Physical exam--obsolete

[Shredder]

K I haven't posted much in some months but I wanted a discussion on this. We're learning the physical exam and I can't help but feel how antiquated it is. Run some Googles on "physical exam obsolete" and there's some decent reading on it. This topic has surely been raised on various parts of SDN before but I wanted a fresh thread with fresh opinions on it. Do cite any good threads on it if you happen to know them--I'll search in a sec.

Rub here, press there, tap that, push this. Docs were doing this 100 years ago, where is the progress. I'd rather run some scans and lab tests and figure out with much greater accuracy and speed what the deal is. Incidentally I only plan on doing rads or path so I think this belief system is acceptable. Is cost the limiting factor? Can't that just be decreased, as technology usually does over time? I don't place any faith in the nostalgia factor, I think it's overrated. I would much prefer a doc not poking me and touching me; their hands are usually cold anyway.

Let me know what you think. Also if you see this as an opportunity to capitalize somehow let me know. I think this is the direction of medicine, as economics dominate nostalgia. I also feel this about cadaver dissection vs prosection but I've voiced that before and it's beside the point.

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[keeping-it-real]

I think you could make an argument that when you have a very low index of suspicion, then maybe the physical exam isn't very useful (i.e. listening to the abdomen of a perfectly healthy teenager who is in for vaccination).

For many other cases, though, I think you're way off mark. Physical exam techniques are cheap, easy, and quick; and many times they'll be able to tell you what's going on. For example, just tonight we had a kid with "difficulty breathing." On exam, lungs were crystal clear, nice tympanic note on percusion. Pt was with dry cough and hx of croup. So in this case we saved the kid a chest film and just gave him a shot of decadron and called it a day.

In this day in age we have great technology that should be used, but that doesn't mean all of our "old" techniques are somehow obsolete. People were also using wheels 100 years ago...

Also, I realize you're trolling here, so don't get too excited. It's just late and I'm bored.

 

[THP]

You will see when you get to 3rd year how frequently you will listen to hearts and lungs as well as monitor progression (or regression) of abdominal distention. You can monitor how well a COPD exacerbation is responding to treatment by listening that you can't with imaging. Plus the number of chest x-rays you would have to order would be unreasonably high. There are many other examples as well.

 

[Blade28]

But it's free...all those tests and scans you're talking about cost money. Plus they can take time.

I guess I don't totally understand your frustration.

 

[Handle]

I giggled.

Shredder, precisely how many physical exams on real patients have you performed?

 

[Ambs]

I think PE is still important, and I use the info I get from it daily. (edited previous post)

 

[MSKalltheway]

We are also in the middle of learning the physical exams and I dont see how it is antiquated. Along with the history, it is the mainstay of a physician's practice. There are times where it is low-yield, and you must use your best discretion on what to leave out. But other posters gave great examples on why you would listen to the lungs as opposed to just getting a plain film...why would you unnecessarily expose a patient to that much radiation when you can just listen to the issues yourself (which often can be diagnosed without imaging)? Why order a CT when you can just palpate lymph nodes yourself? Why an EKG when you can just hear stenosis, prolapse, regurge, etc. on auscultation? Technology should be used, but most of the time it should confirm the physicians suspicion if properly used. Tests are expensive, and the patients are not the only ones who would suffer financially, physicians would get the brunt of it too when insurance decides not to reimburse for unnecessary testing.

Besides, without these "antiquated" techniques, I feel like half of the intellectual fun is taken out of medicine. Just my $0.02.

 

[AmoryBlaine]

I have to throw my hat in with the OP. Much of the PE is total bunk. I look at MOST steps of the PE as basically "on-off" switches for further diagnostic testing.

Crackles? Going to need to see a CXR.
Huge murmur? Gotta get the echo.
Distended belly? Need some films or a CT.

The problem is that the old docs who tend to teach the clinical examination classes fail to simultaneously teach the sensitivity and specificity of physical exam steps.

Example: an S3 is a bad sign in CHF, so if you hear it that is going to tell you something.
Example: board certified vascular surgeons with a patient prepped and draped on the OR table can only feel 60% of CT/US-documented AAAs.

I think my all time favorite is "tactile fremitus."

 

[deleted87716]

I have to throw my hat in with the OP. Much of the PE is total bunk. I look at MOST steps of the PE as basically "on-off" switches for further diagnostic testing.

So...without an exam, you'd have to have those switches perpetually set to "on," right? Is that what you're advocating?

 

[TRAMD]

If you think that the physical exam is worthless than your physical exam skills need work. It is true that many physical exam findings are expected based on history and that other studies are often used to confirm or rule out diagnoses. However, the physical exam is so quick, so easy and so cheap that its findings are certainly worth the time and effort.

