Is the history and physical examination worth performing anymore?

Would it be silly to ask, “Is the history and physical examination worth performing anymore?” especially in this era of high-technology medicine? Does it matter if the diagnosis is made by the bedside in contrast to CT or echocardiography? Someone did ask, and the answer is intriguing and was debated. Let’s look at the data.

Four hundred and forty-two consecutive patients were admitted from the emergency department to an academic hospital over a period of 53 days. A senior medical resident with 4 years of clinical experience (who spent an average of about 40 minutes per patient) and hospital physicians with at least 20 years of experience (who expended usually less than 25 minutes per patient) examined these patients and their accompanying medical records. The resident was correct in her diagnosis 80.1% of the time, the senior physicians 84.4%.

The investigators then determined which modalities were most valuable in reaching a correct diagnosis. They were as follows for the senior resident and hospital physicians, respectively:

  • History alone: 19.8% and 19.3%.
  • Physical examination alone: 0.8% and 0.5%.
  • Basic tests (complete blood cell count, chemistry panel, urinalysis, ECG, chest radiograph) alone: 1.1% and 1.3%.
  • History and physical examination in combination: 39.5% and 38.6%.
  • History plus basic tests: 14.7% and 14.7%.
  • History, physical examination, and basic tests in combination: 16.9% and 18.5%.
  • Imaging studies: 6.5% and 6.1%.

The authors’ conclusion: “We found that more than 80% of newly admitted internal medicine patients could be correctly diagnosed on admission and that basic clinical skills remain a powerful tool, sufficient for achieving an accurate diagnosis in most cases.”1 This conclusion made me happy.

However, an editorialist raised some interesting points. Like me, he is a senior clinician, that is, a euphemism for older (he was a fellow in the 1950s, I was in the 1970s). He went further, suggesting “modern imaging techniques when used appropriately have made the diagnosis of the patient’s disease and management more timely and accurate. There is also no doubt that these imaging techniques are overused … these techniques increase the cost of medical care significantly.”

Older clinicians rely on the history and physical to a greater degree than younger clinicians. In fact, has the pendulum swung too far toward technology? As a result of eroding auscultation skills, many recent graduates can only make cardiac diagnoses by echocardiography.

The editorialist closed with sage advice, “The study by Paley et al. is highly supportive of the physician’s ability using the classic diagnostic tools including a medical history, the physical examination, and basic laboratory studies to make an accurate diagnosis, reserving the expensive imaging techniques for those patients for whom there is diagnostic confusion . . . in this way, we can help reduce the cost to the patient without compromising the quality of their care.”

As a group, we are going to have to identify ways to save money without harming patients. Is a more comprehensive and time-consuming history and physical the answer? What do you think?

Gregory W. Rutecki is Professor of Medicine, University of South Alabama College of Medicine. He is also a member of the editorial board of
Consultant.

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  • drg

    Could not agree more. But the bigger issue is who is going to pay for thinking? Recent RUC article rather discouraging.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Great article. Listening and asking pertinent questions followed by a thorough examination works. Imaging and complex testing is supposed to support or refute your hypothesis or differential diagnosis not be used to replace listening , a thorough history session and physical examination.

  • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

    I find that at times I wish my physical exam skills were better (or rather more thorough , what scares me is that I order far less testing than most providers in my area. I also believe the EMR hurts us here. I here murmurs all the time but chart reviews will show no mention of the murmur previously, however I can clearly see that it is an auto populated field.

  • traumadoc

    semiotics are the basis of a good physical exam without the technology. i am a 3rd world flight doc. been one for 20+years.
    a good P&H is the best route to a decent DX! i truly believe medical schools will be obsolete someday as long as someone comes up with articles such as these. someday everyone might be a medical tech in some specialty. so, my colleagues, please use your knowledge while you can.

  • http://www.facebook.com/shirie.leng Shirie Leng

    In my experience a patient who comes to the ER complaining of abdominal pain has already had blood work and an abdominal CT before a surgeon has even laid eyes on the patient. If you consider the risk of lawsuits, it’s a tricky thing to make a diagnosis without the imaging. It’s become sort of standard of care. I’m not saying it’s right, I’m just saying thats the way it is. You can examine all you want, but you’re still going to get the imaging.
    Actually, I’m usually the last to advocate for technology, but part of the reason disease treatment has gotten better in the last 200 years is that we don’t have to rely solely on physical exam anymore. Ideally, the H &P should guide how we order tests, but realistically you can’t do that anymore

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      When a patient shows up at our local ER and complains of abdominal pain or discomfort and is evaluated by the triage nurse outside the ER the patient is given the abdominal pain protocal automatically which includes lab work ( CBC,CMP, amylase, lipase urinalysis) and imaging BEFORE the patient is seen by an ER provider ( physician, PA or NP). This generates a great deal of revenue on an outpatient basis for the institution before anyone truly trained to make that determination actually sees the patient. This happens everywhere. A history and exam should proceed ordering of tests if one wishes to deliver accurate diagnoses at a reasonable cost.

      • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

        Well said.

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