Clinical Examination: Power of Observation

Clinical Examination: Power of Observation

Sherlock Holmes admonishes Dr. Watson by stating, “You see, but you do not observe.”

My mentor offered a similar commentary to me in reference to my diagnostic abilities, or lack thereof. I trust his critique was intended to be a motivating jab, not an assessment of my ultimate potential.

To instill the lesson, I vividly recall the framed, embossed quotation from the German poet Goethe that greeted all who entered our VA clinic:

Was man weis, man seicht.” Or, “What one knows, one sees.”

Maxwell Wintrobe, the renowned physician-scientist, paraphrased Goethe’s proclamation as “We see what’s behind the eyes,” advocating that a diagnostician should develop acute observational and analytical skills in parallel with ever expanding knowledge. Early in my clinical education, these truths did not hold the same degree of significance for me as they do today.

It is our career-long journey as clinicians to continually sharpen our powers of observation. The arts of interviewing, inspecting, and deducing bring forward talents that allow one to identify patterns and processes that underlie pathologies. To become a consummate diagnostician, one must negotiate this path.

Today we are fortunate to have a number of valuable assessment tools (e.g., videofluoroscopy, endoscopy, manometry) to examine various biomechanical aspects of the pharyngeal phase of swallowing. However, to develop an effective treatment plan, we must consider the whole individual, including underlying neurological mechanisms and other forms of pathophysiology. In a comprehensive clinical examination, we can broadly examine multiple factors that impact patient candidacy for various forms of intervention, ultimately leading to more positive outcomes. Literature reinforces this concept, indicating that identification of aspiration and pharyngeal biomechanics alone did not predict long-term outcomes, such as development of aspiration pneumonia.1-4

Unfortunately, clinical examination skills have been deemphasized in many educational programs. Their utility has been marginalized, in part due to failure to appreciate the full breadth, depth, and value of the examination itself. Yet, when employed by the skillful clinician, it is an indispensable assessment approach. While we may not reach the prodigious level of observational acuity of Sherlock Holmes, we can develop habits that will allow us to expand our clinical diagnostic skills, making us much more valuable clinicians.

Clinical Examination for Dysphagia: Check List

  1. Smithard, D. G., et al. "Complications and outcome after acute stroke: does dysphagia matter?." Stroke 27.7 (1996): 1200-1204.
  2. Langmore, Susan E., et al. "Predictors of aspiration pneumonia: how important is dysphagia?." Dysphagia 13.2 (1998): 69-81.
  3. Addington, W. Robert, Robin R. Ockey, and Robert E. Stephens. "Aspiration screening process for assessing need for modified barium swallow study." U.S. Patent No. 5,904,656. 18 May 1999.
  4. Smithard, D. G., N. C. Smeeton, and C. D. A. Wolfe. "Long-term outcome after stroke: does dysphagia matter?." Age and Ageing 36.1 (2007): 90-94.