 

[45408]

Crackles? Going to need to see a CXR.
Huge murmur? Gotta get the echo.
Distended belly? Need some films or a CT.

But without examining first, you wouldn't know which tests are necessary. You're not going to order all of those right off the bat for somebody who comes in with shortness of breath. A good history is also invaluable for a number of cases.

 

[mlw03]

while i don't think a PE is useless i do think the history is far more informative most of the time. with history alone you can often get a very good idea of what's going on. PE does contribute stuff though - i've found a few murmurs no one had documented before. yes, that then requires an ECHO to evaluate, but without listening no one would have done the echo to see whether that murmur was pathologic or not.

 

[howelljolly]

Yikes! Physicians are becoming obsolete? At best, your argument holds in a filthy rich major metropolitan US city. And, why would you even want to be a cookbook medicine practicing robot? An old saying in medicine is that diagnosis is 90% History, 9% Physical, and 1% Investigations. I think this is still true, but that 9% involves pressing, and squeezing, and pulling, even more now than it used to.

Sure, we have lots of technological advancements, but there’s a right time and place to use them. I think physical examination has a lot to do with deciding their utility. As we advance technologically, why should we regress with physical examination techniques? Why would you say we should only advance technologically. If we wanted to do that, we’d be writing on the Student Engineer Network. There are advancements in physical exam techniques; you might want to jump on that bandwagon. Do a literature search.

Cardiac auscultation is a product of the last century. Contrary to popular belief, cardiac pathology was not invented after the Echo. Doctors used to be able to examine the patient and know exactly what was going on… some of them still can. If you ever get to watch one do a PE, you’ll see just how much you don’t know.

There are so many places where physical exam is not only the best, but also the only option.

I can certainly tell you that the exam isn’t obsolete for Paramedics. As a medic, I had my eyes, ears, hands, and a bag full of tricks which included Lasix. I had to decide if the little old lady had an exacerbation of COPD or CHF, without a fancy CXR, or BNP levels. To pee, or not to pee, that was the question. But what do I know, I’m just an ambulance driver. If the physicians that teach paramedics don’t know Px techniques, we’re all in trouble.

My first two years of Med school were in the Caribbean. There was one CT scanner on the whole island. I’m sure that some regions of the US don’t all sorts of fancy toys, and that patients don’t have all sorts of money. How will you be able to practice in those parts? You aren’t planning on volunteering for Doctors Without Borders or some other similar organization, are you? I want to.

If you would “rather run some scans and lab tests and figure out with much greater accuracy and speed what the deal is”, you’d run into problems. In general, Labs take longer than the Px, and they are accurate only in what they are testing, not what the diagnosis is. E.g., an HbA1C can tell you that the patient’s glucose is chronically elevated. That’s all. It doesn’t tell you anything about the complications of DM in that patient. You need a physical for that. “Treat the patient, not the monitor”…labs, X-ray… The lab report doesn’t come back with a diagnosis, or treatment plan. It tells you what chemicals or cells are going haywire. The rest is why you are a doctor, and the machine in the lab is not. Physicians know the sensitivity and specificity of their labs, and their physical findings as well (ask them), and they know how to weigh their options. I see that as part of being a good physician.

But in a way, I see where you are coming from, since I have a bit of the Pathologist bug in me. I wouldn’t mind writing the pathology report. I appreciate the feeling of certainty with a biopsy, rather than “Well, this doesn’t look tooooo bad”.

So technology, and physical exam each have their place in medicine. While I see how knocking on someone’s back with your middle finger may be boring to you, I don’t think that physical exam is obsolete across the board.

 

[MossPoh]

Wait till you go into radiology (if you do). You'll begin to loathe all the unnecessary studies. You'll get plenty from the ER with very little clinical need for them. You'll also get lots of "Patient complains of 'worst headache of his life'" and then a CT sent.

Time, money, needless exposure to radiation. Money goes on boths sides of the equation. The patient pays more and the hospitals or practices would have to completley redesign their PACS/RIS systems for a whole new level of throughput. Data storage cost money...do you really really want to have to hold onto thousands upon thousands of normal studies? Just because you have the capability to do something doesn't always make it worthwhile. In the end it isn't really "quicker"....unless you work at a place that has a massive radiology department with lots of and lots of resources.

If you get your car checked out at 100,000 miles. They have the power to dissect it down and tell you every single thing wrong with the vehicle. They won't do it...it isn't worth the time or effort and only results in the customer waiting longer for their vehicle. So short story long...you should cheer on physical examinations since they may reduce your workload and actually allow you to see interesting stuff..if you stick with radiology. You'll see enough normal pathology as is without all that. 😉

 

[Bike on a Trek]

Link should work if you have access to your med library

http://archinte.ama-assn.org/cgi/re...el&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

 

[TheMightyAngus]

Wait till you go into radiology (if you do). You'll begin to loathe all the unnecessary studies. You'll get plenty from the ER with very little clinical need for them. You'll also get lots of "Patient complains of 'worst headache of his life'" and then a CT sent.

