more than 150,000 times to examine patients. I miss using it and I wonder when I will get to use it again.
When the World Health Organization declared a global pandemic of the SARS-Cov-2 (COVID-19) on March 11, tens of thousands of family doctors around the world like me did what had previously been unthinkable. In a matter of days, we switched from caring for our patients with in-person, face-to-face visits to providing what is called “virtual care” – everything from e-mailed pictures of rashes and moles to telephone visits and video visits using Zoom.
And zoom, just like that, we were shown to have been the Luddites, stubbornly resisting the use of technology, that our progressive colleagues had long accused us of being. For almost a generation before the pandemic, one part of the face-to-face clinical encounter had already been under siege – the physical exam. Now, in a single blow, the value of face-to-face care, period, was shown to be wanting. Many now see the pandemic as ushering in a brave new world of mainly virtual medical care. I am not one of them.
The debate between the respective strengths and limitations of both virtual and face-to-face care in medicine and which of the two will prevail in future practice reminds me of a great debate that took place more than a century ago in a pastime I took up during the first pandemic of my career.
I began fly-fishing during my clerkship (the final year of medical school spent on the wards) and internship at the old Toronto General Hospital. It was the first of the four pandemics of my medical career – the AIDS crisis – and a time of profound suffering, discrimination and loss. During my internal medicine rotations, most of the patients I looked after were young gay men, many close to my own age. Most were gravely ill and some in my care died. It went against the natural order of things and was hard to understand. Among the many that we cared for, one stands out even after all these years – a 27-year-old man who, like me, had come to Toronto from the prairies to find himself. He died in the company of his partner without his family back home knowing that he was gay, nor that he had AIDS.
Sadly, these experiences were never really discussed either by the senior residents who led our team or the staff physicians who provided overall oversight (the Most Responsible Physician or MRP for each patient’s care). If a patient died in our care – usually due to an opportunistic infection or aggressive cancer – it was on to the next admission without glancing back. At the time I did not think this was strange or problematic, but many years later, looking back, I realized that it was learning to fish with the fly that helped me cope with the strangeness, the loss and the grief. Back then I called it my indoor-outdoor life, and I have been living it ever since.
The allure of fly-fishing back then was helped by the release in 1992 of what among long-time fly-fishers was derisively called “the movie” – A River Runs Through It, based on the Norman Maclean novella. The film was directed by Robert Redford and starred a very young, handsome Redford-type actor named Brad Pitt. It is a coming of age story of two brothers. The relationship between the serious, bookish older brother Norman, played by Craig Sheffer, and the handsome, risk-taking younger brother Paul, played by Mr. Pitt, had echoes of my own relationship with my younger brother Iain in more ways than one. Although we grew up lure and bait-fishing on Winnipeg’s Red River, he was always the better, more successful fisherman.
Over the past 30 years I have gained in experience, skill and, I hope, some degree of mastery as a family physician, but lacking time and opportunity in a busy academic career and family life, I have failed to master the art of fly fishing. But by studying the art and science of the sport, I have come to see the many parallels between it and the practice of medicine. Catching a fish is like making a diagnosis – the skilled fly-fisher must have consummate skills in “history taking” (reading the water, understanding when the seasonal mayfly hatches are on and fish are feeding on them) and “physical examination” (powers of observation as to where fish lie, fly casting skills, and hooking, playing, landing and releasing the fish with care).
Toward the end of the 19th century, a similar schism between purists and progressives occurred in the small, tweedy world of English fly-fishing. On the one side – the traditionalists or purists – stood F. M. Halford. Born Frederic Michael Hyam in 1844 in Birmingham, England, he was part of a wealthy Jewish family who were manufacturers of textiles and clothing in Birmingham, Leeds and Manchester (and who, in 1875, changed their name to Halford). F. M. Halford was what is called a dry fly purist – a fisherman whose only quarry was the wily brown trout of the English chalk streams and whose method was to meticulously “match the hatch” with a dry or floating fly that imitates the natural mayfly hatches.
In Royal Coachman, American fly-fishing historian Paul Schullery described “a highly formalized code of how a dry fly should be fished, a code further developed and popularized later in the 19th century by one of fly fishing’s most eminent authors, Frederic Halford, whose first book, Floating Flies and How to Dress Them, was published in 1886 and took the upper-crust world of British fly-fishing by storm.”
There is no doubt in my mind that if Halford were alive today, and a physician, he would bemoan the loss of traditional clinical skills, especially physical exam skills and the multitudinous and arcane signs and bodily findings that are the bellwethers of disease.
