Are herbalists using clinical examination in practice? Dr Nic Rowley shares why they should and how to nurture confidence in students to encourage clinical skill use with patients.
Do herbalists routinely perform clinical examination?
Despite the many hours that students of herbal medicine spend studying clinical examination, it is only a small proportion of practising herbalists that regularly use the examination routines they learnt during their training.
There are many possible reasons for this, but the commonest seem to be:
- A preference for other diagnostic approaches learned before (and sometimes after) herbal medicine training
- A lack of confidence in the ability to perform ‘full’ clinical examination and interpret findings accurately
- A lack of time (and sometimes space) during consultations
- A lack of opportunity, time and resources to refresh and update clinical examination skills on a regular basis
- A sense that the examination routines learnt during training are not relevant to the majority of patients seen
Do GPs routinely perform clinical examinations?
These days, GPs do not have time to perform the intricate examination routines they learned at medical school, and so they have had to adopt an approach that focuses on those parts of clinical examination that are most likely to help with clinical decision making. GPs thus acknowledge that some parts of the clinical examination process are more important than others, and they concentrate on those parts when a case history suggests the need for some extra clinical information.
But GPs have had the opportunity to practice ‘classical’ examination routines on many hundreds of patients during their years as medical students. In that time they observed countless skilled physicians and surgeons examining patients, and received frequent and focused feedback on the development of their own clinical examination skills.
So, it is not surprising that many herbal medicine students, with only limited hours of clinical training available to them (and often in settings where trainers themselves rarely perform clinical examination), come to regard this part of their training course as something to be endured for the sake of passing the final clinical examination.
As a result, they enter practice with many unanswered questions concerning the techniques they were taught, and face insecurity about their knowledge of physical examination. This is clearly not good for herbal medicine practitioners, patients, or the profession as a whole.
Is the standard orthodox model of clinical examination appropriate for medical herbalists?
After many years of teaching clinical examination skills based on the orthodox medical model, I have come to the conclusion that we need the courage to reimagine this aspect of a herbalist’s clinical training, and focus on simpler and more achievable objectives that promote safe and effective clinical decision making.
In making this change, it is not helpful to compare ourselves with medical doctors. Not only has conventional medical training altered significantly over the past 50 years, the approach to clinical assessment has changed also due to the widespread availability (in many Western countries at least) of different types of scan — and hundreds of biomedical tests — which have become mainstays of medical diagnosis. The emergence of AI as a tool for the analysis of clinical data collected by technology seems likely to widen the gap between the modern medical doctor and the herbal medicine practitioner still further.
Devising a new approach to clinical examination for medical herbalists.
So, in reframing our approach to clinical examination, we need to define our shared objectives in order to ensure that students of herbal medicine are given appropriate and achievable training goals.
Key objectives
- To offer affordable post-qualification mentoring, support and further learning opportunities for those who wish to develop their clinical skills further.
- To develop empathetic, effective and safe practitioners of herbal medicine
- To help students develop their history taking and observation skills to a high level
- To help students acquire a concise but effective repertoire of clinical assessment techniques that they will use routinely to inform their diagnostic reasoning, management plans and referral decisions
- To enable students to develop a rounded, holistic understanding of clinical examination that integrates and values knowledge of herbal traditions as well as contemporary medical science
- To provide concise, clear learning materials to support the development of clinical skills
What could a reimagined course in clinical examination for medical herbalists look like?
Once students have demonstrated ease, confidence, kindness and attentiveness in case history taking, they would engage in a period of personal research in which they would work out every clinical sign — and each sign’s potential clinical significance — from detailed observation of the following:
- The head (including hair, eyes, ears, nose and mouth, but without the use of specialist instruments)
- The neck
- The hands
- The chest and back
- The feet and calves
They would then present their findings in group sessions, and work in pairs to devise their own way of systematising observation of each area of interest, saying out loud exactly what they were looking for, and getting help and prompts from their study partner.
After several sessions, once every member of the group has become confident that they can examine by observation each of the areas listed without hesitation, they would move on to a series of workshops in which they would observe, and then practice:
- The taking of blood pressure
- The taking of pulses
- The use of the stethoscope for listening to the chest, the heart and the abdomen.
- Simple systematic palpation of the neck and the abdomen
- The eliciting of tendon reflexes, and the initial assessment of gross neurological signs associated with common disease processes.
A helpful note
In the use of the stethoscope workshops, students would not be taught the intricate routines that further elucidate the cause of the things heard on auscultation.
- For the heart, aided by audio recordings and partner work, they would learn to recognise the presence of ‘normal’ heart sounds, added heart sounds, rhythm disturbances and murmurs.
- For the chest, again aided by audio recordings and partner work, they would learn to identify sounds characteristic of certain lung conditions.
- For the abdomen, again aided by audio recordings and partner work, they would learn to identify normal bowel sounds, and bowel sounds that may have pathological significance.
The course would end with a series of workshops in which links between various clinical observations and simple examination techniques (stethoscope, pulse, BP, abdominal palpation, simple neurological tests) are made in the context of a variety of case histories.
These discussions would continue as the student progressed from supervised case taking in clinic to responsibility for complete consultations.
The importance of continuing professional development
Crucial to the effectiveness of this scheme would be the offering of regular CPD in clinical skills — organised as a central resource for all students and practitioners of herbal medicine — during which experiences are shared, questions asked, and additional clinical skills added to each practitioner’s repertoire.
Some personal reflections
When I was a medical student, a wise and compassionate teacher once said three things to me that profoundly changed my approach to clinical examination.
The first was, “just remember, if you don’t know what is going on with a patient before they get on the examination couch, you are very unlikely to know what is wrong with them by the time they get off the examination couch…”
The second was, “remember that common things are common…”
And the third was, “the range of ‘normal’ is very wide indeed. If you examine enough people who are generally well, you will inevitably notice the signs when something is amiss. Of course, some physical signs are subtle, but most are like barn doors swinging in the wind if you observe your patients carefully…”
Previously, I had felt that there were so many techniques to learn that I would never get the hang of clinical examination. But the more I thought about what my teacher said, the more I realised that nothing is more important than the story the patient tells us; clinical examination is not about getting answers, it’s about adding information that may help explain aspects of the patient’s history — the key skill required for effective clinical examination is good observation.
This in turn led to an understanding that the key point of clinical examination is actually to notice things that fall outside the (very wide) range of ‘normal’.
My first attempts at clinical assessment of patients consisted mostly of desperate attempts to remember medical eponyms, and wondering what to do next in examination routines that seemed impossible to perform in the time available. Inevitably, my worry that I might miss something or do something wrong ensured that I often missed things and got things wrong, especially when someone was watching me.
But then the same wise physician took me aside and pointed out that my performance anxiety meant that I was hardly in human contact with my patients at all, and that I was so ‘in my head’ that I was almost entirely unlikely to actually observe anything of significance.
I also believed that I should be interpreting my clinical findings on the hoof, in order to be able to move on to even more complex clinical examination techniques. My teacher gently pointed out that, in fact, all I needed to do when examining was pay full attention to the patient, and observe as deeply as I could; and that there would be plenty of time after the clinical examination to gather my thoughts about the significance of what I had observed during the examination.
