Sapira's Art & Science of Bedside Diagnosis
Jane M. Orient, MD (ed.)
(Lippincott, Williams & Wilkins, Philadelphia, PA, 2000, 682 pp., Index, ISBN:0-683-30714-2. )
There are clearly volumes of material being written about the medical industry. Editorials in the national print media describe the hazards of hospitalization, the importance of providing multiple benefits for the sick and infirm, the amazing innovations of technology, and occasionally some rather lurid examples of outrageous behavior (the most recent example being the surgeon who carved his own initials on the patient's abdomen when he completed the C-section).
And then, there are the articles decrying the profound changes that are occurring. Almost universally, there is reference in these latter articles to the patient-physician relationship and how critical this relationship is to the practice of medicine. In these same articles, there is little to no reference to how this relationship is established, or to the elements that establish this relationship. Yet this relationship is clearly sacred to those physicians who are distressed by the changes in the medical marketplace. Even within the ongoing debate, both sides pay homage to this basic relationship without any definition of what it means.
In 1983, Joseph D. Sapira, M.D. published an article describing medicine as a trust (Southern Medical Journal, Vol. 76, p. 76). Doctor Sapira describes how the practice of medicine had been transferred to him as a trust and that he believed he was obligated to hand that same trust to the next generation of physicians. He also described rather notable lapses in the care of hospitalized patients on the teaching service with which he was associated. Fortunately, none of these lapses resulted in a patient injury, but they did demonstrate the failure of physicians to follow through with the trust placed in their hands by those patients.
In this same article, Dr. Sapira gives his opinion that "direct observation and applied logic, openly shared, are what brought medicine to its present position. Once we abandon direct observation and the application of logic, we lose the source of our profession's power that is non-societally determined. The abandonment of direct observation (of all kinds) and of the open application of logic to such observations or, more correctly, the increasingly frequent abandonment of our trust and the use of medicine's institutions for more personal immediate advantage, either monetary or narcissistic, seems to me to be a problem of intellectual honesty in the discharge of our trust."
Certainly not to be accused of simply complaining, Dr. Sapira then proceeded to write a textbook on The Art and Science of Bedside Diagnosis, published in 1989. His editor for that volume was none other than Jane M. Orient, M.D., the current executive director of AAPS, and now, Dr. Orient has completed the second edition of this work. She has continued the original format, using the first 100 pages to describe the details of the patient interview and the organization of the case record. Each organ system is then carefully evaluated, making extensive use of the time-honored aspects of inspection, palpation, percussion and auscultation to determine the physical findings. Frequently interspersed are flags indicating critical and/or important diagnoses confirmed by the physical findings, as well as clinical pearls that enhance the physician's acumen. The chapters on the heart and the lungs have both been expanded to include recent perspectives, but also will assist the examiner in his differential diagnosis and consequently be more precise about diagnostic testing. It is difficult to write a review of such a comprehensive book, especially when the reviewer practices in a rather narrow specialty. But in reading through the various sections, one has no difficulty revisiting the other specialty areas and recalling those symptoms and signs that indicate a generalized disease, or in recognizing physical findings that had not been appreciated. All of this simply emphasizes the beauty of this type of book.
It is noted in the book (page 103) that this is not a textbook of medicine, but more like a book on how to sail your boat. The book presumes a certain amount of knowledge, and does not attempt to give the details of a pathological process. It uses the powers of observation and then leads the examiner into the application of logic to reach a differential diagnosis. This is what Dr. Sapira was talking about when he described medicine as a trust.
It is that trust that is the basis of the patient-physician relationship. That relationship is established by the intimate contact of the physician and the patient. There is no better way of consummating that trust than by The Art and Science of Bedside Diagnosis. This is indeed an invaluable book to be used for reference, continuing education, but more importantly, as the bedrock for that physician who has inherited medicine as a trust and wants to leave that legacy to his descendants.
Reviewed by W. Daniel Jordan, MD
Dr. Jordan is a member of AAPS Board of Directors and the Editorial
Board of the Medical Sentinel. His e-mail is: firstname.lastname@example.org.
Originally published in the Medical Sentinel 2000;5(3);111. Copyright©2000 Association of American Physicians and Surgeons (AAPS)