I am done with my training, but that does not mean that my reasoning is beyond reproach. I welcome your questions and debate.
Let me first be clear that in AbbyNormal's
particular example, I probably would have listened to her lungs. I am not really sure. I wasn't actually there. What I am refuting is her general statement that lack of basic assessment is a lack of assessment. To me, that is just a mindless, knee-jerk statement.
You can come up with infinite clinical examples where a basic physical exam is warranted. But since I am arguing that
NOT ALL clinical scenarios require a physical exam, then I simply need to provide one valid example to the contrary to prove my point.
If you go to the doctor with the complaint of a cut finger, do you find it necessary that he listens to your lungs, if you had no complaints about it? Would he be a quack if he didn't?
Both you and another poster put forth the argument that "you might catch something". Well to me, that is the problem with American medicine. We do all sorts of unwarranted fishing expeditions in the off chance that we might serendipitiously find a problem that the patient never complained about.
In AbbyNormal's scenario, would you have checked a BMP? Who knows, maybe her asthma is really COPD. Perhaps she is a CO2 retainer. Perhaps you should check a CBC. A high hematocrit might suggest chronic hypoxia, this illustrating more hidden pathology! Perhaps you could have her come into clinic weekly, for scheduled lung auscultations. She could develop an asthma exacerbation at any moment, and you would be remiss if you didn't catch it on auscultation before it deteriorated! You could go on forever with this hypothetical game. In fact, plenty of physicians do -- which is one reason why health care costs are astronomical today. The CYA approach to medicine is another major reason.
When I was an intern, I felt reassured by having daily CBCs, BMPs, and electrolytes come back normal every day in each of my patients. I worried when I didn't have them, even in patients where there was no reason to suspect a problem. Yes, I agree that chest auscultation is quick and easy, but that does not change the point.
In medicine, we are a taught a formal approach to diagnosis and treatment, but at some point we have to develop enough clinical judgement to know what is warranted and what is not. A physician needs to develop judgement that transcends rules and protocols and absolutisms. This takes time, but I am confident that at some point in the future you will appreciate my argument.
You appear to be ahead of me in the training process, so I'll preface this "with all due respect," but I disagree.
Whether you're a PCP or surgeon, the two things they always listen to at the very least are the heart and lungs - especially with a + hx involving one or the other. I understand you don't think it's necessary. In a patient w/ MVP or AR, you wouldn't listen to their heart everytime you see them? How about a patient with a hx of TIA - you wouldn't listen for a bruit? Maybe the patient forgot to tell you she's been having more episodes of SOB since spring began but she thought nothing of it or thought it was considered normal for a patient with asthma. How many times have you asked for a surgical hx and they say none, and then later discover they had a hysterectomy 20 years ago? Patients aren't the brightest. There's also a chance of picking up something you didn't find before. A new murmur, bruit, decreased breath sounds in a smoker, etc... If you do hear wheezing in a known asthmatic, it means we need to adjust her tx. Listening to her breathe is a quick and dirty way to monitor her progress. Then there's always the CYA factor. What if the patient leaves your office and has an acute asthma attack. She crashes into a telephone pole or falls down a flight of stairs. I can't imagine a judge would be too sympathetic to the doctor who said he didn't think there was any reason to fully examine the patient. Least important of all is to make the patient feel better. The few PIA patients who say how great their PA or NP is, or bounce around from doctor to doctor are the ones who look for little things like a thorough physical exam.
I know people are making up every excuse in the book (subconsciously maybe because she's a nurse?) but I can't imagine going to a pulmonologist for a consult and he doesn't listen to your lungs (or a cardiology consult who doesn't listen to the heart and goes straight to an echo), I don't care if he's getting PFTs later or a bronchoscopy. Maybe the PCP was wrong and it wasn't asthma, but instead a pleural effusion or atypical pneumonia.
