The value of observant observation.

When I was a medical student I was always amused when a professor began a story by saying "When I was a medical student...." Usually it was a clinical pearl that he or she had learned at the bedside under the tutelage of some great, memorable professor. Many times it was a reference to an era in which they didn't (couldn't) rely on MRIs, immunoassays or tandem mass spectrometry. "When I was a medical student, we didn't have quick access to thyroid hormone levels, so we would come back to the ward at about six p.m., take the patient's pulse, walk outside on the wrap-around porch and count the number of times the cricket "cricked" in a minute, divided them by two, and had a rough idea of the TSH. Of course it would only work in Burma."

So, to my amazement, I recently found myself starting a tutorial to students by saying, "When I was a medical student ..." I guess it's one of the milestones of a physician's career, when what was learned as a medical student, viewed against the backdrop of the current reliance on technology, are "pearls" that are simply lost in the vortex of printouts. The subject was observing and observation--they are not necessarily one and the same--and their value in clinical decision making, not to mention their value in human interaction.

"When I was a medical student," I began (wondering if I had to pay a royalty to the professors I learned it from at the North Middlesex Hospital in London where I trained), I had a professor who always emphasized the significance of observation. He liked to quote the aphorism of Dr. Thomas McCrae, "More is missed by not looking than by not knowing." So one day I was on rounds with this professor as we entered the room of a patient we had been following for about five days for a bleeding ulcer. My hands clenched the fresh reports, notes, lab results and other data I obtained by scurrying around the hospital before ward rounds to provide the professor with the updated clinical picture.

The patient was sound asleep when we entered his room and the professor stood silently at the foot of the bed. After a few minutes the professor turned to me and said "I think he's improving, what do you think?" I was clueless, and started to thumb through the reports to find evidence of "he's improving," because the sleeping patient certainly didn't offer any insight. "You're looking and not observing, Yank" he barked at me as the patient stirred. The professor turned to the patient and said softly, "Sorry to disturb you, Mr. Solomon, we were just remarking about your improved condition. How do you feel today?" Still groggy, the patient said that he was feeling better and that he had finally "paid a penny" the night before (an archaic English expression meaning that he moved his bowels). I found some lab data that indicated that indeed, his condition was improving. The professor turned to me and said, "Forget the labs. Tell me what clues there are to think the bloke's improving." I looked around and there was nothing outstanding that crossed my radar screen, nothing that announced that we should start thinking about discharging him. Actually, I wasn't even sure what I should be looking for; my training so far had emphasized collecting and interpreting clinical data like blood screens, scans that contrasted areas of tissues, fluids and air pockets and levels of every imaginable thing that could be leveled. "Concern yourself with the man, lad, not the reports. Observe what's going on or maybe what's not going on here. Think about who's here and what he's all about." I looked back at the professor with a blank look that I hadn't felt my face form since I was asked three weeks before by my neurology professor to describe the spinothalamic tract. It was enough of a time lapse that my face had almost forgotten how it felt. The face isn't the only thing that feels blank when you come up empty on ward rounds.

The professor turned to me and offered me the equivalent of "are there any final words you would like to say before we carry out the dictates of the tribunal?" Blank again, but with a left eye twitching to demonstrate that my face could do other things.

"I knew our patient was doing better since the last time we saw him yesterday morning because of what's going on here. Look at the table next to the bed. See the book on the table? The bookmark is at least two inches further down the book. Sick people don't read. He's doing better." The labs confirmed the advancing bookmark.

The professor was quick to point out that clinical decision-making should not be based solely on what you see, but your observations shouldn't be ignored, either. Surely medical advancements have propelled us beyond the significance of a patient's handshake, smell, fidgeting, uncombed hair or ketchup-stained tie.... haven't they?

Perhaps no other discipline demands observation--intense, dedicated, purposeful observation--more than developmental disabilities. Clinicians, teachers, therapists, direct support professionals and parents need to look and look hard at people with special healthcare needs. They need to look with all they can see. As Professor Richard Schatzki (Clinical Aphorisms from the Harvard Medical School, 1957) hammered home to his students, "The eyes must finish their work before the gray cells take over."

As we've been stressing here at EP for more than 30 years, parents are our most keen observers. They need to be encouraged to share their observations with the rest of the healthcare and habilitation team. Only when we provide parents with a safe, encouraging milieu in which to share their observations, and we demonstrate our confidence and respect for these observations by following up on them, can we reap the benefits of "parents' eyes." Parents have trained themselves to look and think not only out of the box, but out of the clinic, out of the texts and, most important, out of the predictions. Clinicians and professionals should follow parents' lead and start looking for the bookmarks.

Rick Rader, MD
Editor-in-Chief
Director, Morton J. Kent Habilitation Center
Orange Grove Center, Chattanooga, TN