An old-timer bemoans the demise of the physical exam, or hyposkillia:
We need teachers who truly comprehend the value of a good medical history, the rewards of a pertinent physical examination, the power of knowing how to think, and the importance of accountability; teachers who first use the stethoscope, not an echocardiogram, to detect valvular heart disease; teachers who first use the ophthalmoscope, not magnetic resonance imaging, to detect intracranial hypertension; teachers who first use their eyes, not a blood gas apparatus, to detect cyanosis; teachers who first use their hands, not computed tomography, to detect splenomegaly; and teachers who always use their brains and their hearts, not a horde of consultants, to manage their patients.We need teachers who don’t order expensive, state-of-the-art studies when cheaper, conventional tests supply the same information; teachers who don’t administer a slew of medications in an effort to alleviate every possible ill; teachers who appreciate that doing nothing is, at times, doing a lot; and teachers who realize that many patients get well despite what we do, not because of what we do.
Those days are long over, my friend. Readers of this blog know why this is happening: time pressures in a fee-for-service reimbursement system and defensive, objective-based medicine.
I recently discussed this with someone who is completely unapologetic about the demise of old-school, physical exam-based medicine: “I compare it to this – why travel by horse and buggy when you have a car available? The same goes for today’s medicine.” (via Notes from Dr. RW)
Update:
retired doc comments.
Update 2:
Dr. RW addresses some of the comments here.
Related posts:
- The privilege of being at a patient’s bedside
- Rounding by robot
- Are doctors finding the physical exam useless and obsolete?
- The neck
- The pharynx
- "Why listen when you can order a scan?"
- Old-school doctors
{ 71 comments }
This guy needs to learn that the most important teacher in his hospital, who should be giving 50% of the medical school’s lectures, is the hospital’s risk manager. I still don’t understand why med schools don’t have the risk manager give lectures.
Why do I have the feeling this guy never had to see 40 patients a day at 15-minutes per encounter…I bet his physical exams would leave a lot to be desired at that rate.
While this jag-off is writing bs articles so that he can write MACP (whatever the f*** that is) after his name, the rest of us will keep practicing defense to ward off the sodomites!
I do believe the old saying that over 90% of diagnoses are made from history alone but I wouldn’t accept a 1 in 10 chance of getting sued.
It’s a pity everyone’s out for a quick buck, we all lose in the end with protective medicine; patients have to go through more tests, the public pays higher bills (either taxes or insurance premiums) and doctors create more work for themselves. At least the lawyers get paid by every side…
He paints with a broad brush indeed.
And ends up sounding like a disgruntled faculty member, perhaps because he was “overlooked” for advancement.
In my neurology training almost 30 yrs ago I remember watching our chief methodically examine patients. One thing he did at the bedside was ocular plethysmography — where you apply a pressure-generating gizmo to the side of someone’s eyeball, slowly increasing the pressure while you did an ophthalmoscopic exam watching for the retinal arteries to collapse to get a sense of arterial pressures in the eyes. Yes, a test easily done at the bedside with a good hands-on factor, but these days totally supplanted by better, more useful technology.
I don’t agree that we all lose with defensive medicine…the patients lose, and the public loses, but physicians actually get PAID for defensive medicine…more tests generate more diagnoses (pulmonary nodule, liver cyst, ashd – when someone has an unnecessary cardiac cath and has 1% blocked artery, they have coronary disease! yeah!). So keep up the defense, guys…the patients are trying to screw us, don’t feel bad about it…
Another preacher from the ivory tower. Bet he never spent a day practicing medicine in the real world.
I think Dr. Fred hit the nail on the head.
You think this clown ever had to stand in front of the Powers-that-Be and explain why he didn’t order a Cat Scan on a patient who had a bad outcome: “But I did a Really Good Physical Exam, Really I did!! I thought I heard an S3!
Osler’s dead and he ain’t coming back.
That said, all the modern docs that can’t diagnosis appendicitis without a spiral CT will be up a creek when oil is $250 a barrel, there’s no transportation between communities because of an avian flu-like illness, or a dirty bomb closes the east coast.