Time, money, needless exposure to radiation. Money goes on boths sides of the equation. The patient pays more and the hospitals or practices would have to completley redesign their PACS/RIS systems for a whole new level of throughput. Data storage cost money...do you really really want to have to hold onto thousands upon thousands of normal studies? Just because you have the capability to do something doesn't always make it worthwhile. In the end it isn't really "quicker"....unless you work at a place that has a massive radiology department with lots of and lots of resources.

If you get your car checked out at 100,000 miles. They have the power to dissect it down and tell you every single thing wrong with the vehicle. They won't do it...it isn't worth the time or effort and only results in the customer waiting longer for their vehicle. So short story long...you should cheer on physical examinations since they may reduce your workload and actually allow you to see interesting stuff..if you stick with radiology. You'll see enough normal pathology as is without all that. 😉

Are you saying this based on experience or just speculating? Each radiology study costs money, a portion of which goes to the radiologist. More scans= More money. What radiologist doesn't want more money?

 

[Law2Doc]

I have to throw my hat in with the OP. Much of the PE is total bunk. I look at MOST steps of the PE as basically "on-off" switches for further diagnostic testing.

As Kent W has suggested, your above sentence actually is the strongest argument for the opposite conclusion from which you come to. You need the PE to determine what things are worth getting tests. There are a potentially infinite number of tests you could order (at a potentially infinite cost) and the goal should be to order only the ones that help you make a decision. The PE is the cheapest starting point, so you use that to dictate which further tests are warranted.

Not to mention that there are also quite a few diagnoses that are made solely on PE and for which there is no better diagnostic test, and so by ordering all those tests for every individual you truly rack up worthless costs.

 

[Miami_med]

PE is actually quite valuable on the wards. As a lowly MS-3, I've already diagnosed multiple pneumonias and peripheral edema that turned out to be related to obstruction by metastatic ovarian CA. Yes these were confirmed with imaging (and the attending as I'm an MS-3), but that imaging would never have been ordered without the physical. That's medicine.

 

[Pinner Doc]

I don't place any faith in the nostalgia factor, I think it's overrated. I would much prefer a doc not poking me and touching me; their hands are usually cold anyway.

Let me know what you think. Also if you see this as an opportunity to capitalize somehow let me know. I think this is the direction of medicine, as economics dominate nostalgia. I also feel this about cadaver dissection vs prosection but I've voiced that before and it's beside the point.

I respectfully couldn't disagree more. You're right- what's the utility in fields like path or rads?

I, however, am going into emergency medicine.... where the PE means a great deal more!

 

[RockShox]

Your first statement implies that unless something is changing its not progressing and thus must be bad. But last time I checked people have been putting their pants on in a very similar way for the last 500 years. Is there another more technologically improved way of doing this that we should know about? You do the stuff that works and if it works well it will still work well no matter how long it's done.

"I'd rather run some scans and lab tests and figure out with much greater accuracy and speed" what the deal is."

Clearly you have never had to sit around all damn day for rads to get done playing golf to complete a scan, study, or read a film. This is why we all get to learn how to read our own films and then just use rads for the confirmation (which I why I argue that we should get the reimbursment for reading the film too). When I have a ruptured AAA do you think we have time to take that unstable patient to CT to confirm? Hell no the betch would bleed out while we waited for them to figure out how to turn it on. A perfect example of PE skills.

Second, many, many, many studies are only accurate given a certain clinical context. This is why we don't do stress tests on 30 y/o with out chest pain, crackles, or edema (those pesky physical signs and symptoms grrr) because the false positive rate increases as we go outside the clinical picture. Thus you need the H & the P to make the other tests mean anything at all.

"I think this is the direction of medicine, as economics dominate nostalgia."

As already pointed out to you what the physicians do pales in comparison to the tests and hospital crap. For every doc that is charging $200 and getting $50 there is a hospital charging $1000 for a head CT. Even in rads the doc gets like $80 for reading the CT and the hospital gets $1000 for the CT. So what cost us more the physical labor or the technology? (Incidentally, all this hullabuloo about doctors contributing to rising medical costs is Bulls**t. Every year the doctors beg medicare not to cut their reimbursements but hospitals enjoy a guarenteed increase in their reimbursements every year thanks to the stupid laws, get a clue).

I would much prefer a doc not poking me and touching me; their hands are usually cold anyway.

