Viewpoint: Convention or convenience?

Have you ever found yourself wondering, while hunched over a patient trying to elicit the murmur of mitral regurgitation, why your back feels it's being torn apart? Wouldn't it be easier if you just examined the patient from the left side of the bed?

What about palpating an abdomen? Have you often found (or missed, for that matter) a liver or spleen when only using one hand? Wouldn't it be better to use both hands rather than being made to use a one-handed technique that you're not comfortable with? And does it really matter if, for example, you auscultate before percussing in a respiratory examination, or vice versa?

These are just some of the apparently meaningless and dated issues in the name of convention that need to be surgically removed from the medical education system.

Yes, you need to have structure. Yes, you need to be thorough. Yes, you need to demonstrate clinical competence-but to have a rigid framework that frowns upon someone who examines from the "wrong side" of the bed or in the "wrong sequence" can only be detrimental. Conventions do have a place in medicine, but I feel it is important that they should be loosely adhered to rather than incorporated as cast-iron routines.

Many senior doctors prefer these old fashioned conventions and defend them with great enthusiasm. One senior consultant admitted, however, that he thought using both hands to feel for organomegaly was far superior to using one hand, but he still insisted that we stick to the conventional way of doing it to avoid failing our exams. The real skill of clinical medicine is not whether you can detect a spleen using one finger or one hand, but if you can detect it at all.

I believe it is imperative for doctors and medical students to be comfortable when doing clinical examinations. They can then give their undivided attention to finding clinical signs, rather than worrying about backache or wiping the torrential sweat pouring from their brow.

I'm sure many a medical student will agree that they have missed clinical signs, not due to any incompetence on their part but simply because they were not at ease while examining the patient.

I think it would be advantageous for the new generation of doctors and medical students if more emphasis was placed on nurturing and developing individual examination styles, which are effective as well as practical-instead of insisting on old-school conventions, which at the very least have no clear-cut, overwhelming benefit.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

       

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