On Contemporary Bedside Manners: Are You With the Shirts or the Skins?

Guest Commentary

When I am with older physician friends (ascribing these moments to medical nostalgia), I often lament as to what passes as a cardiovascular examination nowadays. Patients whose echocardiograms are chocked full of abnormalities—severe pulmonary hypertension, tricuspid regurgitation, life-threatening aortic stenosis, yada, yada, yada—are consistently written off as “no JVD, RRR, no ventricular enlargements, and no murmurs.” I have characterized the RRR term, as a “doggie exam” in response to the “arr, arr, arr” (which I bark out loudly to others’ annoyance).

Two things are immediately apparent. First, there is no way much time or effort was put into the exam. Second, if the echo findings were helpful, the learner would return to the bedside after review and carefully reexamine the patient in an effort to hone skills. That rarely happens. A recent “On Being a Doctor” section in the Annals of Internal Medicine made me feel much better because it showed there are others who are concerned about the sad state of physical examination skills.¹

SHIRTS VS SKINS

The author, Joel Stein, MD, visited his dad during his father’s complex postoperative course consequent to a total hip arthroplasty. His dad, a retired physician, was witty and insightful despite his tough times. He told his son, regarding his physicians, that they are on one of “two teams,” that is, “the Shirts and the Skins.” This is an enigmatic statement with an uncomfortable interpretation. The “skins” are identified by a particular behavior (nearly extinct). They place their stethoscopes on his father’s chest (without the imposition of sweaters, blankets, gowns, and breakfast trays) and listen long enough to discern more than a beating heart! The “shirts” in contrast, “graze” the gown (and anything else that is in the way) as the examiner peeks at the ripe fruits of technology (monitors and the like). There was even more of a problem in this instance: Dr Stein’s father was a member in good standing of the “skins”!

SKINS ARE OUTNUMBERED

The “physician-father” then recounted his adventures with a recurrent postoperative supraventricular tachycardia. First to come to his “rescue” was an orthopedic resident (a “shirt”) who put him on telemetry without any examination. A cardiology fellow entered later on his white horse. He made minimal progress with a cursory exam after a lengthy review of the ECG (another “shirt,” but in “skin’s” clothing). He began to chart on his computer. Finally, Dr G., the attending, arrived. It is possible that he was old enough to be my classmate. No peeks at the monitor. He was a “skin” through and through. Palpation and listening were included for the same price! His interest and expertise relaxed his knowledgeable patient and obtained more information from the patient-physician-father.

It was finally time for an ablation. Wait a minute, the story is not over. Consent for the procedure was obtained not by the electrophysiologist (it was not mentioned as to whether he did any examination), but by his fellow. Dr Joel Stein ended with a plea: “It seems it wouldn’t take that much of an effort to have a few of the Shirts strip down a bit and join the other team. At least it would even up the teams and give the Skins a fighting chance.”¹

TIME TO RETURN TO BASICS

I am not a Luddite. I have been the recipient of CT scans, MRI scans (herniated disc), surgery (ruptured Achilles tendon), and an echo (lone atrial fibrillation). The technology was indicated and informative. However, technology and physical examination are not mutually exclusive categories. It is time we returned to the traditional basics, so patients do not request robots in lieu of imitation doctors.

REFERENCE:

1.Stein J. Shirts and Skins. Ann Intern Med. 2013;158:564-565.