Don't worry I will only poke you we actually have to practice medicine on you...and not just talk about the diseases.

Incidentally I only plan on doing rads or path so I think this belief system is acceptable.

This statement perhaps says it all and I am glad, as your opinion about PE reveals either a complete lack of awareness or poor execution...neither of which I want near patients anyhow.

Don't get me wrong tests have their place. I would never dream about diagnosing HIV infection by clinical presentation, I would get the ELISA. However, everything has its purpose and place. Arguing that PE is not needed is like saying we have no need for a screwdriver now that we have the power drill. Many craftsmen will point out that the former out performs the latter depending on the situation.

 

[PeepshowJohnny]

I completely disagree with the original poster. Physical Exam is an absolutely essential part of the physicians arsenal. I'd still say good History taking is more important than Physical Exam, but a good physical exam can get you a ton of information in a relatively short time with zero waiting for results and it's CHEAP!

Now I do want to say that most medical schools overstate how effective a physical exam is. In my experience a lot of Physical Exam classes are taught by old school docs who treat in an antiquated way: a good doctor shouldn't rely on the "crutch" of lab and imaging results, which isn't appropriate for good patient care or to keep yourself from being sued.

 

[Blade28]

To add what was said above, many times you'll know the diagnosis after the history, but before the physical.

 

[BillyWitchDoctr]

Crackles? Going to need to see a CXR.
Huge murmur? Gotta get the echo.
Distended belly? Need some films or a CT.

So are we supposed to get CXR, CT, echo, EKG, etc on everyone who comes in? How would you know to get an echo if you didn't listen to the heart sounds? The PE is just another item in your toolkit. It helps you sometimes make a dx or narrow your differential to where you can get only pertinent imaging/labs rather than pan-imaging everyone.

 

[MossPoh]

Are you saying this based on experience or just speculating? Each radiology study costs money, a portion of which goes to the radiologist. More scans= More money. What radiologist doesn't want more money?

I'm saying this based on experience and interviewing radiologists for research. Those lower studies aren't really making bank, and you still have to treat them as you would a potentially serious one. Its not like you can treat it as a lesser study and speed through those. As it is now, radiologist aren't exactly sitting on their asses and twiddling their thumbs, especially in a hospital where they are understaffed. It is the old life versus work thing....everyone can make more money if they invest more time, but many people rather get home without worrying about it. I've seen radiologists working solo on the weekend loaded up with a crazy amount of studies because of pointless scans. Most aren't too happy about it. You get the big bucks in MR, but many radiologists even have a preference with that stuff. I can think of a couple that despised spine studies simply because it took so much time versus other stuff. One took extra time because of a bad experience missing something and the subsequent lawsuit...he was rushed with a bunch of "stat" studies and missed something....got sued.

A lot of people can make more money if they work harder, but many of those people value a life outside of work as well.

 

[howelljolly]

Diagnosis is 90% History, 9% Physical, 1% Labs/Imaging

Im not saying that its everything, but it certainly isnt useless. It is one part of the evidence you have for making a clinical decision. Unless you can come up with your own new way of arriving at a clinical decision, and get it published, I'll stick to my good old H&P

 

[Coastie]

Those MRCP (Members Royal College of Physicians) have physical exam skills unlike anything I've ever seen. I think Physical Exam becomes MORE important over time, and that physicians need to regain the Physical Exam, and not lean so much on imaging.

 

[Llenroc]

K I haven't posted much in some months but I wanted a discussion on this. We're learning the physical exam and I can't help but feel how antiquated it is. Run some Googles on "physical exam obsolete" and there's some decent reading on it. This topic has surely been raised on various parts of SDN before but I wanted a fresh thread with fresh opinions on it. Do cite any good threads on it if you happen to know them--I'll search in a sec.

Rub here, press there, tap that, push this. Docs were doing this 100 years ago, where is the progress. I'd rather run some scans and lab tests and figure out with much greater accuracy and speed what the deal is. Incidentally I only plan on doing rads or path so I think this belief system is acceptable. Is cost the limiting factor? Can't that just be decreased, as technology usually does over time? I don't place any faith in the nostalgia factor, I think it's overrated. I would much prefer a doc not poking me and touching me; their hands are usually cold anyway.

Let me know what you think. Also if you see this as an opportunity to capitalize somehow let me know. I think this is the direction of medicine, as economics dominate nostalgia. I also feel this about cadaver dissection vs prosection but I've voiced that before and it's beside the point.

I'm a 4th year medical student, and I can probably count on one hand the number of times something has been diagnosed by physical exam (and one of those times was when someone came in with multiple stab wounds to the ER). Just today, I listened to a patient, and thought his heart was RRR. But then I read the chart, and they said +S3. So in order to not look stupid, I told my resident +S3. But then my resident said there was no S3. Even on Cardiology, I was amazed at how little they care about heart sounds. Though, when they do hear an obvious murmur, they make everyone go and listen to it.

