By Associate Professor Lo Yew Long Head and Senior Consultant, Neurology, NNI (SGH Campus) Chief Editor, Proceedings of Singapore Healthcare
"It becomes extremely tempting to conduct a daily clinical round in front of the computer screen."- Assoc Prof Lo Yew Long, Head and Senior Consultant, Neurology, NNI (SGH Campus) and Chief Editor, Proceedings of Singapore Healthcare
In a recent note to The Journal of American Medical Association (JAMA), Elder and colleagues(1) lamented the gradual demise of teaching bedside clinical skills in the US, resulting in the over-reliance on investigations. The authors strongly felt that their trainees lacked any incentive to sharpen these abilities, given the inadequacy of assessment and pervasion of technology.
As a result, skills of physically examining patients have largely lagged behind other systems that emphasise them, such as that in the UK. As physicians caring for ‘real’ and not ‘virtual’ patients, it appears paradoxical that such trends have found their way into Clinical Medicine today. The advent of the Internet and other real-time image recording capabilities has enabled medicine to be practised from afar. It becomes extremely tempting to conduct a daily clinical round in front of the computer screen.
Reflecting on my experience as a Neurologist, the teaching of Neurology in Singapore traditionally followed the British system of education and evaluation. While non-bedside assessment of clinical knowledge has been introduced, emphasis on bedside clinical skills has not been compromised, for several reasons.
First of all, in many instances, it is not feasible or pragmatic to obtain a tissue sample to diagnose diseases involving the central or peripheral nervous system. The clinician is left with blood tests, electrical measurements, imaging and, mostly, sound clinical judgement.
Second, in reality, many neurological disorders do not show unique features that enable diagnosis even if tissue samples are obtained. For example, microscopic examination for demyelinating diseases or multiple sclerosis often serves only to rule out a cancerous lesion, but the likelihood of finding further diagnostic feature is remote.
Third, many neurological disorders are syndromic in nature, that is, a collection of features, both central and peripheral. A classic example would be the Guillain-Barré /Miller Fisher syndrome/Bickerstaff’s Brainstem Encephalitis spectrum of disorders which require clinical, radiological and immunological data to help make a diagnosis(2).
Sophisticated imaging is often unremarkable and any microscopic examination would not be able to reveal the unique features of these disorders. Ultimately, it is the clinical skill of history taking, judging clinical signs and putting evidence together that will contribute towards making the final call.
Finally, the temptation to order expensive investigations should be balanced with sensible clinical judgement. Many neurological investigations serve merely as extensions or correlations of clinical examination.
For example, in degenerative spondylotic myelopathy, it can be technically feasible to do a scan to determine the extent of spinal cord compression. However, the patient’s complaints and presence of physical signs often determine the direction of treatment(3). This cannot be reliably assessed by virtual means, such as using telemedicine, intranet or Internet communication tools. Accurate clinical examination is still mandatory here.
Other fields in Medicine may also find synergy from our experiences in the road to reviving bedside teaching(4). In short, Clinical Medicine has its rightful place at the bedside, and this should not change in the near future.
References1. Elder A, Chi J, Ozdalga E, Kugler J, Verghese A. The Road Back to the Bedside. JAMA 2013; 310: 799-800. 2. Lo YL. Guillain-Barre syndrome. Lancet Neurol 2008; 7: 1082-3. 3. Lo YL, Chan LL, Lim W, Tan SB, Tan CT, Chen JLT, Fook-Chong S, Ratnagopal P. Systematic correlation of transcranial magnetic stimulation and cord compression on MRI in cervical spondylotic myelopathy. Spine 2004; 29: 1137-45. 4. Tamblyn RM, Barrows HS. Bedside clinics in Neurology. An alternate format for the one-day course in continuing medical education. JAMA 1980; 243: 1448-50.
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