The art of medicine is in observation

Learn the art of observation.

“The whole art of medicine is in observation… but to educate the eye to see, the ear to hear and the finger to feel takes time, and to make a beginning, to start a man on the right path, is all that you can do.”
– Wiliam Osler

One of my favourite books as a medical student was Michael Zatouroff’s Physical Signs in General Medicine, a book brimming with weird and wonderful illustrations of humankind’s myriad afflictions. The book begins with an important lesson. The very first photograph is a spider web bejeweled with drops of dew, much like the photograph below.

What can you see?

You see a spider web. Each thread is lined by drops of dew. Look more closely at the drops of dew – now what can be seen?

Through the lens of each dew drop we can see a horizon with sky above and the earth below. This is an interesting observation because a convex lens – like each of these drops of dew – inverts images.

So now what can we see?

An upside down photograph of a spider web lined with drops of dew.

To see this we need to know that drops of dew have the properties of a convex lens and that a convex lens inverts an image. Indeed, we can only see what we know — what we have been taught to see.

Many great medical teachers through the ages have emphasized the paramount importance of the art of observation. Chief among these were Joseph Bell – the Edinburgh surgeon who inspired the creation of Sherlock Holmes – and, of course, the immortal William Osler. I’m sure you’ll agree that Joe Bell’s lesson on the art of observation is one that should never be forgotten.

“Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become expert.”
– William Osler

Yet learning the art of observation is difficult, and may seem an insurmountable task to the novice. Osler well knew the size of this challenge, and he encourages us from the past to persist. Only by observing countless patients over many years can we learn to truly see, and our mastery will grow until the day we each hang up our stethoscopes. Yet, no matter how feeble and immature our talents of observation are, exercising them can reap unimaginable rewards.

“Get the patient in a good light. Use your five senses. We miss more by not seeing than we do by not knowing. Always examine the back. Observe, record, tabulate, communicate.”
– William Osler

As a fledgling medical student I was sent to the emergency department to see a patient with pyelonephritis (a kidney infection) who had been referred to our team. The young woman was an immigrant from South Asia and the mother of two small children. Her presenting complaints were loin pain and fever, and her urine sample was full of white cells — a presentation entirely consistent with the diagnosis of pyelonephritis. Being an ignorant medical student fearful of missing something obvious, I asked her to expose her back so that I could see where she was tender.

I knew little of medicine but it struck me that a visibly discoloured area, markedly tender and boggy to the touch, was not typical of pyelonephritis. Disturbed by this unexpected discovery, I asked my registrar to come see the patient immediately. One glance from the experienced eyes of the registrar led to an urgent surgical consult and the opening of operating theatre doors. The patient lived, thanks to the removal of a couple of kilograms of dead latissimus dorsi. Although I knew little, and had barely even heard of necrotizing fasciitis, by listening to Osler, I was able to see.

“Medicine is learned by the bedside and not in the classroom. Let not your concepts of the manifestations of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But see first. No two eyes see the same thing. No two mirrors give forth the same reflection. Let your word be your slave and not your master.”
– William Osler

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