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Clinical myths
Posted 21-12-2007 at 06:42 PM by Angel
BMJ 2006;332:1341 (3 June), doi:10.1136/bmj.332.7553.1341-a - Link
Clinical myths
I realise now that much of the teaching I received (and much I have given) has actually been rather dishonest. The true variation of disease presentations and the low predictive value of any one of the clinical features were never explained. We were taught "classical" presentations. The pictures in the books—like rashes in a dermatology textbook—were gross examples (in every sense of the word). The descriptions of disease were often from a world long gone. Nobody could miss the vast goitre, the acromegalic who looked as though he should be in a Bond movie, the gross deformity of the rheumatoid hands. But hypothyroidism doesn't present with a huge goitre and slow reflexes any more. We need to stop teaching myths.
Students still carry out a cardiovascular examination and spend an age staring at the hands for Osler's nodes. Astonishing! The Austin-Flint murmur, pre tibial myxoedema, egophony. Why are we wasting their time with these things? But if we ask the student what the chance is that rectal bleeding in a 60 year old signifies colorectal cancer—is it one in a thousand or one in ten?—they won't know, because we don't.
The dishonesty is the myth that somehow symptoms and signs in medicine are highly predictive of disease—or even that we know how predictive they are. Surely we shouldn't still be teaching medical students about whispering pectoriloque and splinter haemorrhages? We should be teaching them about clinical probability and the truly discriminatory factors in the history and examination.
I see people complaining of breathlessness every day of the week. It is a bit embarrassing that if a student asked me whether a breathless 60 year old presenting to me has a one in a thousand chance of having heart failure or a one in ten chance I wouldn't really know. We rely on a "feel" for clinical probability that accrues with experience. That experience is clearly a potent thing because otherwise there would be a lot more mistakes than there are. But it would be nice if we could quantify it and pass it on a bit more efficiently. More relevant than obscure 19th century physical signs, I think.
In future I am going to be more honest about the depth of our numerical ignorance. And if the students are a bit shocked, then maybe we should be too.
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Kevin Barraclough, general practitioner
Painswick, Gloucestershire
Clinical myths
I realise now that much of the teaching I received (and much I have given) has actually been rather dishonest. The true variation of disease presentations and the low predictive value of any one of the clinical features were never explained. We were taught "classical" presentations. The pictures in the books—like rashes in a dermatology textbook—were gross examples (in every sense of the word). The descriptions of disease were often from a world long gone. Nobody could miss the vast goitre, the acromegalic who looked as though he should be in a Bond movie, the gross deformity of the rheumatoid hands. But hypothyroidism doesn't present with a huge goitre and slow reflexes any more. We need to stop teaching myths.
Students still carry out a cardiovascular examination and spend an age staring at the hands for Osler's nodes. Astonishing! The Austin-Flint murmur, pre tibial myxoedema, egophony. Why are we wasting their time with these things? But if we ask the student what the chance is that rectal bleeding in a 60 year old signifies colorectal cancer—is it one in a thousand or one in ten?—they won't know, because we don't.
The dishonesty is the myth that somehow symptoms and signs in medicine are highly predictive of disease—or even that we know how predictive they are. Surely we shouldn't still be teaching medical students about whispering pectoriloque and splinter haemorrhages? We should be teaching them about clinical probability and the truly discriminatory factors in the history and examination.
I see people complaining of breathlessness every day of the week. It is a bit embarrassing that if a student asked me whether a breathless 60 year old presenting to me has a one in a thousand chance of having heart failure or a one in ten chance I wouldn't really know. We rely on a "feel" for clinical probability that accrues with experience. That experience is clearly a potent thing because otherwise there would be a lot more mistakes than there are. But it would be nice if we could quantify it and pass it on a bit more efficiently. More relevant than obscure 19th century physical signs, I think.
In future I am going to be more honest about the depth of our numerical ignorance. And if the students are a bit shocked, then maybe we should be too.
----------------------------------------------
Kevin Barraclough, general practitioner
Painswick, Gloucestershire
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