On the Teaching of Physical Diagnosis

1902 Boston Medical and Surgical Journal  
Tun educated physician who interests himself in medical conditions in the United States cau scarcely fail to be impressed with the fact that those points in which the profession as a body is most deficient depend upon the need of a more thorough early training in the fundamental methods of physical diagnosis and of a more extensive bedside experience in the observation of disease during the 'instruction in the medical schools. The association of medical schools has lengthened the course of
more » ... required for a degree of doctor of medicine to four years, and most of the states have adopted examinations requiring evidence of proficiency on the part of the applicant for a license to practice which in some instances are excellent. Yet none of these laws and but few of our schools insist upon an amount of training in clinical observation equal to that which is demanded, for instance, in England. There is no uniformity in our state laws, and as finas the four-years' work goes, little is required beyond the fact that those years shall have been spent in study or in attending courses of lectures. The student may to-day, as he could forty years ago, graduate and enter into the practice of medicine with a minimum of actual clinical experience. In the last two decades, however, great changes have come about in our methods of medical instruction. The didactic lecture, the demonstration forms of instruction designed to bring out facts with as much economy of time as possible before large classesare rapidly disappearing, giving way to more practical methods of teaching with smaller bodies of men. We seek to-day not so much to lay facts clearly before a class as to teach the student methods by which he can himself control the statements of his instructors and his books, by which he may become independently competent to investigate and to clear up the nature of any anatomical or physiological abnormality with which he may meet. These changes have occurred not only in methods of clinical instruction but in the laboratories themselves. He has a poor knowledge of anatomy who is familiar only with the gross forms, but it is not merely to recognize minute histological changes that the student now demands ; he must have a practical familiarity with those methods of preparation and staining without which he is helpless. And not in medical teaching alone have these changes come about. We seek to leach the child ¡tt school, as well as the student of medicine, howto think, how to work, how to investigate, how to help himself ; to guide him rather than to push him in the way that lie should go. We are but following a method urged by Montaigne about three hundred and fifty years ago. "0» ne cesse," says he, " de criailler à nos aureilles, comme qui verseroit dans -un entonnoir; et nostre charge, ce n'est que redire ce qu'on nous a diet : le vouldrois qu'il eorrigeast cette partie; et que de belle arrivée, selon la portée de l'âme qu'il a en main, il commenceast à la mettre sur la montre, luy faisant goitster les choses, les choisir et discerner d'elle mesme ; quelquefois lut/ ouvrant chemin, quelquefois le luy laissant ouvrir. le ne veulx j>as qu'il invente et parle seule; ie veulx qu'il escoule son disciple parler à son tour. Socrates et depuis Arcesilaus, faisoient premièrement parler leurs disciples et puis il parloient à eux. . . . Qu'il luy face tout passer par l'estamime, et ne loge Hen eu sa teste par simple auctorité et à credit . . . s'il embrasse les opinions de Xenophon et de Platon parson propre discours, ce ne seront plus les leurs, ce seront les siennes : qui sui/t un aultre, il ne suyt rien, il ne treuve rien, voire il -ne cherche rien."-These methods of instruction are bringing to us a different class of men, men trained to independent thought, who are no longer contented with bare statements of fact, but demand proofs and explanations and ask embarrassing questions. At the end of the second year in most of our medical schools, these men have been occupied for nearly a year in studying the manifestations of disease in the pathological laboratory. They are now confronted by ¡t new question, namely, the recognition of these same pathological changes in the living subject. (1) THE NECESSITY OF A GOOD KNOWLEDGE OF REGIONAL ANATOMY AND 01" PRACTICE IN THE PHYSICAL EXAMINATION OF THE NORMAL SUBJECT. For the proper study and comprehension of normal and pathological anatomy a certain amount of technical skill must be acquired, -the technique of dissection and necropsies and the more elaborate technique of preparation of tissues for microscopical examination, as well as that of bacteriology. For the examination of the living subject, a new technique, which may be fully as complicated, is also required. The first step toward acquiring this technique consists in the study of the fundamental methods of physical investigation, -inspection, palpation, percussion, and auscultation. These methods will, however, be of little or no value in helping the student to determine anatomical or physiological changes in internal organs without an accurate knowledge of their normal position and outline, and of the evidences which they give to the eye, the hand and the ear of their normal function. The middle or end of the second year is, in most medical schools, just the period at which the student should, theoretically, be most familiar with topographical anatomy. Nevertheless, an essential part of the course in physical diagnosis should, 1 believe, consist in practical demonstrations of regional anatomy. Why is this s "They [teachers] m-e oternally dinning In our ears us It they were pouring Into a tunnel; and our pnrt la hut to repent what they say to us. I would have the teaeher amend thin procedure; and from the beginning, according to the oharaoter of the mind with which he in treating, he should endeavor to sltmuhitu its action, milking It taste, choose and iudgo of thlmrs of Its own Impulse. sometimes opening the pntli himself, somotlmea allowing the pupil to make his own way. I would not. have him alone suggest and speak ; he should allow his disciple to «peak in his turn. Soci-atcs, and later Arocsllaus, insisted that their pupils speak Ilrst and then took up the subject themselves. . . . "Let him | the teacher | make him | the pupil I investigate everything and lodge nothing in his head through simple authority and on trust ... If he embrace the opinions of Aunophon mid of I'lato through his own powers of reason, these opinions will bo no longer theirs ; they will be his own. He who follows another follows nothing, HinIh nothing, nay, he seeks nothing." (Montaigne:
doi:10.1056/nejm190212251472601 fatcat:dekuu353snhnvcqqfrckuwewey