Medical heresy: ditch the eponyms
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2503 (Published 04 April 2012) Cite this as: BMJ 2012;344:e2503
All rapid responses
There are lots of reasons why Des Spence is wrong. The most crashingly obvious to a gastroenterologist is Crohn's disease. What a useful eponym! I confidently predict that it will long outlast the other pseudo-scientific names for that disorder. Our understanding of aetiology changes every decade, but eponyms last for ever!
Regarding eponymous clinical signs, his point that the hop test (which I will now call the Spence test until he divulges the name of his mentor) is useful does not detract from the value of bedside examination. It adds to it. And while I agree that ultrasound should be more widely used, it should be complementary to clinical examination rather than replacing it. Badly done ultrasound would not be an advance over uncritical bedside examination. We will always need doctors who have sharp clinical acumen, and this starts with good clinical examination. If it lacks an evidence base, let's get the evidence and learn to discriminate between useful (like gynaecomastia or metabolic flap) and non-contributory clinical signs like leuconychia.
Competing interests: No competing interests
I am curious with Dr Spence's article in which he pointed out that many signs lack scientific validation and thus these tests or signs should be thrown out like the bath water.
Some points I would also make in response:
1. It is rarely one sign that makes or breaks a clinical diagnosis, it is usually a constellation of positives and negatives that make the art of medicine so subtle at times.
2. It is cumbersome to call Rovsing’s sign as that test if-you-press-the-left-iliac-fossa-you-get-pain-in-the-right-iliac-fossa (or IYPTLIFYGPITRIF), thus there is always some sort of simplification involved. History is important to us all, otherwise we will have to call that-great-bell-of-the-clock-tower-at-the-north-end-of-the-Westminister-Palace-in-that-capital-of-United-Kingdom-and-her-territories something else.
3. What is the hop test? Which leg does one hop on? Does it matter at all if you jump on both legs? How long does the person hop for? Does the person hop in one spot or moving from one end to another? What if the person cannot hop due to physical disability? Does having pain in the abdomen when you hop count as positive? May I see your personal records of level 5 evidence or did your old GP mentor happened to have published a level 1 paper?
No clinical examination is perfect but we dont always have to rely on RCTs to work out everything.
Competing interests: No competing interests
EVIDENCE-BASED EXAMINATION MUST BE THE FUTURE
Des Spence portraits a rather outdated and stark view of modern medicine in his piece; “Medical heresy: ditch the eponyms”1. We agree that, in general, eponyms are redundant, but many have already been replaced; for example Rieter’s syndrome by reactive arthritis and Wegener’s granulomatosis by granulomatosis with polyangiitis. Some eponyms still have a role as shorthand for complex abnormality and therefore have a role in teaching e.g. Colles’ fracture or Fallot’s tetralogy?
Dr Spence’s colleague’s ‘Hop test’ may be of value in the diagnosis of acute appendicitis, but does not appear to have been subject to ‘Evidence-based’ investigation. In contrast, Rovsing’s sign (pressure over the descending colon in the left lower quadrant, causing pain in the right lower abdomen in acute appendicitis – old central European reference provided2) has at least been scrutinised with respect to validity.
Surely Dr Spence still believes that talking with patients and a focussed examination is the bedrock of clinical practice. Otherwise, uncontrolled over-investigation with blood tests, ultrasound, CT and MR will become reality3.
The forthcoming 13th edition of Macleod’s Clinical Examination (given an eponymous title in 1995 on the retiral of Dr John Macleod) will have referenced ‘Evidence-based Examination’ points to emphasis the value of certain examination techniques and, of course, many fewer eponyms.
Editors of Macleod’s Clinical Examination
Graham Douglas
Fiona Nicol
Colin Robertson
1. Des Spence. Medical heresy: ditch the eponyms. [From the Frontline] BMJ 2012; 344: e2503
2. N. T. Rovsing: Indirektes Hervorrufen des typischen Schmerzes an McBurney's Punkt. Ein Beitrag zur diagnostik der Appendicitis und
Typhlitis. Zentralblatt für Chirurgie, Leipzig, 1907, 34: 1257-1259.
3. McGee S. Evidence based Physical Diagnosis. 2nd edition. Saunders/Elsevier 2007 p577
Competing interests: Editors of Macleod's Clinical Examination
Of course clinical examination and history are fundamental to care. But the book is too long, too complicated and is not reflective on the predictive value of the examinations. I am sorry to harsh. We need a radical rationalization of what is taught.
In respect to Rvosing sign. I suspect in 1907 the presentation and the differential was very different from today. Please research the "hop test" , you could even call it the "Des Spence Sign” if you prefer ! It works guaranteed in early peritonism.
Thanks and look forward to the new edition.
Competing interests: No competing interests
I think Des is getting his issues mixed up. I agree with him that Rosving's sign is not very useful in practice....and the same can be said for many other eponymous clinical signs. But that doesn't mean that all eponyms should be thrown out. Learning a bit of medical history about Dupytren, Addison and Graves etc. can be very interesting and replacing many eponymous disease names with bland descriptive terms only will not provide the same enrichment!
Competing interests: Before I saw the light and joined the pharmaceutical industry, I was a GP and wrote about Medical Eponyms in the GP press
Re: Medical heresy: ditch the eponyms
As usual, Des Spence writes a heretical article that stimulates the rest of us to ponder what it is we do, and more importantly think.
The other rapid responders have righly highlighted the usefulness of eponyms, both for their scientific validity and for their ease of use. But, have we ever questioned all of the reasons why we use these eponyms - as Des says, it can often be a situation of demonstrating that I know more than you, implicitedly or explicitely. It serves as a barrier to patient involvement, to knowledge sharing, to standardisation of evidence and might even be construed as a knowledge barrier within the realms of trade protectionism.
Many of these signs, triads, disease nomenclatures were not entirely due to the intelligence of their originator; rather they are testement to the vagaries of good fortune and history. How many signs or disease patterns carry one person's name even when they were comprehensively described by another many years previously. Is it not even a little bit unethical to commemorate one person at the expense of another when we have ample historical record to correct the misnomer?
I congratulate Des in his ability to raise the contentious questions that pricks our sensibilites.
Competing interests: No competing interests