Could happen sooner than you think.
“when oil is $250 a barrel, there’s no transportation between communities because of an avian flu-like illness, or a dirty bomb closes the east coast
Could happen sooner than you think”
Perhaps an abridged version has been noticed already in New Orleans and the only factor that came into the way of patient-care
was liability concerns(anecdotes although). A devastated hospital that had no spiral CT MRI ,still showed professionalism and provided excellent service with means at hand. Absent all these doctors and nurses the nemesis that is hanging loose “could happen sooner than you think”
“when oil is $250 a barrel, there’s no transportation between communities because of an avian flu-like illness, or a dirty bomb closes the east coast
Could happen sooner than you think”
Perhaps an abridged version has been noticed already in New Orleans and the only factor that came into the way of patient-care
was liability concerns(anecdotes although). A devastated hospital that had no spiral CT MRI ,still showed professionalism and provided excellent service with means at hand. Absent all these doctors and nurses the nemesis that is hanging loose “could happen sooner than you think”
sorry for the repeat post.I apologize.
Professionalism? In the medical industry? Perhaps you anonymice can go observe.
We observe and practice it everday but you will need eyes for it. What you don’t see with your eyes, don’t invent with your mouth
You need to read some of these anonymous comments a little closer.
CT scan for a patient who presented with a large zit on the lip. What did this test add to the care of this patient? What medicolegal exposure would have been incurred by NOT ordering this test? Does every patient who has an acute otitis media need followup wiht a specialist?
Do you all still wonder why the gov’t and insurers taek the attitude that primary care doc’s can be replaced by PA’s and NP’s??
Two sodomites from the same law firm were having lunch when suddenly one of them jumped up and said, “I have to go back to the office – I forgot to lock the safe!”
The other sodomite replied, “What are you worried about? We’re both here.”
With primary care docs gone I would prefer following up from a specialist rather than a PA or NP if my hearing is at stake.The choice is yours where you will put your money and how much.By the way who was the doctor ordered CT for a “zit” on the lip? was it a Squamous Cancer, melanoma? was it biopsied?if indicated it will require CT scan for diagnosing metastasis and follow up. So you see medicolegal concerns are there in appropriate cases.
The zit CT was on a healthy young man who presented to the ED with pain , swelling, and redness of the lip. You have to be a collosal moron to think you’re dealing with a melanoma in this setting. Again, what does the CT add to this patient’s care??
And to the other poster, what makes you think your hearing is at risk after an isolated episode of acute otitis media? Your concern will make audiologists allover this conuntyr jump for joy.
The “zit” on the lip could possibly be an external manifestation of an oral infection that has spread to the deep planes of the neck, AKA Ludwigs Angina. I would probab;ly concur with this ER doc and do a neck CT scan “just in case”. Remember, if you miss a Ludwig’s Angina you will be called on the carpet for missing such an easy diagnosis, in retrospect.
With respect to htis article posted. the whole point is that a properly trained physician will recognize a Ludwig’s Angina on the spot and won’t need a damn CT scan to tell him what his eyes (a grossly underrated organ in these sad times) could in a second. Why not get a CT for every acute otitis media, since you can’t trust your eyeballs? The analogy is totally apropos.
What kind of idiot would go to the er for a swollen lip is the question that should be asked…
“The zit CT was on a healthy young man who presented to the ED with pain , swelling, and redness of the lip.”
You never said these before.Presentation like this doesn’t make him ‘healthy’ either because he wouldnt be in an ER in the first place but it does make you a “collosal moron”.encerta dictionary says Zit is a slang word for a pimple or blemish
“Again, what does the CT add to this patient’s care”
Same moronic behavior.what CT it was a head CT or Neck CT? Both may be indicated .Neck CT as my fellow gentleman has pointed out to exclude ludwig’s angina or any neck space infection.To add my two cents the lip anatomically is the dangerous area of the face from where the infection through the venous radicles is carried to the intracranial venous sinuses in the form of emboli leading to sinus thrombosis.It can happen suddenly and be life-threatening. In 2 to 3 out of every 10 cases it can be fatal.Doing a Head CT scan was definitely medicolegally practical.However I don’t know if you are still hiding anything
“after an “isolated” episode of acute otitis media”
Similar moronic omission in the first post. Are you in a position to advise me where from i get my follow-ups
“a properly trained physician will recognize a Ludwig’s Angina on the spot and won’t need a damn CT scan to tell him what his eyes (a grossly underrated organ in these sad times) could in a second”
There will be hundreads of (im)properly trained lawyers searching for a “properly trained physician” like this ,to sue “in a second”. In your words ,”will make them allover this “conuntyr” jump for joy”
Stop being a jack of all trades.
