Dr. Alberto J. Muniagurria
Medicine is a humanitarian, service profession that exists for the benefit of others. As Walsh McDermott defines it ... it is a scholarly profession, deeply rooted in a number of sciences, and with an obligation to apply them for the benefit of man. "
The practice of medicine, through Clinical Semiology, is both science and art. It is science and it is art because it is based on scientifically proven principles and develops a series of advances ordered through a method to elaborate knowledge that allows it to recognize, define, correct and intervene to maintain the state of health of individuals.
The doctor must possess, on the one hand, solid and extensive knowledge that constitutes the foundation of his medical capacity, and on the other hand, have judgment, tact, prudence, compassion (1) and interest in the care of his patients.
Contact with the patient is developed through a relationship, which must be established considering him, not as a case or a disease, but as a human being, with all its complexity, emotionally charged, sometimes anxieties and anxieties, eager to be heard and understood, and at the same time full of hope.
The patients who come to the consultation are individuals whose problems are much more important than the verbalized reasons or complaints. Most approach the doctor with a degree of fear, sometimes trying to convince themselves that there is no disease, or developing defense mechanisms, unconsciously to distract attention from the real problems that would be life-threatening. Sometimes the disease is used to attract attention or to get out of situations that generate anxiety. Some patients even pretend illnesses. That is why the doctor must internalize himself in the human being, where, from health, illness can occur, in his family environment and in his social environment. In other words, in its singularity, particularity and generality.
Signs, symptoms (data) and syndromes
Whether in health or disease, there are data provided by the patient, which are classically known as symptoms (subjective sensation, perceived by the person) and / or signs (objective manifestation detected by the same person or the health worker) . They are an explicit way of exposing both health and the presence of an abnormality.
The color of the skin, or the amount of the urine, the feeling of well-being, or the respiratory rate can serve as an example of symptoms and signs, which often overlap being symptoms and signs at the same time (fever).
These manifestations or expressions of physiological or pathophysiological mechanisms offer the necessary information to build knowledge, on the part of the physician, of the physical state of the patient who consults. In other words, establish a diagnosis.
Often in medicine, these manifestations of symptoms and signs can be grouped into a "group or constellation" of them or also called syndromes, which respond to different origins or causes (etiologies), as well as different pathophysiological mechanisms.
An example is the pneumonic syndrome (cough, expectoration, pain in the side stitch, dyspnea and fever, inspiratory crackles, etc. etc.) that can respond to different bacterial, virological or parasitic forms and which develop, with their presence, different inflammatory mechanisms. Another classic example of the syndrome is heart failure (dyspnea, nocturnal cough, expectoration in meat lavage, peripheral edema, hepato-jugular reflux, variations in cardiac output by echocardiogram) which may be due to myocardial, endocardial-valve, flow disorders circulating, peripheral resistance etc. etc.
The recognition of syndromes is detected by questioning, by physical examination or by complementary studies (the laboratory, imaging diagnostics or special procedures). The syndromes expose various pathophysiological mechanisms and etiologies; and its recognition allows guiding the methodological order of the study of patients. (Clinical method).
This way of constructing information, which starts from listening to symptoms, observing and contacting signs, and recognizing syndromes, has led to classifying diagnoses according to the level reached in knowledge of the mechanisms put into play, in pathophysiological, syndromic and finally when it can be defined in its cause, etiological.
The record of the information obtained, in the doctor-patient interview, through the Interrogation, the Physical Examination, and the results obtained from both the Clinical Laboratory studies and those of Imaging, and Special Procedures is known as the Clinical History..(Harvey's five fingers)
The Clinical History begins with the interrogation or anamnesis, which is one of the most important skills available to the doctor, and very often can provide the data that defines the clinical picture.
During the course of it, different diagnostic hypotheses originate and accept or reject, which will then be confirmed or discarded in the study of the patient. This study of the patient will depend to a great extent on the information obtained in the interrogation.
