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.
—William Osler, Aequanimitas
Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become an expert.
—William Osler, in “Osler the Teacher.” Johns Hopkins Bulletin. 1919;198.
The book Leonardo’s Brain, by neurosurgeon Dr. Leonard Shlain,(1) focused on the observation skills of the great artist, inventor, cartographer, anatomist, botanist, and physicist (just to name a few of his areas of interest and expertise). Leonardo’s keen observation skills were attributed to a “super-fast eye” that allowed him to visualize momentary changes such as the flutter of dragonfly wings.
Leonardo, a polymath who lived from 1452 to 1519, showed in his drawings that a dragonfly has two sets of wings. He noted that when a dragonfly’s front wings are raised, the hind wings are lowered — a motion that happens very rapidly. Leonardo’s eye was so keen he managed to spot this incredible and momentary change in motion of the dragonfly’s wings. He documented in his drawings that the anterior and posterior wings of dragonflies move asynchronously, a discovery that was finally verified four centuries later using high-speed, slow-motion photography.
Leonardo wrote in his notebook, “The dragonfly flies with four wings, and when those in front are raised those behind are lowered.” Research several centuries later showed that a dragonfly’s back wings are out of sync with the front wings by about 1/100th of a second. The comment in his notebooks suggests that Leonardo could see that 1/100th of a second difference, which corresponds to a “flicker fusion frequency” of 100 hertz, or 100 times a second — roughly twice the flicker fusion frequency of the average human eye. This unique eye–brain physiology of Leonardo and some modern sports stars may have a genetic basis, perhaps in the genes that control the development of the potassium channels in the cells of the retina.
So, what is the implication for physicians and their observation skills?
During typical medical training, medical students receive very little instruction on the importance of observation of the patient. Medical students rarely are observed by their teachers. Less than half of medical students recall ever being observed conducting a clinical encounter.(2)
Even when faculty and students share a clinical session, less than 5% of the total amount of time involves direct observation of resident performance.(2)
Whatever observation does take place is more likely to be focused on arriving at the diagnosis, ordering imaging studies, sending a prescription electronically to the pharmacist, and performing procedural skills rather than close observation of the patient — the clinical encounters that form the heart and soul of family medicine.
Observation skills are crucial for physicians. A physician should be able to pick up clues by being a keen observer and consequently prevent a symptom from getting worse. Good observation skills can help a physician offer better care to his or her patients.
Sir Joseph Bell, a professor of surgery at Edinburgh Medical School, when teaching observational skills to medical students had a keen sense of humor and a unique teaching method for eliciting careful observation.(3) He said to his medical students, “You must observe everything, gentlemen (and ladies). Use your eyes; use your fingers; use all your faculties before coming to a decision about anything.” He held up a tube containing fluid of a nauseating nature, probably urine.
“Now, gentlemen, apply your powers of observation to this sample. Before attempting to carry out any lab tests or procedures, do as I do. Look at it — observe its color, see whether it is opalescent or clear. Smell it: has it any odor that you can recognize? Taste it.” He put his finger into the glass and raised his hand to his mouth and licking his finger, making a grimace. The sample was then handed around the class, and each student in turn looked at it, smelled it, put his finger in it, tasted it, and grimaced. When they had all finished Bell then addressed the students again: “That, gentlemen, indicates the complete lack of observation in the members of this class. Not one of you observed that when you thought you saw me place my forefinger in the glass, it was my middle finger that I put in my mouth.” I think it was a lesson that they never forgot and would certainly never be used today in medical school!
Observational skills can be divided into two categories: objective and subjective. Objective observation usually is factual: that is, what a doctor can see and measure. Such observations include monitoring vital signs, including pulse rate, body temperature, blood pressure, and respiration, and taking note of anything that is abnormal. Subjective observations are those you cannot measure but that often are communicated by the patient, such as verbalization of conditions or complaints of symptoms such as headache, nausea, and abdominal pain.
Developing Observation Skills
A doctor should be able to differentiate between what is normal and what is abnormal. That requires having the knowledge of what to look for.
Always watch for changes in a patient’s mood, physical movement, skin color, and so forth. These observations are especially important when the patient is unable to verbalize their problems, whether as the result of the patient’s medical condition or state of mind, or possibly a language barrier. Proper observation and documentation allow physicians to understand the progress or deterioration in a patient’s condition.
Recording your observations in the patient record, as well as communicating your thoughts to nurses or to colleagues participating in the patient’s care, are essential for them to understand your evaluation and your opinion on how to proceed with treatment.
Observation and inspection are fundamental to physical examination and begin with the first point of contact with a patient. Although the terms observation and inspection often are used interchangeably, they are not the same. Observation is a general term that refers to the careful use of one’s senses to gain information. Inspection is an act limited to what one can observe visually, and, when referring to physical examination, typically refers to findings on the surface of the body, rather than to behaviors. Skilled clinicians use all their senses to assist with gaining an understanding of their patients, relying primarily on vision, touch (percussion and palpation), and hearing (percussion and auscultation). Smell also can provide important diagnostic information during the patient encounter (e.g., personal hygiene, substance use, or metabolic diseases). Fortunately, the sense of taste is largely a historical relic in medicine, although it is interesting to note that diabetes mellitus was diagnosed for many centuries by the sweet taste of the urine. Through experience, clinicians develop an important sixth sense — the gut instinct — that can only be gained through deliberate practice of clinical skills on thousands of patients over many years. The clinician’s gut instinct, which is based largely on bedside observations, has been shown to be a strong predictor of the diagnosis of the patient.
The power of observation is underestimated. True observation employs multiple senses. It is an active process of recognizing, probing, and feeling. It goes beyond merely seeing or hearing. It is arguably an art form and a skill that takes time to develop.