Why are you guys arguing with this moron…you guys are physicians, he is some loser who only wishes he could be called doctor…God knows what kind of low-skill job he has (if any…)
Don’t debase yourselves…you shouldn’t breathe the same air as that guy let alone converse with him…go back and practice some defense…
Seriously, you guys are better than everyone. You shouldn’t have to be accountable to the commoners now that you have medical degrees.
“Why are you guys arguing with this moron”
Just to know how his thought process operates. It is enjoyable
“Don’t debase yourselves”
No way ,all this conversation lets you peep into the relms of human nature like this.
“You shouldn’t have to be accountable to the commoners now that you have medical degrees”
you don’t have to.Be truithful to the “commoners” you accept as patient.
Accepting the difference of knowledge between a layman and professional I must say each person is unique in his/her own way.The word “comonner” is a slander to those you’re trying to represent.Just we all need to recognize our boundaries.
yeah, you’re right…the thought process of the litigious patient is useful to know about…it will be another tool we can use to defend ourselves…thanks for setting me straight.
So you’ll still CT scan a healthy guy with a lip zit eh? YOU’RE the moron who’s bankrupting the medical system. Didn’t you learn ANYTHING in medical school? The point of the article is the unbelievable lack of physical examination skills and accompanying logical thought processes that foollwo form mastery of those skills. You’re clearly demonstrating this. Your lack of clinical skills is no excuse for managing a patient no better than the average nurse or first year medical student. Nothing about what I was “hiding” changes any of the points I made. Remember that when your job is taken by a PA in a few years.
who’s the bigger moron: the person who orders the ct with a flick of a pen or a few keystrokes, or the doofus who agrees to it and gets irradiated?
I have never ordered a CT for zit of the lip, but I have ordered a CT scan and MRI for zit on the nose and found a cavernous sinus thrombosis — a life threatening emergency. Venous nasal drainage can go to central venous drainage.
DEFENSE. DEFENSE. Order CT/MRI for any zit on the nose. Don’t let a lawyer with a retrospectoscope tell what a moron you were.
All I can say is…good catch. But seriously, was there something that led you to order the ct, or are you just the king of defense…tell me more.
It’s very sad to see what kind of guys are now part of the medical profession. It would do every one of you good to pay attention to what the retired Doc. is trying to tell you.
You have cheapened your profession to the point that it won’t be long until the general public is “on to you”..You order CTs for patients and then call them (pts) morons for allowing it to be done. In fact you are calling yourself a moron because you are the only one who realizes how you practice medicine. the patient still believes in you. So who is the REAL mnoron?
I guess you can enjoy this lazy, disgraceful, uneducated way of practicing medicine for awhile. But, one day when we all figure out what you are doing it will be a different story. I guess we can just look up our own symptoms and then call the hospital, lab or whatever and order our own tests. You know, maybe cut you right out of the mix..Get the reports sent directly to us and if need be just take ourselves off to a specialist.
Walk into the ER and fill out a form that says headache, back pains, abdominal pains, etc….check here..Then there could be multiple choice tests or procedures that MIGHT show something. We can pick and choose what we like… No need for you at all, if you arent going to be a REAL physician.
Yes, maybe we should just do that..No PCP, no ER Docs except maybe one on call for true emergencies. Then he can be paid by the actually work he does instead of seeing all these patients that really don’t need a Dr. at all.
“So you’ll still CT scan a healthy guy with a lip zit eh? YOU’RE the moron who’s bankrupting the medical system. Didn’t you learn ANYTHING in medical school?”
