Powers of observation

And the curious case of the Lowcock leg..

How conduct and values have changed! I was a young doctor and the consultant asked me to teach first-year medical students. The topic was, “How to examine the chest?” and the date – probably the early 1970s. The memory of the event is excruciating. The patient I chose for the demonstration was a middle-aged woman with lung disease. The curtains were drawn round her and four students looked on. I asked the patient to strip down to her underpants and lie on the bed. There she lay exposed for twenty minutes or so as I explained to the students first her background and then how important it was to see her (or any other patient) fully. ‘Inspection’, as it is called, is a crucial part of the diagnostic procedure and not having sight of the entire part would be a derogation of duty. After all, the patient might have had a tiny mole somewhere on her skin that had turned cancerous and to miss it by not doing a full examination would have been negligent.

After a while the patient asked if she could cover herself with her dressing gown and I said I preferred not. Then, one by one, over a further 30 minutes, the students looked her over and examined her torso back and front, with me showing them in turn exactly how. In those days we had no concern for a patient’s rights or sensitivities.

Within fifteen years or so, all had changed. Exposure in this way would have been unthinkable and leaving someone cold, exposed, and anxious as I did, especially in front of gawking students, would be seen as a disciplinary offence. Yes, the responsible doctor would still be expected to be thorough and if the thoroughness caused offence, a solution would have had to be found.

Sometimes observation was hampered by intent. For whatever reason the patient did not want you to see the clues. The anaemic person who hid her pallor by using make-up, or her fingernail changes by nail varnish, was well recognised. But these could easily be resolved by checking next time after the masking has been removed. It is not so simple when a parent or guardian wants to keep things secret and the tragic effects of the clinician failing to examine abused children are well documented.

A recent, and somewhat comic, illustration of the importance of careful examination comes not from the world of medicine but from that of crime. The courts had imposed on a Christopher Lowcock a curfew for driving and drug offences as well as for being in possession of an offensive weapon. To this end he was ordered to be electronically tagged, with the anklet to be applied at his home.

The first officer arrived and applied the tag around Lowcock’s heavily bandaged ankle. The limb was not carefully inspected, possibly out of respect or out of laziness or maybe for fear of revealing something unsightly. Had the appropriate examination been carried out, the said limb would have been found to be false – the officer had tagged a very convincing prosthetic limb. Accordingly, by taking off the tagged leg and leaving it at home, Mr Lowcock could go out whenever he pleased. Some time later, and in accordance with protocol, a second officer came to check the tag. He too failed to check the authenticity of the bandaged leg so left things as they were. Mr Lowcock’s libertine lifestyle continued unencumbered, until he was arrested on a new charge of driving while banned and without insurance.

Turning back to medicine, while my behaviour in the 70s as a doctor and teacher was unforgiveable, I expect that things have now gone the other way with many a diagnosis delayed or missed by dint of requests for privacy. But the barriers raised by excessive prudery won’t be new. How much would have been missed in the Victorian era when women, rather than being examined in any detail, would discuss their signs and symptoms by reference to a doll?