ericdamiansean

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We got an earful from a senior clinician about how doctors are now relying too much on technology rather than proper history taking and physical exam to make a diagnosis, even differentials.
She ended with this quote: You must not be a servant to technology but it's master...you are future clinicians, not technicians

Another IM doc, who's one of the best in my hospital and who's been all over the world says that he does not like the US system because it relies too much on technology.

Now, I know that it is important to make diagnoses which are almost 100% correct, and that it is to avoid being sued with malpractice being so high.

What do you think? As a US student yourself, since I'm foreign
 

kutastha

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ericdamiansean said:
We got an earful from a senior clinician about how doctors are now relying too much on technology rather than proper history taking and physical exam to make a diagnosis, even differentials.
She ended with this quote: You must not be a servant to technology but it's master...you are future clinicians, not technicians

Another IM doc, who's one of the best in my hospital and who's been all over the world says that he does not like the US system because it relies too much on technology.

Now, I know that it is important to make diagnoses which are almost 100% correct, and that it is to avoid being sued with malpractice being so high.

What do you think? As a US student yourself, since I'm foreign
I agree with this. The physical exam is becoming a lost art. Indeed, it's nice to have them to narrow down a diagnosis, however one can elicit a lot from a good history and a focused physical exam. Add in appropriate labs and you can get a lot of information. MRI, CT scans can be used as an adjunct when further elucidation is needed, but shouldn't be depended on all the time.
 
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ericdamiansean

ericdamiansean

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A good history gives you 80% of the diagnosis most of the time..physicals and tests give you more than 95%

The problem with physicals..most of the signs that you see/read in books, do not present today due to early intervention.

I'm pretty pro-US for a non US citizen, maybe it's because I have relatives here, am planning to move here, and I like the system here, but when I heard the doc rant on and on about how the system sucks in the US ie. how they rely on doing a full battery of tests etc..I was wondering how true this is
 

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I think technology has in large part supplanted the physical exam. Right or wrong, you have to admit that imaging studies are more accurate and you tend to have more confidence in their results than your exam.

Example...would you have more confidence in hearing crackles as a sign of pulmonary edema or if you actually saw it on a Chest xray?

Decreased breath sounds....pleural effusion? Maybe not. Dullness to percussion...pleural effusion? Uhm....no idea.

Chest xray shows the effusion...Dada!

RUQ pain...positive Murphy's sign? Rebound tenderness? Would you put your money on this? Heck, get an ultrasound!

You look at most disease processes and it's the same thing.
 

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Part of it is us taking the easy way out... part of it is defensive doctoring. If I do a neuro. exam on a guy who hit his head, find nothing wrong, send him home and he passes out in the car and plows into an orphanage, I will get violated in court. If I CT scan his head and it's negative and the same thing happens, I've got the CT scan to back me up. People can argue that my physical exam could be wrong... heck they can say the same thing about the reading of the CT scan but that's not my problem.
 

kutastha

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StudKnight said:
I think technology has in large part supplanted the physical exam. Right or wrong, you have to admit that imaging studies are more accurate and you tend to have more confidence in their results than your exam.

Example...would you have more confidence in hearing crackles as a sign of pulmonary edema or if you actually saw it on a Chest xray?

Decreased breath sounds....pleural effusion? Maybe not. Dullness to percussion...pleural effusion? Uhm....no idea.

Chest xray shows the effusion...Dada!
If all you want to do is say the patient has crackles, perhaps you're right. Of course you could always look at laterality of the sounds. In CHF, they're usually bilateral. If it's only on one side, then you have some different pathology. You could use percussion with your stethoscope, in the lateral and supine positions. You can place your stethoscope on the back while tapping with direct percussion to notice auditory differences (Guarino's test) - You can find air water lines in this case. You could have the patient cough to see if the sounds clear. You could also use whispered pectoriloquy, egophony, or tactile fremitus. You could try a carotid massage, which can relieve pulmonary edema 80% of the time. You can look for movement of the subcostal angles (right moving less than left) due to RV enlargement (Hoover's sign). There's many more lung exam techniques as well.

But then, why bother if all you need is a CXR?
 

stomper627

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kutastha said:
If all you want to do is say the patient has crackles, perhaps you're right. Of course you could always look at laterality of the sounds. In CHF, they're usually bilateral. If it's only on one side, then you have some different pathology. You could use percussion with your stethoscope, in the lateral and supine positions. You can place your stethoscope on the back while tapping with direct percussion to notice auditory differences (Guarino's test) - You can find air water lines in this case. You could have the patient cough to see if the sounds clear. You could also use whispered pectoriloquy, egophony, or tactile fremitus. You could try a carotid massage, which can relieve pulmonary edema 80% of the time. You can look for movement of the subcostal angles (right moving less than left) due to RV enlargement (Hoover's sign). There's many more lung exam techniques as well.

But then, why bother if all you need is a CXR?
Hmm....time.
10min vs. 15 sec?
In the ED, I can tell you I dont have time for all that PE, Im better off getting the CXR so I can manage more pts in an efficient manner.
 

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stomper627 said:
Hmm....time.
10min vs. 15 sec?
In the ED, I can tell you I dont have time for all that PE, Im better off getting the CXR so I can manage more pts in an efficient manner.
You can get a CXR ordered, done, developed and read in 15 sec? Definitely efficient. If you don't even lay a stethoscope on the patient, you could save even more time.
 
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ericdamiansean

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One of my points is that, even cardiologist are not even bothered to properly examine a patient, say with VSD/ASD and just send the kid for an echo

Of course, you can't beat x-rays to properly determine respiratory problems, but at least PEs help to give you a provisional diagnosis
 

stomper627

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kutastha said:
You can get a CXR ordered, done, developed and read in 15 sec? Definitely efficient. If you don't even lay a stethoscope on the patient, you could save even more time.
Very true....and yes, that happens in quite a few EDs. Often times triage policies dictate the CXR, even before the pt is seen by a doc (hopsital policy on the defensive....another great thing attorneys have given us) Otherwise, its a quick 5min H and P, order the Xray, and move on to the next pt. while I wait for the tech to take it/develop it (PACS is even nicer....)
When that thing is developed, I can read a CXR (or the ED attending) and I can DC or admit accordingly all while managing many patients.
Im not defending the practice, just saying that it is efficient. More so then spending more time with each pt in the ED.
stomper
 

AF_PedsBoy

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I'm impressed by the old-school physicians who knew physical findings because they had to - on attending rounds the director of the peds residency program went through how to diagnose about fifteen different conditions just by looking at someone's HANDS for 15 seconds. I think physical diagnosis is an invaluable technique, especially if you have to make a diagnosis and you don't happen to have a hospital behind you (i.e. on the street or in an emergency) ...but I'd still get the tests for confirmation and CMA.
 
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AF_PedsBoy said:
I'm impressed by the old-school physicians who knew physical findings because they had to - on attending rounds the director of the peds residency program went through how to diagnose about fifteen different conditions just by looking at someone's HANDS for 15 seconds. I think physical diagnosis is an invaluable technique, especially if you have to make a diagnosis and you don't happen to have a hospital behind you (i.e. on the street or in an emergency) ...but I'd still get the tests for confirmation and CMA.
Exactly my point, only in certain situations should tests be done before physicals, and we should not be servants of technology