How could we. Great clinicians like you got retired.Couldn’t learn the voodoo medicine you practice.
“Your lack of clinical skills is no excuse for managing a patient no better than the average nurse or first year medical student”
nobody has browbeaten you to visit ER or even a doctor.You always have the choice.
“Nothing about what I was “hiding” changes any of the points I made”
You have to be a real doctor to understand that. What you don’t see with your eyes, don’t invent with your big mouth.
“good catch. But seriously, was there something that led you to order the ct”
Then what is not so serious about this good catch.
“It would do every one of you good to pay attention to what the retired Doc. is trying to tell you”
Then understand what people are trying to tell you here. Do Unto Others As You’d Have Done Unto You.
“You have cheapened your profession to the point that it won’t be long until the general public is “on to you”..”
Won’t happen in your lifetime not even mine.the face of medicine has changed and people do understand that.
“In fact you are calling yourself a moron because you are the only one who realizes how you practice medicine. the patient still believes in you. So who is the REAL mnoron?
Don’t understand what are you trying to say.but name calling started from your side.Why your statemnts are so disorganized. Are you demented?
“But, one day when we all figure out what you are doing it will be a different story”
Acc to you you’ve figured it out already.So all the best for your campaign to raise awareness.
“You know, maybe cut you right out of the mix..Get the reports sent directly to us and if need be just take ourselves off to a specialist”
You can interpret your test reports,what prevents you to treat yourself.Why even need a specialist .Are you sure he is not “lazy, disgraceful and uneducated ” like a PCP,whom you despise.
“No ER Docs except maybe one on call for true emergencies”
Are u a real doc? In which ER you have worked? A million doller question here.
Amazing to see what a jackass you are
” Your lack of clinical skills is no excuse for managing a patient no better than the average nurse or first year medical student.”
What does DEFENSE have to do with my (or anybody’s clinical Skills? It takes me one minute to figure out with 99% certainty what is wrong with a patient. Then I order defensive tests (THOUSANDS OF THEM) to bring my sensitivity as close to 100% as I can. That’s the only way to protect myself from the Sodomites. And I’ll still get sued, I’m in a high risk specialty. Just not as often.
If you ignore the obscene language, there is actually truth in what Anon 112 is saying in this thread.
– amd
“Yes, maybe we should just do that..No PCP, no ER Docs except maybe one on call for true emergencies. Then he can be paid by the actually work he does instead of seeing all these patients that really don’t need a Dr. at all.”
I love how this moron thinks he has the power to change the medical system (he’s some retired loser who probably goes to the doc every time he gets a sniffle)…in your dreams pal…we’re going to keep making money of the defensive testing you idiots give us the opportunity to order…enjoy!
“Yes, maybe we should just do that..No PCP, no ER Docs except maybe one on call for true emergencies.”
OK, then the next time you get a viral URI, your nose is stuffed with Buggers, and you RUSH to the ER and complain about the 3 hour wait because some 14 year old has 14 bullet wounds and is tying up the ER staff (”That’s not my problem, how much longer, i’m really sick”) Whi will prescribe Broad spectrum antibiotics for your cold?
William Osler would be deported back to England if he practiced medicine in the US in the 21st century. How the hell am I supposed to do Histories, physicals, order tests and spend hours documenting in the computer to cover my ASS and see 40 patients in an 8 hour ER shift? SOmething’s got to be left out, abd the only thing I can sacrifice is the H + P. WHen we go to Continuing ED lectures , you think they talk about good physical exam skills? “Interactions that Create/Prevent Malpractice” ….that’s all we hear at lectures. We’re not doctors anymore, we’re Lawyer Avoiders.
I think you are putting too much blame on the lawyers…it takes two to file a suit…a lawyer and a litigious patient. The patients are just getting the kind of care they deserve, what goes around comes around…they just don’t know it. DEFENSE RULES!