That said though, it is important to go and listen to a patients heart and lungs, and maybe check their abdomen every morning. You don't want to miss something really obvious.

 

[Llenroc]

Diagnosis is 90% History, 9% Physical, 1% Labs/Imaging

Im not saying that its everything, but it certainly isnt useless. It is one part of the evidence you have for making a clinical decision. Unless you can come up with your own new way of arriving at a clinical decision, and get it published, I'll stick to my good old H&P

It depends what specialty we're talking about. In Trauma Surgery and Dermatology, the physical exam is a lot more important. In PM&R, the Neuro exam is fairly important. In Cardiology, the ECG and Echocardiogram results are king. In Pediatric Infectious Diseases, the physical exam is incredibly vague, though still performed.

History is important everywhere.

 

[deleted87716]

I listened to a patient, and thought his heart was RRR. But then I read the chart, and they said +S3. So in order to not look stupid, I told my resident +S3. But then my resident said there was no S3.

First of all, you should always report and record what you personally find on exam, not what the last person found. If you don't, you will eventually live to regret it. It's much better to miss something because you haven't developed your skills yet than to be caught lying.

Second, "RRR" doesn't have anything to do with murmurs, which is what an S3 is. It stands (somewhat incorrectly) for "regular rate and rhythm" (it's incorrect because you can't tell rhythm without an EKG). It's probably more accurate just to say "regular." But I digress. 😉

 

[Taurus]

K I haven't posted much in some months but I wanted a discussion on this. We're learning the physical exam and I can't help but feel how antiquated it is. Run some Googles on "physical exam obsolete" and there's some decent reading on it. This topic has surely been raised on various parts of SDN before but I wanted a fresh thread with fresh opinions on it. Do cite any good threads on it if you happen to know them--I'll search in a sec.

Rub here, press there, tap that, push this. Docs were doing this 100 years ago, where is the progress. I'd rather run some scans and lab tests and figure out with much greater accuracy and speed what the deal is. Incidentally I only plan on doing rads or path so I think this belief system is acceptable. Is cost the limiting factor? Can't that just be decreased, as technology usually does over time? I don't place any faith in the nostalgia factor, I think it's overrated. I would much prefer a doc not poking me and touching me; their hands are usually cold anyway.

Let me know what you think. Also if you see this as an opportunity to capitalize somehow let me know. I think this is the direction of medicine, as economics dominate nostalgia. I also feel this about cadaver dissection vs prosection but I've voiced that before and it's beside the point.

Stop thinking like a pre-med. You're a medical student now. To even suggest the the PE is outdated is freaking ridiculous. Don't let your preceptor hear you say this.

 

[cleothecat]

Physical exam is critical in guiding the subsequent workup, as well as in determining the accuracy and applicability of the test results.

A good physical exam will enable the physician to determine if the test results are true or false positives. Often an imaging test report is a false negative until the radiologist gets that phone call to relook at the study because there is a discrepancy between the exam and the Imaging report.

I feel that the history and physical exam is essential to ensure that the patient receives the most relevant therapy.

Oh yes, I am a diagnostic radiologist!

 

[howelljolly]

I would think that the 90/9/1% think holds for almost every field (maybe not psychiatry?)

In Cardiology, where they have nice tests like EKGs and Echo, wouldnt the physical be proportionally (i.e. nine times) more important? Wouldnt you want to know, based on the physiology that you've quantified with EKGs and Echos, how they are functioning? Wouldnt you need to know, based on how the old ticker is working, what their exercise tolerance is? Or how they are perfusing? Or what is the probability that he'll throw a clot? Or if you need to be agressive or conservative with anti-coagulants? Or if he shouldn't do movie stunts anymore, and instead become the Governer of Cali?

You have tests to determine cardiac anatomy and physiology, I would think that the physical exam becomes that much more important to determine if the ol' heart is in good enough shape for that individual.

What about practicing medicine in areas without fancy equipment? Shouldnt American doctors be able to do that?

 

[Law2Doc]

It should also be noted that if you order every test and look hard enough, you are likely going to find something wrong with everyone. But that doesn't mean that what you found in your rads or path study isn't something unrelated to their presenting ailment, and/or something they couldn't live forever without caring about. The physical exam directs what to look for, not go on a goose chase to find a litany of things that might be unrelatedly wrong.