The questioning should be comprehensive, including all the significant medical facts of life. If the questioning is taken chronologically, recent episodes should be ranked and receive the most attention. If the problem history medical guidance system is used, those problems that are dominant should be considered first.
Knowing how to listen is extremely important, allowing oneself to intervene when clarity can be incorporated into what is narrated by the patient. The facial expression of this, his tone of voice and the way of speaking, his attitude, are giving keys to guide the diagnosis and to detect the meaning and importance of the symptoms. By listening, you learn not only about the disease, but also about the sick.
The doctor learns, through experience, to know the difficulties that arise when doing a good questioning and it is here where the knowledge, practice, and skill of the professional are most clearly manifested. In fact, the interrogation, the initial part of the medical interview, and the opening of the medical history, constitutes the fundamental means of beginning and expanding the relationship with the patient, gaining trust and obtaining his collaboration.
The Physical Examination is carried out after the interrogation, following a methodological order and must be carried out completely.
In practice, the inspection starts and will provide data from the beginning of the consultation.
The normal or abnormal findings found constitute signs, or objective facts, markers of health or disease, which may or may not confirm the suspicion caused by the history. Sometimes the sign found is the only manifestation of the disease, such as a breast lump.
The Physical Examination is understood pedagogically as a skill, but it is not part of it alone, since it is part of a line of knowledge, which can vary from patient to patient. (inspection, palpation, percusion and auscultation). Hearing a murmur is a skill, but adaptation to the case of the patient in question, type of consultation, routine or emergency, with a defined or "unclear" reason for consultation, requires adaptation to the circumstance that exceeds the limits of the habilities.
Findings or signs, normal as well as abnormal, from the physical examination should be recorded or recorded regularly. These can change or disappear, which makes it important to repeat it periodically as many times as necessary.
Over the years, the increase in the number, availability and precision of complementary laboratory tests have led to trust, and rely on them, for the solution and definition of clinical problems.
These studies are, of course, important, and in particular form the basis of screening programs for the early diagnosis of various diseases. Most of these tests are not perfect, and can sometimes make a healthy person sick or fail to detect pathology. Therefore, it is of utmost importance in evaluating the results obtained, to take into account the limitations of these studies. Remember that they are impersonal, they have the possibility of technical errors, and of interpretation, which undoubtedly requires working with a quality controlled service.
In evaluating the results, it is essential to consider the sensitivity, specificity and prevalence of the studies for the different pathologies.
Sensitivity is the probability that the disease exists when the result is positive. The Specificity is the probability that the result is negative when the disease does not exist. (see box). The Prevalence is the relationship between all patients with the disease and evaluated the study, which adds an epidemiological factor.
The massive use of analysis does not relieve the doctor of his responsibility to interrogate and examine the patient and recognize and observe him as a whole.
The cost of the studies and the benefit of the results must be taken into account.
Evidence-based medicine has contributed in this regard its share of utility in these recognitions.
The study classified as (a) is one in which the preponderance of the data supporting this result is derived from level 1 studies, which cover all the evidence criteria for that type of study.
The one classified with (b) is the one in which the preponderance of the data supporting this result is derived from level 2 studies, which cover one of the evidence criteria for this type of study.
Those classified as (c) are those that the preponderance of the data that supports that result is derived from 3rd level studies which do not have evidence criteria for this type of study or are based on the opinion of experts supported by their experience, or in consensus of opinion.
A reason for consultation or a finding in the physical examination will guide the studies to request. In the case of an abnormal result in a patient who does not present any symptoms and without signs in the review, the study should be repeated to exclude an error. If the abnormal result is repeated, the clinical judgment will indicate the conduct to follow.
