Bedside Manners

I was taught to tap and thump my patients and listen for the sounds of sickness and health. But this is fast becoming a lost art, and that’s bad for everyone.

WHEN IT WAS TIME TO HANG PICTURES in our new house in San Antonio, my wife asked me to buy a stud finder. As a husband I demurred; as an internist I flat-out refused. We internists make it our business to divine the stutters and stumbles of lungs, hearts, brains, adrenals, guts, gonads—hence the term “internal medicine.” Once upon a time, doctors examined patients not with CAT scans or MRIs but with their senses. “Surely,” I said, “skills that can find pus behind the chest wall can find a stud behind drywall.”

Under her skeptical eye, I dragged my fingertips along the wallpaper. I flattened my palm and tapped on the back of my left middle finger using the tip of my right middle finger. My hands drummed over the pressed gypsum, sounding it, discovering the spots where the resonance became muffled, abbreviated— thud rather than thoom. In the medical world, this is known as percussion, a technique that physicians have employed for centuries to sound the body’s depths. Using it, I had found the upright wooden timbers that even in the best circles of society are called studs. My brother-in-law, who fought in Korea, who wears ten-gallon hats, and who is fond of me but feels that most medical professionals are in it for the luxury cars, golf, exotic vacations, and early retirement, was impressed. As we hammered the nails in and hung the pictures, he said, “I didn’t think a doctor could do that anymore.”

My wife thinks of me as a Luddite. She believes that if a gadget has found its way onto a catalog page and if its price is many multiples of a bar of soap, it must be useful. But that evening the pendulum swung in my favor. It was one of those man-puts-machines-to-pasture moments where the sheeplike drift of consumer society toward another “must have” is momentarily halted. Please, I beg you, say no to pet dishes on legs that enable Fido to drink in an “anatomically correct” fashion, say no to battery-operated fridge air purifiers, and say no to stud finders. I fell asleep that night thinking about an instructional pamphlet that I would put in every homeowner’s Welcome Wagon basket, alongside the coupons, refrigerator magnets, and recipes for orange-peel-flavored scones: “Find the Hidden Stud in Your New Texas Home.”

The sad thing is that a homeowner armed with such a pamphlet and with one other critical ingredient—faith—can soon become more skilled at percussion than the average physician. It is fast becoming a lost art. In the past 25 years, I have taught hundreds of medical students the four classic steps in the physical examination: inspect, palpate, percuss, and auscultate. Their eyes sparkle. This is the way they imagined themselves: semioticians at the bedside, reading the signs to find the varmint in the patient’s body. Alas, a shock awaits the students when they finally arrive on the wards in the third year of medical school, their pockets laden with reflex hammers, tuning forks, ophthalmoscopes, otoscopes, penlights, and stethoscopes, only to discover that the ebb and flow of the modern hospital centers on MRIs, CAT scans, echocardiograms, angiograms, and myriad lab tests. Often, interns and residents have so little faith in bedside diagnostic skills that, as one student told me, “a man with a missing finger must get an X-ray before anyone will believe he has only four.” As for neat pocket tools, only a few die-hards still carry them. The stethoscope alone peeks out of the doctor’s pocket as a hollow symbol of the profession. (I prefer seeing it in the pocket to seeing it draped over the neck like the beads and gris-gris of Wodaabe tribesmen of the Sahara, a vulgar display meant to signal that the wearer is a sound marriage prospect and has, if not cows and land, then the prospect of luxury cars, golf, exotic vacations, and early retirement.)

When I travel as a visiting professor to teaching hospitals, I have the distinct feeling that the patient in America is becoming invisible. She is unseen and unheard. She is “presented” to me by the intern and resident team in a conference room far away from where she lies. Her illness has been translated into binary signals stored in the computer. When I ask a question about her, the intern’s head instinctively turns to the computer screen, like a pitcher checking first base. I gently insist we go to the bedside, but that is often a place where the team is no longer at ease. I realize what has happened: The patient in the bed is merely an icon for the real patient, who exists in the computer. How strange this is! When one knows how to look, the patient’s body is an illuminated manuscript. Indeed, in an elderly patient with a double-digit “problem list” that scrolls off the screen, only at the bedside does one understand which problem is most important. As my brother-in-law would put it, “You have to kick the tires.”

I am no economist, but even a landlubber on a sinking ship is entitled to make observations about the rent in the hull that is about to alter his fate: The present crisis in American health care is only secondarily a fiscal one; the real crisis is that the “art” of bedside diagnosis at which a previous generation excelled has died with the next. Personal-injury lawyers allow us the wonderful excuse that we order batteries of tests because we are practicing “defensive” medicine. The truth is that even without the threat of malpractice, we would still need just as many CAT scans and echocardiograms as we do now. We know no other way. Take away our stud finders and we can’t hang a picture. We are like owners of playerless pianos asked to entertain during a blackout: Our fingers and ears may be intact, but we can no longer play or percuss.

It was an innkeeper’s son, Josef Leopold Auenbrugger, who discovered percussion. I have dreamed this scene so

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