On the other side of the debate between traditionalism versus progress in the sport stood G. E. M. Skues. George Edward MacKenzie Skues was a British lawyer, writer and fly-fisherman recognized as the inventor of modern nymph fishing (underwater fly-fishing where fish feed 90 per cent of the time on the larval form of the mayfly and other aquatic insects known as nymphs). Skues, born in 1858, was the author of two modestly titled books that turned fly-fishing upside down – 1910′s Minor Tactics of the Chalk Stream and 1921′s The Way of a Trout with a Fly.
British fly-fishing historian Andrew Herd wrote of Skues that he was “without any doubt, one of the greatest trout fishermen that ever lived. His achievement was the invention of fly-fishing with the nymph, a discovery that put a full stop to half a century of stagnation in fly-fishing for trout, and formed the bedrock for modern sunk fly-fishing. Skues’s achievement was not without controversy, and provoked what was perhaps the most bitter dispute in fly-fishing history.”
In the current debate over the value of virtual care versus the traditional face-to-face visit complete with physical exam, on the side of virtual care would be Skues, if he were a physician.
Progressive thinkers in health care have legitimately criticized the problems of face-to-face care. It is time consuming, especially for patients who must travel from work or home to the doctor’s office. It is also resource-intensive, expensive, bad for the environment and especially hard on vulnerable people, including those with chronic illness affecting their mobility, people with disabilities, those living in rural and remote communities, and Indigenous peoples, especially those living in remote communities.
One of the key arguments of traditionalists has been the importance of the physical exam. Over the past three decades, I have observed a steady decline in the importance of this fundamental craft. It is hard to pinpoint the beginning of this decline, but for most family physicians it probably began with the periodic health exam, known to most people as the annual check-up. In the 1970s, the check-up was a ritual of care for which there was not much evidence of benefit either to any individual patient or on a population basis. In the late 1970s the Canadian Task Force on the Periodic Health Examination was struck, with the purpose of systematically evaluating the evidence of benefit of various aspects of the check-up. Much of what family physicians were doing was found to have little benefit, and in some cases was harmful. As a screening test – other than checking blood pressure, height and weight, unless patients have particular symptoms – the physical exam has been sidelined. But most patients still expect their family doctor to examine them during their check-up.
Even when patients present to their doctor with symptoms, there are two camps when it comes to the exam. In the first are those who long for the old days and bemoan the loss of bedside clinical exam skills. In the second are those who say good riddance and point out that evidence-based studies show that most physical exam signs are useless. Some even argue that examining the patient is a waste of time. Those in the latter camp may not welcome the pandemic, but they might be pleased that the rapid shift to virtual care provides further evidence that the physical exam is of limited value.
Few have spoken or written so clearly or passionately about the enduring value of the bedside physical exam as Stanford internist and writer Abraham Verghese. His TED talk called “A Doctor’s Touch” has 300,000 views on YouTube. He and his colleagues at Stanford University Medical School have even created a website with a series of videos demonstrating the essential physical examination skills a doctor needs, called The Stanford 25, and they host an annual conference to promote these skills.
In making the case for the physical exam, Dr. Verghese has mainly focused on two aspects – its continued utility and its importance as ritual. His utilitarian arguments have centred on the evidence that skilled examiners make better use of tests, that many physical signs cannot be discerned by any imaging tests, and that the physical exam is useful in settings where access to laboratory tests or diagnostic imaging is limited or non-existent. In his TED talk and his writing, he has beautifully articulated that the physical exam is a vital ritual – that rituals are about transformation, and the formation of the doctor-patient bond.
In addition to its practical value and its importance as part of the ritual of care, there is an aspect of face-to-face care and, in particular, the physical exam that is implied rather than explicitly stated by Dr. Verghese and his colleagues, yet of profound importance to both the physician and the patient – craftsmanship.
There is a marvellous scene in A River Runs Through It in which Mr. Pitt’s character, Paul, breaks free of his father’s old-fashioned casting technique and finds his own rhythm – false casting the fly over and over, creating a man-made reproduction of a mayfly hatch – a scene and expression of the physical grace and beauty of fly-fishing that may have sealed the deal for a generation of new fly-fishers who saw the film.
My third-year tutor in internal medicine at Toronto Western Hospital, legendary internist Herbert Ho Ping Kong, taught us about examining patients with style. At the time I had not the vaguest idea of what he meant, but now, after so many years in practice, I think I understand. Inherent in the idea of style is a kinesthetic sense of pleasure in examining a patient with grace and efficiency, providing the physician with a sense of true craftsmanship and mastery of their art and inspiring in the patient an intangible sense of confidence that they are in the hands of a skilled clinician. It may not be as graceful as false casting on a wild and beautiful Montana river, but after so many years of practice, there is pleasure in it.
