The hands-off culture of American medicine

Maurice Bernstein points to a study suggesting the uselessness of the physical exam:

In the United States, many of them do not know how to do it and do not see why they should. Asymptomatic patients do not seem to need it; the US Preventive Services Task Force found insufficient evidence to recommend periodic physical examination of the breast, prostate, heart or anything else. Sick patients do not seem to benefit much from it either, most of them tested to death regardless of their physical findings. It is hard to say which is the chicken or the egg here, but physical diagnosis instruction in many US medical schools now is either out of date (emeritus faculty members teaching useless arcana like percussion of Traube’s space), out of touch (junior faculty members making rounds in a conference room, not at the bedside), or both.

Young physicians trained outside the US are bewildered about this, too. Many of them, meticulously trained in physical examination, are appalled upon first encountering the “hands off” culture of US medicine. But they learn quickly, in the process often unlearning much of what they had learned before. The pace and clinical impact of this remarkable phenomenon is unknown because no one has studied it, a bewildering thing in itself.

I admit as a resident, I conducted part of rounds in the conference room. This was often done to analyze and interpret the sheer volume of laboratory and diagnostic tests from the day before. Once this was done, we went to the bedside to talk with and examine the patient.

There are several reasons why American medicine is so test dependent.

First is the sheer availability of CT scanners, MRIs and ultrasounds. Why auscultate a heart murmur when an echocardiogram can be easily ordered?

Next is a payment system to encourages volume. Doctors are under pressure to maximize quantity. Under this circumstance, it becomes easier and faster to simply order a test than to perform a thorough physical exam.

Finally, the American patient expects a certain degree of certainty. Perhaps moreso when compared to patients in other countries. “Failure to diagnose” is the most common cause of malpractice lawsuits, and when patients read these cases in the media, they presume that more testing can prevent physician malpractice.

Similarly, physicians want to avoid being placed in a malpractice situation, and generally are complicit with the patient demand to be more “certain” of their diagnosis.

What to do? Well, divorcing financial incentives from sheer volume is the imperative first step. Nothing else can follow unless this is reformed.

Secondary solutions involve educating patients that more testing does not necessarily mean better medicine. This can include an emphasis on shared decision making, which has been shown to decrease patient demand for tests.

But these points are moot unless the limiting factor of incentivizing quantity is resolved first.