There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.
The good observer is not limited to the large hospital.
— Sir William Osler’s Aphorisms
Mrs. Stirrer makes an appointment with you because she’s concerned that her son, Daniel, is pale and weak lately. Looking out the window of your office, you notice, as she arrives, that Daniel is racing around with great energy! In the waiting room, he’s very active and certainly doesn’t appear weak. Your observations, while not definitive diagnostically, are a key part of your history and physical examination. I always teach my residents to watch their patients in the waiting room.
Observation in clinical medicine has a long and distinguished history. The English physician Thomas Sydenham was a famous observer. His 1686 observation of the chorea bearing his name is a classic description of chorea even today:
St Vitus dance is a sort of convulsion which attacks boys and girls from the tenth year till they have done growing. At first it shows itself by a halting, or rather an unsteady movement of one of the legs, which the patient drags. Then it is seen in the hand of the same side. The patient cannot keep it a moment in its place, whether he lay it upon his breast or any other part of his body. Do what he may, it will be jerked elsewhere convulsively.
— Sir Thomas Sydenham, Schedula monitoria de novae febris ingressia (1686)
Physicians should make more use of the ubiquitous digital camera/smartphone, with its capability to record short videos as well as pictures. Some recent examples in my practice have taught me how helpful this can be. The first was a 2-year-old girl who was having abnormal stools. From the parents’ descriptions, I wasn’t sure if it really was abnormal. I asked them to photograph it and bring in the pictures. These clearly showed malabsorptive-type stools, which led to further investigation and diagnosis of celiac disease.
Worth a 1000 words
Another recent case was the young mother who came to my office with her 2-month-old infant complaining that the child’s breathing was irregular at night. A short video clip taken with her digital camera cleared the issue immediately, as it showed normal periodic breathing of infants with no apnea. Another mother complained that her breastfeeding infant was developing blue lips; she documented this with a picture on her digital camera which indeed demonstrated the blue colouration. Further questioning revealed that she’d dabbed an aphthous ulcer in her mouth with methylene blue some 30 minutes before breastfeeding!
There’s also a role for digital cameras and smartphones in monitoring treatment progress in dermatologic conditions. And they can help in documenting questionable seizure activity.
As Osler said, excellent clinicians are physicians who have learned the importance of observation in the physical examination. Modern technology can extend our observations beyond the office and the clinic — it’s not used nearly enough.
Richard Haber, MD, FAAP, FRCPC is an associate professor of pediatrics at McGill University and the Director of the Pediatric Consultation Centre at the Montreal Children’s Hospital.