The imaging studies, with rays, echoes, radioactive isotopes, magnetism, endoscopies such as conventional radiology, scintigraphy, ultrasound, Computed Axial Tomography, Nuclear Magnetic Resonance, Doppler, PET Scanner, Axial Tomography by multiple cuts (Multislice), virtual endoscopies, diagnostic laparoscopies, etc. , etc., contribute to the study of the patient and provide important information to establish a diagnosis, define the anatomy of the lesion, as well as follow the evolution. It should be emphasized that the same reserves should be applied in these studies as for the clinical laboratory. The sensitivity, specificity, prevalence as well as the cost of the procedure must be evaluated in relation to the information they provide. Consideration should also be given to the changes in behavior to be followed, provided by the study,
The clinical method is the process or ordered sequence of actions or established order that the physician executes to organize and elaborate the information obtained in the examination of the patient, (establish knowledge of the clinical situation or, if possible, establish a diagnosis). This line of work has been running since the beginning of the scientific era.
It is the scientific method applied to clinical practice, or the order in order to study and understand the process of health and illness of a subject in all its social, biological and psychological integrity.
When describing its steps, one must imagine an action in motion where "everything" is linked and each part of it is concatenated with the other, and cannot exist individually.
As stated when applying the clinical method, medical knowledge is being elaborated and constructed.
Regarding knowledge, it is interesting to highlight the following types:
- Popular knowledge: it is the daily knowledge that is transmitted from person to person through the word.
- Pseudoscientific knowledge : it is a systematized, social and methodical knowledge, which is not the scientific knowledge of medicine, but rather knowledge with rudimentary characteristics from the perspective of science.
- The scientific knowledge proper to medicine starts from reliably demonstrated paradigms and with these knowledge uses a way of reasoning the medical problems posed for which it applies an order or method, called the clinical method. This has been systematized over time as an order-method sequence to address the problems of health and illness of individuals.
The clinical method can be analyzed, from:
The objective of studying and understanding the health and / or disease process of a patient, immersed in a problem that leads him to the consultation, implies establishing a diagnosis (knowing), a prognosis (getting ahead of time interpreting what may happen) and offer treatment recommendations to resolve the situation and avoid the consequences.
To diagnose is to recognize and is a cognitive activity of the doctor, which begins as soon as he meets the patient. Starting from the encounter itself, it begins with a sequence of conjecturing a diagnostic hypothesis or presumptive diagnosis that allows the theoretical problem to be explained. Successively you should work to confirm this proposal through exploratory resources, replace the hypothesis with others and if the confirmation does not occur, continue until knowledge of the situation allows you to correspond to that presumptive diagnosis satisfactorily, with all the data obtained in the consultation .
The information obtained generates a number of hypotheses, which are worked, controlled and validated through an order and under certain conditions.
A spiraling process of knowledge construction occurs, a coming and going from theory * to facts * and from facts to theory, which will result in the confirmation or discard of the proposed diagnosis ( contrast ).
The diagnosis must be comprehensive or comprehensive. The organic-biological is only part of the integrity of the person, to which must be added the social.
Applying the holistic medical model is taking into account the subject's spaces not only in the biological, but also in the psychological and social. That is, the subject from his perception (how he thinks and feels himself), within his family and society.
Therefore, each medical examination has its own figure and content that give it a uniqueness. This is clearly outlined in the metaphor " there are no diseases but sick people ".
- Hypothesis: are the possibilities or existing knowledge bases of health and disease
- Theory: it is the "proven" hypothesis.
- Facts: is the problem that happens.
Likewise, the observation developed by the doctor is permanent during the consultation, "all the time", in search of symptoms and key signs (semiology), to which the patient's response must be added to them, and which together form part of the diagnosis to build.
When defining a diagnosis, the doctor is able, through his training, added to his experiences, to establish the evolutionary guidelines for the condition: forecast and correct. The diagnostic task fulfills the two requirements that the etymology of the term "diagnosis" carries with it: knowing by distinguishing (say as "between") and knowing by penetrating (say as "through").
The realization conditions :
The conditions of performance are the contexts in which the medical activity or practice is carried out.
The context of the doctor-patient interview occurs in the instance of the medical consultation. This usually takes place in an office, but it can occur in the hospital during hospitalization, at home or at home visit, in a classroom or community space, peripheral health center, geriatric, etc. In these mentioned scenarios it is the place where the clinical method is applied.