The importance of observation has been emphasized by great medical teachers over the centuries. Hippocrates, known as the father of medicine, was renowned for the emphasis he placed on clinical inspection and observation.
The doctor–patient encounter is always introduced with the need to first observe the patient. Next comes active attention. In fact, recognizing the importance of observation in clinical training, one team in the United States went the extra mile.(4) To improve medical students’ observation skills, researchers at the University of Pennsylvania looked to the visual arts to assess whether an education in art observation and interpretation could be applied to medical training. They named it the “Artful Thinking” approach. Instruction included sessions in front of works of art, group discussions, and training in visual arts vocabulary. It was designed to encourage creative questioning, reasoning, and perspective taking. The course was successful in improving the observational skills of the students. The art training developed their ability to see the whole clinical picture and helped them to become more emotionally attuned to their patients. Furthermore, these students were better able to navigate visually complex clinical situations.
Observation plays a crucial role in medicine, and also in life beyond medicine. It is easy to be caught up in our own thoughts, but mindful observation is a powerful tool and can offer an insightful lens onto a hidden world. It can’t be learned with our faces glued to the computer screen instead of focusing on the patient and being an attentive observer.
The general appearance of a patient may provide diagnostic clues to the illness, severity of disease, and the patient’s values, social status, and personality. The astute physician will begin to gather this information immediately upon meeting the patient.
The following are examples of observations that should be systematically evaluated:
Facies and expression.
Gait.
Clothing. Are clothes appropriate for the time of year? What does jewelry or makeup say about the patient? Is a particular scarf, hat, or patch covering an area of deformity or disease?
Stature. Observe the patient’s body build. Very short stature will be seen in dwarfism, pseudohypoparathyroidism, Turner syndrome, or prepubertal steroid therapy. Tall and lanky individuals with long, thin extremities suggest the possibility of Marfan or Klinefelter syndrome
Posture. The normal state of resting tone in muscle groups results in healthy, upright posture, with tone greatest in antigravity muscles. Alteration in this tone may result in the characteristic postures of Parkinson disease, stroke, or cerebellar abnormalities.
Odor of breath and body. Breath odor may suggest poor hygiene or anaerobic infection. The breath may have the fruity odor of diabetic ketoacidosis.
Let me elaborate on just one component of observational skills, the handshake. (I know this may be controversial in this post-pandemic era, but doctors can still safely shake hands with a patient and then wash their hands after the physical examination.)
The hands say a lot about a patient. In most cultures, strong hands are associated with hard work, confidence, and vigor. A firm grip can tell the physician some things about a patient’s health. Obviously, the strength of the patient’s grip says a lot about the health of the musculoskeletal system. If the grip is weak, it could be an indicator of conditions, diseases, or serious problems. As patients age, their grip strength naturally decreases to some extent, but if it is deteriorating rapidly, it could be an early warning sign of osteoarthritis or rheumatoid arthritis. Hand weakness in young people can indicate orthopedic problems such as tendonitis, or repetitive motion injuries, also called repetitive stress injuries, or even neuropathy.
A study published in The Lancet in 2015 revealed an even more alarming cause of weak grip strength.(5) This study found a link between weakness in the hands and increased risk of heart attack and stroke. The findings show that every 5-kg decline in grip strength was associated with a 16% increased risk of death from any cause; a 17% greater risk of cardiovascular death; a 17% higher risk of non-cardiovascular mortality; and more modest increases in the risk of having a heart attack (7%) or a stroke (9%).
The authors believe this link may not be direct cause and effect, but that grip strength is a good indicator of overall health in the cardiovascular system and is associated with people who get regular exercise. A low grip strength was linked with higher death rates in people who develop cardiovascular (e.g., heart attack or stroke) and noncardiovascular (e.g., cancer) diseases, suggesting that muscle strength can predict the risk of death in people who develop a major illness. This is just one example of the importance of being a keen observer of the patient.
My personal observation from over 40 years in practice is that if a man demonstrated a weak handshake, it was an indication that a thorough cardiovascular workup was indicated before considering an elective surgical procedure. I also observed that if a patient had difficulty moving from the sitting position to the standing position, this was an indication of frailty and again was a strong indicator for caution regarding elective surgery.
Information gleaned from the patient’s appearance is particularly valuable, because it is usually the first bit of objective data. Examining the general appearance of the patient may be likened to surveying the forest before walking among the trees. Writings of 50 or more years ago contain the very best descriptions relating patient appearance to disease. The sensitivity and specificity of patient appearance have withstood the test of time. Excellent clinicians continue to use this technique with great success.
Bottom Line: The next time you are in the backyard or in the forest, look for a dragonfly and see if you can see the asynchronicity of its two sets of wings, or is it a blur like it is for my eyes? If you can see the alternating beatings of the wings, you might just be another Leonardo.
References
Shlain L. Leonardo’s Brain: Understanding Da Vinci’s Creative Genius. New York: Lyons Press; 2014.
Rattner SL, Louis DZ, Rabinowitz C, et al. Documenting and comparing medical students’ clinical experiences. JAMA. 2001;286(9):1035-1040. doi:10.1001/jama.286.9.1035.
Holmboe ES, Hawkins RE, Huot SJ. Effects of training in direct observation of medical residents’ clinical competence: a randomized trial. Ann Intern Med. 2004;140(11):874-881. doi:10.7326/0003-4819-140-11-200406010-00008.
Aminoff MJ. Sir Charles Bell: His Life, Art, Neurological Concepts, and Controversial Legacy. Oxford University Press; 2017.
Kogan JR, Hatala R, Hauer KE, Holmboe E. Guidelines: The do’s, don’ts and don’t knows of direct observation of clinical skills in medical education. Perspect Med Educ. 2017;6(5):286-305. doi:10.1007/s40037-017-0376-7.