Clinical skills still provoke debateBMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7005.627 (Published 02 September 1995) Cite this as: BMJ 1995;311:627
Clinical skills are complemented by technology
EDITOR,--J Goodwin's editorial on the importance of clinical skills fails to offer any worthwhile evidence for the hypotheses proposed.1 The author opines that only the “clinically inexperienced” depend on the Swan-Ganz catheter for measuring intracardiac pressures in critically ill patients, yet the author offers no evidence to support this “good example” of undue reliance on technology and ignores objective studies that show that clinical assessment of the haemodynamic status of critically ill patients is extremely unreliable.2
Having insulted those of us who use pulmonary artery catheterisation, Goodwin then accuses those of us who teach of allowing our clinical skills to wane by citing a “recent” (1988) story in a Sunday newspaper (fictitious) and two articles from a single issue of Annals of Internal Medicine in 1992 (both wrongly referenced),3 4 which are of no relevance to medical training in Britain and do not show that doctors are less skilful now than they were in Goodwin's imaginary good old days. When Goodwin refers disparagingly to the use of computers in diagnosis I presume that this is an allusion to the development of artificial intelligence and expert systems. Those who develop such systems have done much research into the logical processes of expert clinicians and attempt to emulate them. This work serves to preserve and enhance rather than destroy the best clinical skills.5 Goodwin's final unsubstantiated insult is to imply that those of us who use technology fail to talk to our patients.
I agree that basic clinical skills must be preserved and taught, but if colleges are to draw up guidelines on clinical skills these must be based on balanced evidence of their practical utility and not on technophobic prejudices. Uncritical reliance on values obtained by machines can be dangerous, but uncritical reliance on clinical skills is no safer.