When a medical consultation is started, a communication relationship is established between the doctor and the patient, known as the doctor-patient relationship.
Each encounter with each patient is a moment of uniqueness. At this time, the physician is an observer-listener of the patient's verbal and paraverbal language. Both, doctor and patient, seek a goal and an exchange occurs through this link in pursuit of decisions that will lead to the search to solve the problems that afflict the patient.
The medical consultation can be approached from multiple perspectives.
The relational, regarding the meeting of two individuals, medical subject and patient subject; the intercultural, by the sociocultural belongings of the doctor and the patient; the communicational, which implies the interaction between sender and receiver through messages; the emotional is an aspect that interweaves with the psychological and the social and the ethical.
A contextual patient is the individual inserted in a socio-political-cultural space, where the general and particular characteristics of the environment play: biological, economic, social, and cultural, plus the unique socio-economic and genetic-biological characteristics of himself .
This dimension of context participates and operates on the possibilities of selecting, using and applying the techniques and the concretion of the recommendations, either by resources of the health services or by the actions of the subject himself.
Actions or procedures:
It is the operation of this process of obtaining information through selected methodologies and techniques (skills).
Through its application subjective and objective data is collected.
The instrument used to collect and record the data is what is known as the clinical history and which includes the interrogation, the physical examination and the evaluation of the complementary studies.
In summary, the clinical method is a work order prepared by the medical professional within the instance of the medical consultation, through the development of a doctor-patient relationship, with a registration tool, the medical history, with the aim of arrive at a comprehensive diagnosis of the health-disease process of a contextual individual.
The doctor with the ability to implement the clinical method is the one closest to the core of the profession. Hippocrates does not describe another space for the doctor that has so much dimension and prominence.
No one better than José Emilio Burucúa knew how to express it: ... "I would say that if it were to find out what knowledge has remained faithful to the philosophy of its existential need and still retain the indisputable right to be considered in all plans teaching, and I would say even more, they have become increasingly necessary to understand the organic or functional diseases that afflict patients, as well as to arbitrate the resources that make their recognition possible, only pathological anatomy and semiology are the the only ones that meet those requirements and conditions ... "
Medicine and its academic tool, Clinical Semiology as science and art must, on the one hand, generate knowledge and transmit it to the members of the medical community, and on the other, use that knowledge to defend ethical principles of professional conduct, or professionalism . Support the development of behaviors with a high ethical and moral sense in each of the individuals involved in the care and recovery of health.
The doctor must consider ethical issues in all clinical reasoning approaches, which involve the diagnosis, therapeutics, the quality of life of the patient, his possibilities of cure, as well as the consideration of his interests, handling of the information to transmit to the patient and family. He must be very careful in respecting the limits of correction and behavior in his contact with the patient, knowing how to defend the distances that medical dignity imposes on him. Also careful in handling the private information provided to you.
The concept of beneficence , which defines that the first thing that matters is the health of the patient, their right to autonomy, that is, to be able to make decisions that influence their health, as well as the trust based on the doctor-patient relationship, must be followed and respected.
The fact of possessing knowledge, which is necessarily limited, and of making decisions that affect one's neighbor, should not make the doctor fall into pride or let him be led by the sense of omnipotence, which he is far from possessing.
Remember the words that Dr. David Staffieri addressed to his medical son, when referring to the type of doctor he wished him to be, and defined him as "... a little artist, a bit a saint, a bit a wise man ..., I don't know if you will reach the goal, but I would be more concerned if you are not encouraged by the fervent desire to reach it. "
The synthesis of the idea is that the medical professional must imbue himself with an attitude of permanent search with compassion (1) for the patient, who trusts his health in his knowledge.
(1) compassion: Feeling or emotion that occurs when seeing someone suffer and that prompts to alleviate, remedy or avoid their pain or suffering. Vox Manual Dictionary of the Spanish Language. © 2007 Larousse Editorial, SL