Along the drug-seekers theme… A significant percentage of the population has at least one of the following characteristics (some have all), addiction, dishonesty, malingering, mental illness, and plain stupidity. This mix of attributes makes many of your histories and physicals utterly useless. On one extreme, you have the regular guy, with vague belly pain, minimal tenderness over the right lower quadrant and no rebound tenderness, normal vitals, who refuses pain medicine and ends up having an appy. On the other extreme, you have the screaming in pain, guarding to palpation, came in by ambulance who has absolutely nothing.
I recall one schizophrenic patient that frequented the ER of my residency. He had a very flat affect and tended to come to the ER and to the out-patient clinics on a very frequent basis, often complaining of things like "toe pain". I once saw him for the main complaint of "Blindness". I asked him if he was currently blind, he said, "No, only when I do this" and he closed his eyes real tight. I saw him for the complaint of abdominal pain/chest pain. He had left upper quadrant tenderness. I looked at the previous 8 visits to out-patient clinics/ER for chest pain in the past year and noted that he hadn't had a troponin drawn with any visit (He was 37 years old, didn't smoke, had no hypertension, and no family history of CAD). Trop was over 3, with a normal EKG. 3 days later, he is status post quadruple CABG.
Combine this unreliable history/physical exam with a nightmare of medicolegal climate and heavy patient satisfaction combined with at times extreme time constraints, and pressure to "move the meat", we have become increasingly dependent on imaging studies/laboratory testing to pick up all emergencies.
This is contrary to the old adage that 95% of diagnosis comes from history and physical that your professor will try to beat into you during your "history and physical class". This is often taught by old-timers in your medical school, who practiced in a different time. The attendings of our attendings made a lot of diagnoses that were probably wrong, but it didn't matter because the they couldn't do a darn thing about so many diagnoses. "You are having a heart attack! That is not good. Here is an aspirin. You need less stress in your life. Good luck with that." Think about the advances in cardiothoracic surgery, with bypass, aortic repair, and valve repair. Think about the advances in neurosurgery, with aneurysmal clipping and coiling. It wasn't imperative that doctors make so many serious diagnoses 50 years ago. People died, and that was life. People don't accept the "crap happens" excuse anymore.
Also think of the now innumerable pharmacologic treatments that are now available that weren't to physicians 50 years ago.
Interesting article about this:
http://www.time.com/time/magazine/article/0,9171,872488,00.html
Writing of pharmaceutical chemists in Clinical Pharmacology and Therapeutics, Dr. Modell asked: "Will they realize that there are too many drugs for the patient, for the physician, and, surprisingly enough, for the pharmaceutical industry?" No fewer than 150,000 preparations are now in use, of which 90% did not exist 25 years ago, and 75% did not exist ten years ago. About 15,000 new mixtures and dosages hit the market each year, while about 12,000 die off.