A few weeks ago I visited my favorite otolaryngologist. He's my favorite because he doesn't cut first and ask questions later. He is also very good at explaining things to parents. Bob is about my age and had already been in practice for a couple of years when I arrived in town in 1974.
My appointment was the first and last attempt to find a treatable cause for my dwindling hearing. I have long suspected that it is simply the result of years of auditory abuse, and reading the studies documenting that most pediatricians are exposed to noise levels deemed unsafe by the standards of the Occupational Safety and Health Administration only added to my suspicions. Although I feared that my difficulty catching every word in group conversations was the inevitable audiologic equivalent of presbyopia, I was in denial. I hoped that Bob could cure the problem by removing 35 years' worth of stethoscope-compacted cerumen.
After checking in with the receptionist, I spent a few minutes in his bare-bones waiting room catching up on Hollywood gossip and chatting with one of my teenage patients, who had just recovered from a bout of sinusitis-induced septicemia. When it was my turn, Bob ushered me into his small examining room and sat me down in what could have been an old barber chair. Since neither of us is a frequent attendee at hospital staff meetings, we had lots of catching up to do. The conversation ranged from children's weddings to our painful attempts at reacquiring tennis skills that had been allowed to atrophy over the last 2 decades.
After what seemed like less than 5 minutes of banter, he paused and said, “Well, the good news is that you don't have any wax in your ears. The bad news is that I bet you'll be wanting a hearing aid in a couple of years.” He then spent 10 minutes explaining the physiologic process that was eroding my hearing and what I could do to remedy the situation. We parted with an agreement to get together for some doubles in a couple of weeks.
As I climbed back into my truck for the trip home, I wondered how Bob could sound so confident about the cause of my deafness without even looking in my ears. The examination portion of the visit had flown by so quickly that I didn't remember him using an otoscope.
As I turned onto the highway, I attempted to reconstruct our encounter. He had moved so smoothly and efficiently through the exam that my focus had been on our conversation and not his invasion into every orifice in my head. I began to recall that he had not only looked in my ears, but he had also removed a small bit of cerumen and insufflated my tympanic membranes. He had looked past my turbinates, sterilized a mirror with an alcohol lamp, and taken a peek at my vocal cords. His fingers had nimbly danced over my thyroid and all the nodes above my clavicles.
As I thought about it, I realized that Bob had done an extremely thorough head and neck exam. Because of his efficiency, which came from more than 30 years of experience and the familiar surroundings of an office where every instrument was exactly where it was supposed to be, the process had taken no more than 4 or 5 minutes. Thirty years of trial and error guided his hands to find my tympanic membranes on the first pass and locate my vocal cords without triggering my gag reflex.
In the hands of an experienced clinician, a good, focused physical exam doesn't take much time. The true test of our clinical ability is not the speed at which we have learned to perform a thorough examination but what we do with the time we have saved. Do we reinvest it in the patient we have just examined by conveying to them what we have discovered in a manner that says we care? Or do we use the time we have gained through our efficiency to rush on to the next patient? Fortunately for me, Bob has chosen to do the former, and that's another reason he's my favorite.