As an example, low back pain is one of the most common problems that family doctors like me see, and most of it is self-limiting. Under such circumstances it is easy over the years to get sloppy and cut corners, especially with the physical exam, since we rarely find evidence of a more serious underlying problem. My routine has been to lean into the assessment of back pain, especially the exam. The first step is to leave the room and ask the patient to undress and put on a gown. When I return, the exam begins with visual inspection of the person, then the back. Next, still standing, assessing the range of movements and any limitations. Then, moving beside the examination table, assessing strength; moving next onto the table to examine leg raising, the reflexes; and ending with the patient getting dressed after I leave the room. It is a series of smooth, efficient and harmonious movements that wastes no energy and signals that the physician knows what they are doing. But it is not a mere matter of aesthetics – when patients are sick, weak or in pain, an artful exam minimizes suffering while maximizing information.
The final aspect of the face-to-face care and the physical exam that is crucial, but rarely if ever expressed, is connoisseurship, which has been so well articulated by philosopher Michael Polanyi. In his book Personal Knowledge, he wrote:
“Connoisseurship, like skill, can be communicated only by example, not precept. To become an expert wine taster, to acquire a knowledge of innumerable different blends of tea or to be trained as a medical diagnostician, you must go through a long course of experience under the guidance of a master.”
In clinical practice, connoisseurship comes with years of practise and knowing one’s patients.
A few years ago, a 65-year-old man who has been in my practice for many years came in on a Tuesday morning for his check-up. As I moved from one exam room to another, I saw him out of the corner of my eye, sitting in the waiting room.
“He doesn’t quite look himself today,” I quietly noted to myself.
This was a man who did not drink or smoke, who walked and swam regularly and whose only family history was of an older brother diagnosed in his 60s with prostate cancer.
When I eventually called him to come to the exam room, I watched him closely as he made his way. Nothing seemed out of the ordinary. Close questioning before eventually I invited him to change into a gown revealed nothing overt.
“I’m a little more tired lately, but then again, I haven’t been exercising as much as I usually do,” he said as I probed a little more.
When I went back into the room to examine him I carefully checked his skin for signs of pallor or jaundice, gradually making my way down from the head and neck examination to check his lungs, his heart, then his abdomen, where I found what I was sure was the cause of the problem. As I moved from inspection to percussion to palpation, there it was – a firm, non-tender mass slipping under my fingers as I pressed deeply beneath the lower end of his breast bone, not something I would have done had I been following the “evidence.”
With some blood tests, an ultrasound exam and then a CT scan that were arranged in quick succession, a preliminary diagnosis of lymphoma was made and he was equally quickly seen by an oncologist. He is alive today, and whether or not because of my intuition that led to a thorough exam, I think he might say so.
In recent years the ideological tension among sport fishers has been between the “purist” fly-fisher and those who fish with bait and the myriad artificial lures now available. One of my favourite writers and one of the great writers on fishing ever is Canadian Roderick Haig-Brown. In “The Maculate Purist,” an essay in the 1951 collection Fisherman’s Spring, Haig-Brown parses both the earlier schism between dry fly purists such as Halford and the underwater nymph fishing tactics of Skues as well as the latter-day schism among sport fishers between fly-fishers and all other types and concludes:
“I will not limit myself to the dry fly, even for fresh water trout, because I believe that both wet and dry flies have their uses and their fascination. But I’m inclined to think it is a waste of pleasure to catch fish on a sunk fly when they could be taken on a floater. So, I’ll stay with the fly from now on. I haven’t so many fish left to catch that I can afford to settle for the lesser pleasure.”
Like Haig-Brown the fly-fisher, I feel myself as a physician to be a “maculate purist.” During the COVID-19 pandemic, I have seen the great value of virtual care in my own practice and in those of my colleagues. It has allowed us to provide good-enough care for many of our patients while keeping them away from our clinic and hospital where they could run the risk of exposure to the disease. But a great deal of our ability to provide such care has been built on a foundation of years of past face-to-face care and the acquisition of tacit knowledge of each person. In the post-COVID-19 world, it is hard to know how much of the care physicians provide will be virtual and how much face to face. But without opportunities for human connection, rituals of care and the sheer pleasure of practising our craft, being a doctor will be a diminished calling.
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