The cornerstone of all medical science and practice is internal medicine. Its principles should be readily available to all adults, especially in today's chaotic medical environment, which is full of complexities, inefficiencies, and difficult access issues. Take advantage of Dr. Goodman's expertise based on his 33 years' experience in virtually every medical situation and setting. [Editor's note: Dr. Goodman no longer contributes to Silver Planet, but we have made his archived blog entries available as a service to our readers.]
In September 1969, I entered Tufts University School of Medicine, in Boston. The classes of the first two or three days were lectures about introduction and orientation to the new and bewildering world that was to be our professional universe for the next four years and beyond.
One lecture in particular grabbed me, as it outlined the essence of the medical profession, right then on the very first day of my medical career. Its enduring message has helped me every day for nearly 40 years. Unfortunately, I have forgotten the name of the lecturer, but I do recall that he was a professor of pediatrics who had immigrated to the United States from his native South Africa. In his beautiful South African accent, he said that day: "I will now teach you the 'hippy' approach to medicine, except that I spell it this way: 'H-I-P-P-A-Y'—History, Inspection, Percussion, Palpation, Auscultation, and Yell for help."
I now share his words of wisdom:
History is, of course, the dialogue between patient and physician that includes detailed descriptions of the presence or absence of symptoms and their chronologies. (In previous Silver Planet articles, I wrote more about this vital entity.)
Inspection is what the physician sees, simply by looking at the patient as a whole person (with the patient both clothed and unclothed), and by looking at the exterior aspects of the patient's isolated parts. For example: Is the patient thin? Apprehensive? Walking with difficulty? Is there redness, swelling, rash, or deformity of a part?
Percussion is the technique wherein the physician places over a patient's chest or abdomen the palm aspect of the physician's third finger while tapping the top of this finger with the third finger of his or her other hand—much as a drumstick strikes a drum. The resulting percussion notes can distinguish between air, fluid, or solid material beneath the surface of the tapped portion of skin, and the sizes thereof. This technique, when skillfully done, can help diagnose pneumonia, collapsed lung, enlarged heart, enlarged liver or spleen, tumors, perforated bowel, and much more.
Palpation is the technique of touch and feel using the hand (or both hands at times) and fingers to delineate all accessible surface and internal structures of the body. Enlargement of organs such as the heart, liver, spleen, and others becomes apparent. The absence of enlargement is also important, as are the consistencies of the palpated entities. Bones, joints, and skin are also eager to yield their secrets to skillful palpation.
Auscultation utilizes hearing and the stethoscope, which augments hearing manyfold. Characteristic sounds of health and disease become readily apparent to the physician who takes the time to listen to the body. The lungs, heart, and abdomen are the areas for which detailed auscultation is mandatory for proper assessment. Illnesses such as asthma, pneumonia, heart failure, and bowel obstruction are but a few of the myriad illnesses that are readily apparent upon auscultation. Auscultation also helps diagnose the presence or absence of diseases of the large arteries, especially in the neck, abdomen, and lower extremities.
(A side note: The stethoscope is truly indispensable for the physician, and it is difficult to image a physician without one. Most physicians feel naked without it on their person. But, well-developed principles of auscultation were in place long before the circa-1820 invention of the stethoscope. In "the old days," skillful physicians placed their ears directly upon their patients' chests and abdomens and could actually discern the same normal and abnormal sounds for which we modern physicians must use the stethoscope—some of which now have built-in, battery-powered sound amplification. Our predecessor colleagues used their senses and power of observation much more acutely than we do today. They had no tests to order, and there were no reports for them to read. History, physical examination, and infinite equanimity were their only resources.)
Yell for help reminds us that medicine is a team game. No physician individually can do very much for a patient. We are only as good as our colleagues and institutions. For example, I can be a brilliant internist and diagnose early appendicitis. But, both the patient and I need a surgeon to properly "close the deal." In turn, a surgeon needs an internist to co-manage the medical problems a patient might have before and after surgery. All of us need the hospital's equipment, facilities, x-rays, lab, technicians, therapists, nurses, pharmacists, etc. I require the input of medical consultants and specialists at least some of the time for almost every patient. Thus, I am always "yelling for help."
(It follows, therefore, that the concept of "The Shingle" practice or "The Boutique" practice is nonsense, as these imply that one physician [or single specialty group] can provide financially feasible, comprehensive medical care independent of other colleagues and institutions. It just is not so.)
So where do machines, technology, and tests come in? These complement and enhance the HIPPAY approach, but they do not and cannot replace it. No test result, be it normal or abnormal, is meaningful when isolated from the context of the patient. For it is a fact that most patients who are sick have mostly normal test results, while patients who are healthy usually have at least some abnormal results. This is why tests at health fairs and commercial disease-process screening tests are usually worthless or misleading.
Thus, in medicine, as it is for life in general, context is everything. And it is only the HIPPAY approach that can formulate that medical context.
Eli Goodman, MD
Medical Insights Blog