I think the OP's view is flawed in that he is making the assumption that the test will give you the answer, rather than often simply be a rule out tool. But, in fact, an awful lot of diagnoses are those of exclusion. The goal should always be to build a differential diagnosis, and use tests calculated to narrow the scope. If a test won't narrow the ddx list, it shouldn't be ordered. If you start with the tests, you often lose the thought process necessary and try to jump right to the conclusion - effectively trying to grab a needle out of a haystack at random, rather than methodically analyzing where in the haystack the needle must be. This tends to be more costly--you are ordering tests for things you often could have ruled out for free with the PE, as well as ordering tests which often don't even actually narrow your ddx.

 

[SoCuteMD]

The problem is that the old docs who tend to teach the clinical examination classes fail to simultaneously teach the sensitivity and specificity of physical exam steps.

You realize this information is in textbooks, right? I seriously hope that your approach to learning clinical medicine isn't "Wait for a lecture on it from an attending."

 

[GreenShirt]

Here's an example we learned in medical skills today: You have patient come into the ER with difficulty breathing. Why bother doing a percussion or auscultation exam? Why not just send them for an x-ray?.....How about if the patient has a pneumothorax? By the time they get an x-ray processed, they'll could be dead.

 

[LifetimeDoc]

One mantra that our professors keep pushing is that the history is the most important part of formulating your diagnosis. Even the physical exam, or for that matter tests/scans/etc. are just to confirm or de-confirm what you determined from the history. Tests are not perfect, and may lead you to unreliable conclusions whereas the history and simply interacting with the patient gives the most reliable information. Besides, we tend to order those tests because of defensive medicine anyways.

 

[smq123]

One mantra that our professors keep pushing is that the history is the most important part of formulating your diagnosis. Even the physical exam, or for that matter tests/scans/etc. are just to confirm or de-confirm what you determined from the history. Tests are not perfect, and may lead you to unreliable conclusions whereas the history and simply interacting with the patient gives the most reliable information. Besides, we tend to order those tests because of defensive medicine anyways.

Did your professors actually say this? 😕

 

[howelljolly]

Here's an example we learned in medical skills today: You have patient come into the ER with difficulty breathing. Why bother doing a percussion or auscultation exam? Why not just send them for an x-ray?.....How about if the patient has a pneumothorax? By the time they get an x-ray processed, they'll could be dead.

Also, what about medical clearance? How are you going to decide if your patient is healthy enough to undergo a study? If you send a AAA to ultrasound, and your patient explodes on the table, you're going to have one cranky tech, and one giant lawsuit

 

[TRAMD]

First of all, you should always report and record what you personally find on exam, not what the last person found. If you don't, you will eventually live to regret it. It's much better to miss something because you haven't developed your skills yet than to be caught lying.

Second, "RRR" doesn't have anything to do with murmurs, which is what an S3 is. It stands (somewhat incorrectly) for "regular rate and rhythm" (it's incorrect because you can't tell rhythm without an EKG). It's probably more accurate just to say "regular." But I digress. 😉

You can usually determine that there is a regular rhythm without an EKG. You can also oftentimes determine there is an arrhythmia by PE but will usually need an EKG to discern WHICH arrhythmia . . . only A-fib can be somewhat easily determined by PE. A regular rate and rhythm simply means a rate between 60-100 bpm and a rhythm that shows approximately equal timing between and during beats from beat-to-beat. You don't need to see the sheet music to know that a song has regular rhythm, you simply need to hear it. I do think it would be more accurate to say "normal rate and regular rhythm" but I still use RRR, normal S1, S2, no murmurs. Although it seems like I hear a lot of grade 2/6 midsystolic innocent murmurs.

 

[Law2Doc]

... whereas the history and simply interacting with the patient gives the most reliable information. Besides, we tend to order those tests because of defensive medicine anyways.

Disagree with both these points. While I agree that the history is absolutely the most important part of the exam, both because a good history can give you more diagnostic information than any test and because building rapport with a patient aids the process, I'm not sure you can call it the "most reliable info" -- it is very patient dependant. Patients often lie. Patients sometimes give you the answer they think you are looking for. Patients often show up with their own theories of causation and tailor their history to fit (i.e. the person with the slowly growing brain tumor who explains his injury as having been caused when he bumped his head last week). So you often get a ton of info, but it is up to you to decipher what is reliable (if any) and what isn't.

As for defensive medicine -- this is greatly overemphasized by many, especially on this board. In fact, if you order exactly the tests you need, the things that are appropriate to narrow the ddx, and nothing more, you are fairly well protected in any litigation. It's only when you don't have a good theory of the diagnosis, and thus don't order the appropriate test that you are at risk for negligence. So some doctors over order.

