Old Examiners RIP (rest-in-pasture);

A New Paradigm for Diagnosis and Treatment

(History and Physical exam are not important).
Orthopaedic surgeons lay great store upon the ability to perform a good physical
examination of a patient. As the musculoskeletal system nicely lends it self to
examination and the demonstration of mechanical problems (eg unstable knee or ankle).
In fact they condemn registrars to years of learning how to do this (pretty much to the
exclusion of everything else, the registrars are encouraged to park their brain in
NEUTRAL) and then after 4 to 7 years, some old orthopaedic surgeon examiner* still
likes to declare that in the recent exam candidates did not know how to examine the
patient. What tripe. So these highly motivated and intelligent registrars have not learnt to
examine to your “high standards”?
You may recall the detailed chest exam technique taught over 40 years ago. Listening for
whispering pectoriloquy etc. Then we moved quickly onto CXR and other exam,
suddenly this detailed and laborious exam technique was no longer necessary. The same
can be said of listening to heart sounds with the availability of echocardiograms. Only
orthopaedics has not yet caught up and bang on about physical exam technique.
So let us consider what is:
History
Examination
Investigations
(As the goal of all medical/surgical treatment is to arrive at a Diagnosis so that treatment
can be given. By the way, in orthopaedics arriving at the diagnosis is usually quick and
easy; the challenge starts with treatment and deciding the best treatment).
We keep sprouting on about these without actually thinking about how they fit together
(much the same way we do about most thinking in medicine or surgery).
Arriving at the Diagnosis
In History (the ONE patient’s knowledge) the patient tells you what worries them. Of
course you guide them, but this is subjective.
In Examination (YOUR knowledge) you examine the patient and then formulate what
you think is wrong with them i.e. Objective, based on your knowledge/experience of
medicine and surgery so the knowledge base is expanded and you move closer to a
Diagnosis.
Investigations (ALL doctors’ knowledge). You do a test, often an X ray or blood test, the
results of which are based on many thousands , if not millions of patients’ x rays or
blood tests where the normal has been compiled i.e. the patient of interest is being
compared to the parameters of many thousands/millions of patients. Thus it could be said
your knowledge base is immeasurably expanded to the whole of known medical
knowledge. The Diagnosis is made and Treatment can be started.

Diagnosis. Graph shows how Knowledge database expands almost exponentially with the addition of 
investigations. Assumptions made are: It takes 10,000hours to become an expert in some area of human 
endeavour (so assign one such hour to patient; 10,000 hours to doctor for attending medical school, another 
10,000 for becoming a specialist and then allow another 10,000 for experience; for investigations, assume it 
represents the combined knowledge of 1000 doctors; but is certainly a lot more).

Now onto the Treatment

In Orthopaedics deciding the best treatment is the hardest part (again, consider that
performing the surgery/treatment is the hardest or most challenging part for up until now
it has been all talk, now we get to the action/skills part).
Options are to ask a colleague or two (very slow), BUT best to search on the net. Again
same effect, exponential increase in knowledge base.
Graph: Treatment. Getting the opinion of (say two other colleagues) re treatment
increases the database re treatment by 3x.
Assumptions here are: One orthopaedic surgeon’s database is 30,000 hours. You either go
with your opinion or goto the Internet (read others).
But by using the internet your treatment Knowledge database increases exponentially.
(There are about 100,000 orthopaedic surgeons in the world. Let’s assume that only 1%
has contributed knowledge to the internet. So the knowledge base there is 1% of 100,000
x 30,000 hours (= 300,000,000 hours).
In Summary, History and Physical exam play only a small part in arriving at a diagnosis
and treatment and it is best not to waste too much time on these and move quickly to
investigations (which is an x ray in most of orthopaedics, followed by ultra sounds, CT
scans, bone scan and then an MRI until diagnosis apparent). It depends upon the size
of the database you want to or can afford to draw upon.
When it comes to treatment, getting a second opinion does increase the size of your
database but not to the same exponential extent UNLESS you use the internet.
So old examiners should be moved out to pasture (RIP=rest in pasture), (maybe re
discover your relationship with your wife!) and the registrars’ time should not be wasted
on this physical examination hegemony (a waste of the time and effort of these clever
registrars which should be better directed at solving some of the long standing problems
in orthopaedics and medicine- rather than drilled to death over something that hardly
matters. No doubt some old examiner will have a heart attack over this heresy and not get
to ideally RIP.
So here it is the new orthopaedic model/paradigm for arriving at Diagnosis &
Treatment. You could call it the Ford Model T (or Nano Car) of Orthopaedics.

History Ask: “Where does it worry/hurt you?” Quick

Physical Touch that part and ask: “Is it here?” Quick
Investigations Straightaway order x ray, blood test, U/S, Quick
CT, Bone scan or MRI( in that order)
Diagnosis Made Almost DONE
Treatment Your Opinion/Colleagues/Internet DON

*Usually from a rural area that has never been to an international meeting, nor published a paper, is not 
known outside his own bridge club, and wants to show how important he is. Oh shock. Horror. What is 
happening to the good old standards( you mean­ when you attended an exam course, 50 years ago, after a 
mere 12 or 18 months of training to get the FRCS in the UK, returned home,   to bluff your way for the next 
50 years about how well trained registrars were then).You think I am exaggerating?

Well only last year, I read one such report on a gifted candidate who was said to not to be
able to perform the most elementary of hip examinations (performing the Trendelenburg
test). As if, a someone who is in their early forties and spent the last 15 years in
orthopaedics cannot do this test (what you really mean he cannot do it the way you think
it should be done based upon your re collection of how it was taught at the Apley Course
you went to 50 years ago where you substituted surgical training for exam technique to
come up QUIDS).
(Private opinions of E (sic) only)
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