Hyposkillia: deficiency of clinical skills.

To the Editor: I thoroughly enjoyed Fred's editorial on hyposkillia,1 in which he deplored the deficiency of clinical skills of today's medical profession, especially among residents in training. I'd like to propose an alternative term, gadgetophilia (over-reliance on gadgets), to describe this modern-day medical malady. Present-day physicians, especially gastroenterologists and cardiologists, rely too much on gadgets. The gastroenterologists like to pass scopes either from above or from below to make a diagnosis of peptic ulcer or ulcerative colitis, respectively, instead of taking a good history. Among cardiologists, I always like to use the diagnosis of mitral valve prolapse to illustrate gadgetophilia. Whenever this diagnosis is brought up on medical rounds, the 1st question the housestaff asks is, “What did the echocardiogram show?”—instead of “What are the auscultatory findings?” The diagnosis of mitral valve prolapse, or Barlow's syndrome, was first made by John Brereton Barlow by clinical auscultation, not by echocardiography.2 The use of a stethoscope is an art of medicine that is being lost amid growing reliance on gadgetry such as echocardiography, computed tomography, magnetic resonance imaging, and cardiac catheterization. A stethoscope weighs less than a pound, does not need an electric outlet or a video recorder, is not radioactive, has no adverse side effects, and fits easily into a coat pocket.3 Although the stethoscope is still being used by every physician, it is more an ornament than a diagnostic tool. Just witness all the popular television shows in which the only way to identify the doctors is from the stethoscopes wrapped around their necks, because doctors in the hospital usually do not wear uniforms nowadays. Bedside rounds have been largely replaced by rounds held in conference rooms or auditoriums. The following is an excerpt from an editorial published in 1997 in the New England Journal of Medicine.4 The content of rounds has also changed. They are now more focused on discussing the results of a variety of laboratory and imaging studies. It is therefore easier to discuss cases in the conference room, where all these results are available for viewing. As a consequence, the skills of history taking and physical examination have declined, making both trainees and attending physicians less willing to “expose” themselves at the bedside. This becomes a self-fulfilling prophecy, because the less one goes to the bedside, the more uncomfortable one is there, either conducting rounds or participating in them. It has become more and more uncommon for physicians to “make the rounds.” Let us bring rounds back to the bedside, where history and physical examination, instead of reliance on laboratory tests, should play a major role in the management of our patients. As Fred said, “We need teachers who don't order expensive, state-of-the-art studies when cheaper, conventional tests supply the same information; …”1 Osler's maxim still pertains: “the four points of a medical student's compass are: Inspection, Palpation, Percussion, and Auscultation.”5 Tsung O. Cheng, MD Professor of Medicine, George Washington University Medical Center, Washington, DC