 

[LifetimeDoc]

Disagree with both these points. While I agree that the history is absolutely the most important part of the exam, both because a good history can give you more diagnostic information than any test and because building rapport with a patient aids the process, I'm not sure you can call it the "most reliable info" -- it is very patient dependant. Patients often lie. Patients sometimes give you the answer they think you are looking for. Patients often show up with their own theories of causation and tailor their history to fit (i.e. the person with the slowly growing brain tumor who explains his injury as having been caused when he bumped his head last week). So you often get a ton of info, but it is up to you to decipher what is reliable (if any) and what isn't.

Well, maybe reliable wasn't the correct description. How can you say that it's the most important part, and then totally dismiss it because of patient unreliability? Not all patents are liars, except in certain situations (drug seeking, altered, etc.). Also, blindly performing the latest and greatest test can lead you down the wrong diagnostic path when you neglect the basics of the history and simply touching/interacting with the patient. Of course there are basic diagnostics you'll need to do in many situations (an x-ray, blood test, whatever where appropriate), but just relying on the latest technology to do the job of a physician for you can lead to failure. I love gadgets and new tech just as much as anyone, but it's not always good medicine to blindly use it.

As for defensive medicine -- this is greatly overemphasized by many, especially on this board. In fact, if you order exactly the tests you need, the things that are appropriate to narrow the ddx, and nothing more, you are fairly well protected in any litigation. It's only when you don't have a good theory of the diagnosis, and thus don't order the appropriate test that you are at risk for negligence. So some doctors over order.

Exactly, people over order because they think that it is protecting them, or that it will give them (i.e. by itself determine) the diagnosis over what they could learn from the history or even the supposedly obsolete physical exam. Defensive medicine is just that, over ordering to create a paper trail.

 

[Rhuby]

An accurate diagnosis can be made 60% of the time based on physical exam findings ALONE. This is bumped up to 90% with a history and physical. And that is before all of the fancy tests...

So, while we do have all of this great technology available at our finger tips, it costs a lot of money. And how are you ever going to know what tests to order if you haven't done an H&P??? Full-body MRI on every patient who walks through the door? You listen to the teenager's heart and lung sounds because primary care and preventive medicine is the key to healthcare. So you listen, just in case there might be something wrong. Not just to "look like a doctor." An ounce of prevention beats a pound of cure as they say.

 

[PeepshowJohnny]

You realize this information is in textbooks, right? I seriously hope that your approach to learning clinical medicine isn't "Wait for a lecture on it from an attending."

I agree on this, but I think a lot of times, as I alluded to earlier, some older more traditional docs inflate their physical exam skills, or even the ability of the human body in general.

I've had old school doctors allude to how unless you can document pneumonia signs on physical exam, you should NOT order a chest x ray. This is just blatantly not true. Research has shown that the sensitivity and specificity of even trained experts ears is not good enough for adequate testing for pneumonia. The heads of ID of our hospital has stressed the importance of chest x ray for diagnosis of pneumonia.

So I don't think the problem is necessarilly people not doing their own self learning, but hearing incomplete or incorrect information from instructors.

 

[Law2Doc]

Exactly, people over order because they think that it is protecting them, or that it will give them (i.e. by itself determine) the diagnosis over what they could learn from the history or even the supposedly obsolete physical exam. Defensive medicine is just that, over ordering to create a paper trail.

It's not about a paper trail -- you have that in the records already. It's mostly about not understanding how to correctly work up a ddx, taking the shotgun approach suggested by the OP, and then justifying it by blaming litigation risk. In fact, if you approached the ddx systematically, and ordered only the tests warranted, you are usually in decent shape when the lawyers come out of the woodwork. Thus I think the term defensive medicine is mostly a crutch to justify some folks haphazard approach to medicine.

 

[smq123]

Well, maybe reliable wasn't the correct description. How can you say that it's the most important part, and then totally dismiss it because of patient unreliability? Not all patents are liars, except in certain situations (drug seeking, altered, etc.).

Because the way they explain history-taking in MS-1 is a vast over simplification of the way it often works. The history is important - not just because of what the patient directly tells you, but what you observe from the patient's reaction to your questions, your reaction to the patient, etc. It's also important because it creates the patient-doctor relationship. But, if you based your diff dx solely on what the patient told you, you'd be screwed. Some are excessively good historians - i.e., they'll tell you about every mosquito bite they got in the past 6 years - or else they're terrible historians (i.e. "No doctor, I've never had surgery in my life. Oh, that gigantic scar across my pelvic area? That is from when I had my gallbladder and right ovary removed. I guess I did have surgery after all.")

You're right - not all patients are liars. But a LOT of patients are extremely forgetful. (My personal favorite is this patient who told my classmate that she couldn't remember how many times she'd been pregnant. No, she had no psych problems - I think she ended up being a G15 or something.)