Unrealistic expectation of the patient and the lawyer’s gaming of the system reinforce each other. With so many law grads churned out the fight for cases, the line of money and power has become quite murky. The selection of the cases has been mostly on the tragic outcomes, regardless of an element of malpractice. Otherwise how can a doctor win 75% of the time, with juries who unequivocally put themselves in the common man’s shoes. Virtually it is a trial of 13 plaintiffs. Sad to see it has been allowed to persist unchallenged until recently.
“I think you are putting too much blame on the lawyers…it takes two to file a suit…a lawyer and a litigious patient.”
I disagree. The Sodomites advertise on TV when most people are working, late night, and midday, so the unemployed and welfare population they are trying to reach (who are looking for a financial way not to work) are watching and will call. You’re sitting at home, unemployed, you see a commercial for a sodomite who says “did a doctor hurt you?, well hurt him back”, and you think to yourself, “well Uncle Ernie died last year, maybe I’ll call this lawyer and he’ll get me some money from that hospital he died in”.
That’s exactly my point…if the patients had any respect for the doctors helping them, they wouldn’t call…they deserve to be hurt back, not just the lawyers…
I disagree with you…despite what some of the trolls on this website say (CJD and his disciples, Sarah etc.) I actually like the patients I see and I don’t blame them for being sucked in by the opportunity at an easy quick buck at our expense. As for the sodomites, as Mark Twain sorta said, the only good lawyer is a DEAD lawyer.
Don’t forget, one little mistake and all those patients that you love so much will turn on you like a pit bull…just stick to the defense and you won’t get burnt.
“We’re not doctors anymore, we’re Lawyer Avoiders.”
You may still be a doctor, but you’re clearly not a professional.
We still have a license to do procedures and whatever we want to you…I guess that makes us professionals?
And you wonder why the “profession” of medicine has lost so much respect?
By the way, do you really think your ISP can’t be figured out and you can’t be traced? These posts will make some compelling reading for 12 people some day.
I hate lawyers. I think they are the scum of the earth, as well as several other planets. If a jury is going to award the lottery to one of you sodomites because I write about how you parasites suck, it reinforces what is wrong with the system.
I think it’s your disdain for your patients that will be your downfall. Wonder how this will play in Peoria:
“We still have a license to do procedures and whatever we want to you”
and
“if the patients had any respect for the doctors helping them, they wouldn’t call…they deserve to be hurt back, not just the lawyers…”
Better start posting from the public library with all the other psychos.
“You may still be a doctor, but you’re clearly not a professional”
But we don’t choose to be sacrificial lamb for the legal ‘profession’ either. So tough to keep your grubby hand off us.
“And you wonder why the “profession” of medicine has lost so much respect?”
Medicine is in a sense a victim of its own success. Transplants of heart, lungs and liver seem so routine that we are surprised when they don’t take. A fetus can be operated on in the womb, and extremely premature babies regularly survive, and so we now view any birth-related injury as someone’s fault. All the time we presume a cure. A bad outcome is a betrayal; lawyers repeat the cliché “it is un-American”. More we become critical of it reinforces the fact that it is effective and is supposed to be.
Basically this is the reason why medicine is loosing respect I think. But having said that, it is well above how people view the lawyers, especially the trial lawyer variety and most of them don’t bite the hand that cares for them.
“These posts will make some compelling reading for 12 people some day.”
Would like to apply a Stanford –Binet test on you. No judge will admit a blog like this as evidence, unless you’ve heavily campaigned for his/her election. Even if it is there it is supposed to be interpreted by a group of my peers who are active and informed.
Just to refresh your memory, in the first Vioxx trial seven jurors had only high school educations, while two went to college for two years and one for four. The other two didn’t indicate where their education stopped. They could easily be persuaded to believe that the pharmaceutical companies are enemies of the ‘common man’ on the basis of some internal documents and emails. In the second trial Lawyers tried to play the same cards but a group of jurors including a former prosecutor a insurance defense lawyer a retired real estate agent, a bank manager, a casino supervisor, an accountant, a grade-school teacher and an administrative assistant were not that gullible .They didn’t buy the story of email conspiracy. To quote one , Juror Patricia Harley, 44, said the internal emails weren’t a problem for Merck. “If someone peeked through all my emails, forget about it,” .And the rest is history
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