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In praise of hands

Last week, I was on-call in Labour and Delivery.

I was working with a first-year family medicine resident. She’s part of the cohort whose entire clerkship took place during the pandemic. McGill made the decision that since the students were not yet physicians, they should be protected from the virus as much as possible. As a result, this resident, like all in her cohort, has spent much of her clerkship in the virtual space. They’ve practiced on simulations, done mostly telemedicine and have had, in general, less practical and hands-on experiences than those before them. 

In the course of the day, we did pelvic examinations, delivered a baby, did newborn and postpartum assessments. I’d prepped her with hands-on practices, and guided her through her examinations. She was knowledgeable, hardworking and wanting to learn. Yet when we were about to sew up the very straightforward second-degree tear she did not even know how to hold the needle driver properly or how to turn her wrist and catch the needle so that it moved smoothly through the tissues. While she had practiced her knots, she did not feel comfortable to do the one handed tie that is needed during perineal repair. It had not even occurred to me that this was something an R1 would not have learned during their clerkship. I did the repair, and afterwards we spent about half an hour sewing some towels together.

It should not have surprised me. This year, I’ve taught people how to put on a blood pressure cuff, how to do a breast examination and how to examine an ear. These are all those simple hand skills that we learned at the bedside, that we practiced on any number of patients as we followed our senior residents and preceptors around as clerks. 

In the past several years, physical examination skills have been considered less and less important. The periodic health examination, bimanual exams with pap tests, even routine breast examinations have been shown to be “not evidence based” or even actively harmful in large cohort studies. Imaging, and bedside ultrasound have become much more widely used tools and are almost as ubiquitous as a stethoscope. Generally, this is a good thing. 

I have a caveat however. Just like you need to kiss a lot of frogs before you find a prince, you need to feel a lot of normal before you recognise an abnormal. Our fingers need to learn the feeling of right and not right.  If you don’t know what you are looking for, you’ll never find it. And If you don’t know what it isn’t, it is hard to know what it is. 

While 80% of diagnosis is in the history and 10% in the investigation, I’d argue that the 10% left to physical examination skills is a crucial and sometimes life-changing part of the understanding of the patients’ illness and disease. 

The hand skills of cutting, sewing, examining, injecting, etc. all need practice. Certainly it’s fair to start with simulations, but sooner or later we need to work on real patients. Now that I’m at the end of my career, I feel a pressure to pass on these skills. 

But I’ve never been handy. I left Obstetrics largely because I knew I’d never be an excellent technical surgeon. I’ve always been a communication skills geek. Yet, here I find myself insisting and supporting the teaching of what my hands know.  Yes, it may be ethically questionable to use patients for our learning, but not if this is the only way to educate skilled clinicians. 

To quote my esteemed predecessor, Sir William Osler “To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.”