Exactly, people over order because they think that it is protecting them, or that it will give them (i.e. by itself determine) the diagnosis over what they could learn from the history or even the supposedly obsolete physical exam. Defensive medicine is just that, over ordering to create a paper trail.

Some doctors order tests because they're concerned that they actually missed something - not just to cover themselves. In some specialties (like OB), imaging studies are sometimes just as important (if not more important) than physical exam. Physical exam is still very important, but there are some things that you absolutely NEED technology for, and therefore should always be ordered.

Plus, even some die-hard PE proponents will tell you that for some areas of the body (notably the abdomen), PE isn't all that useful and will tell you very little.

 

[Law2Doc]

But, if you based your diff dx solely on what the patient told you, you'd be screwed. Some are excessively good historians - i.e., they'll tell you about every mosquito bite they got in the past 6 years - or else they're terrible historians (i.e. "No doctor, I've never had surgery in my life. Oh, that gigantic scar across my pelvic area? That is from when I had my gallbladder and right ovary removed. I guess I did have surgery after all.")

You're right - not all patients are liars. But a LOT of patients are extremely forgetful. (My personal favorite is this patient who told my classmate that she couldn't remember how many times she'd been pregnant. No, she had no psych problems - I think she ended up being a G15 or something.)

Exactly. And some questions simply aren't prone to be answered accurately, unless you ask them exactly right. If you ask someone how much they typically drink, they are going to frequently underestimate it --eg a couple of drinks a month. If however, you ask a patient how many drinks a night they drink, sometimes the same person will say one or two.

 

[Miami_med]

Exactly. And some questions simply aren't prone to be answered accurately, unless you ask them exactly right. If you ask someone how much they typically drink, they are going to frequently underestimate it --eg a couple of drinks a month. If however, you ask a patient how many drinks a night they drink, sometimes the same person will say one or two.

Very true, and in Miami, a drink is actually a 40 of Old English.

 

[TRAMD]

It's not about a paper trail -- you have that in the records already. It's mostly about not understanding how to correctly work up a ddx, taking the shotgun approach suggested by the OP, and then justifying it by blaming litigation risk. In fact, if you approached the ddx systematically, and ordered only the tests warranted, you are usually in decent shape when the lawyers come out of the woodwork. Thus I think the term defensive medicine is mostly a crutch to justify some folks haphazard approach to medicine.

We definitely practice defensive medicine in the US. The number of tests done that come back normal is ridiculous. Fear of litigation is a big problem in medicine. Costs could be kept lower if we didn't order a test when we were 95% sure it is going to come back negative--most of the time. We order the test so that we are 99% sure--nothing is 100%. There is an expectation of perfection and we go so far for our patients and then just a little further to cover our asses. The litigious nature of the US is why we always go that extra step. Patient care and outcomes are affected minimally by it but you better make damn sure you did it in case something goes wrong.

 

[Shredder]

thx for the replies. i was frustrated after a long and boring PE class when i wrote the thread. I really feel like palpating, percussing and auscultating have been around for too long. It seems that the only justification for PE is cost. Basically I too am looking at this from a cost effectiveness standpoint, also time effectiveness (same thing, as time is money). Lab tests and imaging just haven't yet become cheap enough (maybe fast enough too) to supplant the PE. At some point they will right? What's keeping this from happening? It's feasible to think that the PE will be obsolete in some number of years. History alone should suffice, followed by the appropriate tests and scans. No more palpating etc. Hippocrates was doing that. The tech equivalent would be using vacuum tubes to run servers.

Anyone have data on the cost of lab tests and imaging? Oh yeah and defensive medicine for sure; better to order up a storm and avoid lawsuits. Even if PE diagnoses 90% of things the other 10% will get you.

 

[TRAMD]

thx for the replies. i was frustrated after a long and boring PE class when i wrote the thread. I really feel like palpating, percussing and auscultating have been around for too long. It seems that the only justification for PE is cost. Basically I too am looking at this from a cost effectiveness standpoint, also time effectiveness (same thing, as time is money). Lab tests and imaging just haven't yet become cheap enough (maybe fast enough too) to supplant the PE. At some point they will right? What's keeping this from happening? It's feasible to think that the PE will be obsolete in some number of years. History alone should suffice, followed by the appropriate tests and scans. No more palpating etc. Hippocrates was doing that. The tech equivalent would be using vacuum tubes to run servers.

Anyone have data on the cost of lab tests and imaging? Oh yeah and defensive medicine for sure; better to order up a storm and avoid lawsuits. Even if PE diagnoses 90% of things the other 10% will get you.

Going to the ER and getting a few labs drawn and ran will cost about $200-$300. An X-ray or two will cost around $300-$500. A CT or MRI are about $2000 each.