The Limits of Physical Diagnosis

Just a few days ago, I took the streetcar across downtown Toronto, something I don't have the opportunity to do very often. I spend plenty of time on the subway and our commuter train network, but the streetcar isn't part of the route I normally take. Streetcars are used by people to go short distances, usually, and this one was heading through one of the inner city neighbourhoods next to downtown. It was crowded, and as I worked my way back from the front door, past a lot of people with packages and shopping carts, I looked up and saw a hand grasping the pole in front of me. Not unusual in itself, but what caught my eye was the perfect example of clubbing that the hand displayed.



Clubbing is a physical sign that we in Internal Medicine look for, and talk about, a lot but don't see very often. It is a change in the fingernails, and sometimes toenails, that occurs in people with a number of different illnesses, but we most frequently associate it with lung cancer. It remains a curiosity, one of those things that provides an enigmatic glimpse into a person's health, because although we don't really understand why it happens, when we see it, we know with few exceptions that it represents a potentially dangerous problem.

We go to great lengths to teach our trainees about how to determine whether the person in front of them really has clubbing, instead of an unusual shape of their nails. A whole system to diagnose the clubbing itself has arisen, and I have spent countless hours at the bedside of patients, many of whom did not actually have clubbing, explaining to students and residents how to make the distinction.




So this hand in front of me, were I in a teaching hospital, might have served as a great opportunity to teach, and pass on the wisdom of the profession, about physical diagnosis, the art of looking for seemingly small changes as portents of big problems. I might have even asked its owner's permission to give his name to my colleagues, so that they could also bring their students to see the hand, palpate its nail beds for sponginess, look for periungual suffusion, and check for the "diamond sign". As I said, we don't see "classic" (some might say, without mentioning the irony, "beautiful") examples of clubbing that often. So this hand would have been a great opportunity.

But I was on the Dundas streetcar, heading through downtown. No crowd of students around. No one looking at the hand apart from me. Even its owner, who was not my patient, seemed to pay it no mind. As I gazed at it (it was about 10 inches from my face), I noticed that the nails were blackened and chipped, and the rough creases of the hand were dirty. Nicotine stained the thumb and first two fingers, and small, burn-shaped scars were visible on the back. The arm was enclosed in a torn, dirty and old wool sweater, which gave off the unmistakable odour of many days' sweat. The man whose hand attracted me was possibly in his fifties, with long dishevelled grey and black hair, which was very dirty and almost covered his face. His cheeks had a good deal of stubble on them, along with a big purple bruise on his right cheekbone, accompanying a black eye. His other hand held about 5 filthy plastic bags, one of which was filled with empty beer bottles, possibly on their way back to the beer store for return of deposit. The other bags had clothes in them, equally dirty to what he was wearing. This man was ignoring me, but muttering under his breath, apparently to someone who wasn't visible to the rest of us. He shook his head a couple of times and cursed in a louder voice. People started to give him more space, and as the next stop approached, he shuffled toward the rear door and stepped out when we got there.

We pulled away and I kept thinking about his hand. If he had been in the safe and clean setting of my teaching hospital ward or clinic, I could have sat with him, talked about the clubbing and the need to investigate urgently, planned out tests and consultations. I could have spoken to him about addictions and social services, and linked him to a mental health professional. With universal health care and a social safety net, everyone should be able to get the care they need, especially when the stakes are high, with a potentially life threatening illness. And perhaps all that had already happened for this man, and I just happened to see him when he was moving from place to place, taking care of his daily business. But this encounter made me think long and hard about the limits of the physical diagnosis that I like to teach, when barriers exist to care, like mental health problems and addictions, poverty, and violence and lack of access to services. What good could it possibly do to recognize classic clubbing, when there is no possibility to intervene, and when so many other issues crowd the landscape and interfere with the "right approach" to the problem? And as an educator, how do I incorporate these issues into my teaching?

The next time I teach about clubbing, I'm going to have to go beyond the simple steps of ascertaining the diagnosis, and branch into less comfortable territory. What do you do when you meet someone outside of a medical encounter, where you know that they have a physical finding that portends something ominous? How do you prioritize problems like lung cancer, violence and mental health? How do you promote access to subspecialty care amongst marginalized people? These are the ways I have thought of that can help go beyond the limitations of physical diagnosis. But I'll take any suggestions you have.