Top 10 Forgotten Diagnostic Procedures

As the decay of the Chew Dynasty grew worse, studies were neglected and the scribes became more and more ignorant. When they did not remember the genuine character, they blunderingly invented a false one. These non-genuine characters, copied out again by other ignorant writers, became usual.¹

L. Wieger

It is becoming increasingly evident that various modern technologies are replacing the physical examination in its traditional role of confirming a medical diagnosis, as well as cementing the patient-doctor relationship. In the modern health care system, instruments such as ultrasound and various computerized scanners have largely superseded the traditional physical examination maneuvers. Indeed, it is now possible for a medical student to graduate without ever having felt an enlarged spleen. Yet, many have argued that this tendency toward the mechanization of our health care system has resulted in increased costs and a greater degree of patient alienation, without always improving on diagnostic accuracy.^2,3

Specifically, there are certain procedures that were once the domain of general practitioners that are now almost uniquely practised by specialists in the field in question. For example, rare is the generalist these days who can assess tympanic membrane mobility using a pneumatic attachment to an otoscope, a procedure that is still considered the criterion standard to confirm even common conditions such as middle ear infections.

Previous work (B. Rochwerg and D. Ponka, unpublished data, 2008) identified the top 10 procedures—chosen from among those listed in detail by Pfenniger and Fowler,⁴ the classic treatise on this topic—most in need of being rekindled in medical education. Faculty in the Department of Family Medicine at University of Ottawa sites (including remote Baffin Island, Nunavut) were surveyed on what procedures they thought were the most important to teach yet believed they were the least equipped to demonstrate, and the result is this top 10 list, which will be published in upcoming issues of Canadian Family Physician. The first in the series, Wood lamp examination, appears in this issue (page 976).⁵

Various authors have suggested that the only remedy to the present decline in traditional physical examination is a renewed emphasis in medical education.⁶ This teaching tool takes the same format as the previously published Top Ten Differential Diagnoses in Family Medicine booklet⁷ and is the second in an emerging series highlighting this need to reemphasize basic bedside care.

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