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Dear Dr Molyneux,

What kind of dreadful insecurity problems do doctors have to have to read a lightweight Nostalgia Aint Wot It Used To Be opinion piece in a Tuesday tabloid and perceive it as either a personal affront or a devastating attack on the profession? Oh to wield such power, I would be sure to use it wisely. Our story starts in Marrakech ( roll VT, stock travelogue footage, pan and zoom to riad poolside... ). My phone beeps and its an e-mail from Kate who for many years was my Main Man at The Times and who now works for the Daily Mails Good Health section. Shes heard that a handful of PCTs plan to restrict GPs access to sophisticated imaging like CT and MRI. Would I care to knock out a few hundred words along the Mails beloved Millions will die as a result of delayed cancer diagnosis!! axis by 7pm local time? Actually Kate, I think Ill pass, firstly because Id much rather have another beer but mainly because its a really crap idea for an article. When I get home, how about a piece based on the idea that if PCTs restricted access to imaging or the departments went on strike then GPs would have to fall back on the old fashioned technique of taking a history and examining the patient to make a diagnosis. Youve done that piece before. Yeah, but that was in The Times where no-one wouldve noticed it. Giggle at joke at former employers expense. So, Grumpy Old Doc writes the piece, a few hundred words of op-ed, including an anecdote ( theyre allowed, nay even encouraged in opinion pieces ) about a newly qualified doctor whod never been taught how to examine patients knees at med school. No disrespect intended to the student / junior doc. Im sure that the current generation is every bit as smart and dedicated as mine was twenty-odd years ago, but what were they learning when they werent learning how to check a cruciate ligament or a cartilage? My fear is that they were spending quality time in lectures and seminars that would sit equally well in a Media Studies course as they would in a medical curriculum. The GP registrars that I work alongside tell similar tales of the content of their Wednesday afternoon vocational training scheme. This, I assert, is a Bad Thing. Two lots of feedback a storm of protest from the crocodile pit that is the doctors internet chat room, which needed only the occasional lobbing in of

sacrificial gnus to keep the feeding frenzy going for days and days and a bunch of A GP who still examine patients? Where can I find one? stuff on the Mails online comment section. Both polarised and equally extreme.

A widely held patients perception is that doctors just order tests rather than bother with stethoscopes and tendon hammers. We dont get patients to say 99 any more a line I included not because I have strong views about the value of tactile vocal fremitus or even much confidence in my own ability to elicit it but because it was a part of the physical exam that I thought that many of the Mail-reading middle classes would remember from decades past. And it set up an ice-cream related punch-line which didnt survive the sub-editing process. Verily, they do cut all the jokes out. Id just about decided that all the juice had been squeezed out of the topic ( but did enjoy reading the exchanges of views that followed in the chat room ) but a patient came along to see me on Monday morning with a painful shoulder that had been troubling him for a few months. Youre the fourth doctor Ive seen about this was his opening gambit. I always hate that one. It makes me wonder what he thinks Id have up my sleeve that the previous three didnt. One routine shoulder exam later I told him that I thought he had something called Shoulder Impingement. As he put his shirt back on he asked me why none of the previous doctors had done that. Done what? Asked him to Make like a penguin ( active shoulder abduction ), put him into a weird and oddly painful armlock ( Neers test ), what? Examined my shoulder. Contrary to your implied assertion, I dont diss colleagues in front of mutual patients. I just felt uncomfortable on their behalf, smiled sheepishly and said something about different doctors doing things differently and there being more than one way to make a perfect omelette. As it turned out an MRI scan had already been ordered, by doctor #3. What he really wanted to know was whether it would be worth his while paying to have it done sooner by having it done privately. The fact that no-one seemed to be able to tell him what was wrong with his shoulder and what might need to be done about it had been preying on his mind. Now he was as happy as a man with a painful shoulder could be. I referred him to my favourite shoulder guy and hoped that we could get consultant, patient and MRI result into the same out-patient clinic room at the same time. You might argue that clinical examinations of knees and shoulder and hearts and testicles is time wasted now we have access to MRI scans, echocardiograms and

ultrasound scans and if you have instant access to any or all of those services, you might be right. I dont. You might think that some examinations are so open to interpretation as to be valueless, and Id be inclined to agree, although the more I read my colleagues postings about the pros and cons of the JVP et al the more confused I become. But this much I know. On the odd occasion when I strike lucky and get the diagnosis right, a torn collateral ligament confirmed by an MRI scan, a malignant melanoma before the biopsy or dermatoscopy, then Ive gone a long way to cementing a relationship with that patient that might mean that he or she is more likely to take on board lifestyle advice or to comply with a prescribed medication routine sometime down the line, which for present purposes Ill assert is a Good Thing.

And when I fill in the ultrasound form or the MRI scan request and get to the box labelled Clinical / Examination Findings I dont feel embarrassed about writing Probable epididymal cyst or Possible cartilage tear, whereas I would feel bad if I had nothing to offer. When I see the fabulous detail revealed by modern imaging techniques and think back to time spent looking at shoulder X-rays and speculating about the profile of the acromion process I know exactly how Paul Simon must have felt when he wrote that these are the days of miracles and wonder. But I still believe that an investigation should only be ordered if the result will either confirm a working diagnosis or change a patients management. Its just the way I was taught.

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