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.
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{ 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.
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