Technology doesn't necessarily equal Diagnosis

Ace844 · August 1, 2006

Hello Everyone,

After a recent discussion with a colleague here over whether technology, and fancy hospital tests{alone} = accurate diagnosis; as oppossed to pertinent thorough H&P-P/E alone to arrive at your diagnosis. After our discussion of this issue I decided to do some research and here is just one of the studies that show this. It was also done at the MD level so thus taking away the 'prehospital vs. hospital educational and capability' portion of the debate.

(Ann Neurol. 1990 Jul;28(1):86-7.

The accuracy of bedside neurological diagnoses.

Chimowitz MI @ Logigian EL, Caplan LR.

Department of Neurology, New England Medical Center, Boston, MA.)

The accuracy of bedside diagnoses was prospectively studied in 100 consecutive patients admitted to the neurology service at New England Medical Center, Boston. Each patient was evaluated independently by a junior resident, a senior resident, and a staff neurologist, who were required to make an anatomical and etiological diagnosis based solely on the history and physical examination.[/font:559bdc54a9] Fourteen patients were excluded because their diagnoses were known before admission. Of the remaining 86 patients, it was possible to confirm anatomical and etiological diagnoses in 40 by matching the clinical syndromes with highly specific laboratory findings. In the other 46 patients, the diagnoses could not be confirmed because the laboratory studies (including magnetic resonance imaging) were negative or nondiagnostic. In the 40 patients with laboratory confirmed final diagnoses, the clinical diagnoses of the junior residents, senior residents, and staff neurologists were correct in 26 (65%), 30 (75%), and 31 (77%), respectively. There was a trend for error rates to be higher among junior residents than staff (p = 0.06). The errors by the junior residents, [senior residents], (staff) were attributed to incomplete history and examination in 4 [1] (0), inadequate fund of knowledge in 4 [3] (3), and poor diagnostic reasoning in 6 [6] (6). These results indicate that technology is not a panacea for our diagnostic difficulties and that there is room for improvement in our clinical skills, especially diagnostic reasoning.

(Good diagnostic skills should begin at the bedside

Improving physical exams and history-taking can help you become more efficient and compassionate

By Christine Kuehn Kelly

Improve your auscultation skills)

A University of Miami patient had experienced chronic undulating fevers for six months, but tests continued to be inconclusive. It wasn't until an infectious disease specialist asked him about his hobbies that the diagnosis became obvious. An avid hunter, the patient spent most of his vacations in the Southwest, hunting and skinning the animals he killed. The diagnosis: brucellosis.

Echocardiograms, CT scans, ultrasound—there's no question that imaging and lab tests play a key role in making the difficult diagnosis. But it's the physical exam and history that account for 80% of diagnoses, experts point out.

"The labs and imaging studies complement the picture of the patient created by a good history and physical exam," said Kavita Patel, ACP-ASIM Associate, a second-year internal medicine resident at Oregon Health Sciences University in Portland. That's why educators and residents alike say it's essential that residents learn how to conduct effective physical exams and practice on patients.

"Don't let your residency go by without learning all you can about the physical exam and history," emphasized ACP-ASIM Associate Max Brito, a fellow in infectious disease at the University of Miami Jackson Memorial Hospital.

Physical diagnosis is an important therapeutic instrument, noted Faith Fitzgerald, MACP, professor of medicine at University of California, Davis, School of Medicine. Physical examination and bedside diagnosis put the patient at the center of the physician's attention. "The physical exam is gratifying to doctors," she said. "It gives you a chance to get to know the patient, satisfy your basic impulse to make a diagnosis and make the patient feel better."

Furthermore, the bedside exam gives attendings the best chance to teach intuitive diagnostic skills and therapeutic techniques that make a patient feel better, Dr. Fitzgerald said. Ten minutes with a patient will teach you more than 20 pages with a textbook, added Dr. Brito.

And once you reach private practice, physical diagnosis skills can help you practice more efficiently. Expert diagnosticians point out that when you're pressed for time, it's important to maximize your face-to-face time with patients. Knowing what to look for—and how to rank a patient's symptoms—comes from experience and bedside teaching.

As you become more experienced, for example, you aren't likely to routinely do certain maneuvers when examining a heart patient who complains of a sore knee, and not shortness of breath. While first-year residents will think of dozens of possible diagnoses, third-year residents can zero in on the top five or six possibilities. With experience, you will learn which questions you can safely rule out when you take a history.

Physical diagnosis skills also serve as a filter for more intelligent use of diagnostic testing, according to Sal Mangione, MD, associate professor of medicine and director of the physical diagnosis curriculum at Jefferson Medical College in Philadelphia. Because unnecessary tests beget more tests (you usually find something unexpected), the lack of any filtering can increase costs and perhaps even harm the patient.

Take evaluation of a systolic murmur, a very common and usually benign finding. Studies indicate that an accurate physical examination can usually separate innocent from pathologic murmurs, thus leading to more intelligent, cost-effective use of technology.

Building your skills

Here are some tips to help you get through the bedside physical diagnosis more efficiently—and compassionately:

Control the environment. The noisy hospital room, with its ever-present television, dim lights and busy corridor sounds is not conducive to an accurate examination. Draw the curtain, turn up the lights and find a comfortable position to begin the physical exam.

Build rapport. Know the patient's name when you walk into a hospital or exam room. Always ask patients' permission before you begin the exam. Then ask questions and listen. If you're visiting for just five minutes, try to spend at least three minutes listening to the patient.

Start at the top. When performing the physical exam, start with the eyes and hands, and work your way down. You can learn a lot from visible signs such as clubbed fingers (possible respiratory disease) or a crease in the earlobe (possible cardiovascular problems).

Consider environmental factors. Asking about hobbies, sports activities, travel, country of origin, family history, pets and diet can help pinpoint genetic conditions or disease vectors you might not otherwise consider.

Look for mentors. Ask your program director about attendings or faculty who are expert at physical diagnosis, and round with them. A mentor is especially important when learning auscultation skills.

Get help from journals. A large body of evidence-based medicine can help you pinpoint the most effective physical maneuvers to help you diagnose. A frequently cited series of articles that has been published in The Journal of the American Medical Association (JAMA) called "The Rational Physical Exam" discusses key physical signs and diagnostic maneuvers for major conditions.

Take the long view. Honing physical diagnosis skills is a lifelong process. Building these skills in the hospital will ease the transition to an office or clinic setting, where patients want an immediate diagnosis and you generally cannot rely on a technological quick fix for the answer.

Challenges

Although there are many benefits to knowing how to do a good physical exam and history, said Dr. Mangione from Jefferson, most physicians still spend too little time during residency and medical school teaching these skills. "Bedside rounds are often not at the bedside at all," he explained. "Surveys have indicated that less than 16% of attending time may be spent at a patient's side." Another study showed that residents on rounds spent a median of nine minutes per patient at the bedside, compared to 32 minutes spent elsewhere on the floor.

The constraints of managed care also affect how attendings and residents interact with patients. With outpatient visits limited to an average of 15 minutes and hospital encounters growing shorter all the time, residents have less time to interact with patients. Faculty also face increasing constraints on their bedside teaching time as they are required to take on more patients.

Another reason educators are not teaching physical exam skills may be that many faculty simply lack confidence in their bedside diagnostic skills, pointed out Herbert S. Waxman, FACP, the College's Senior Vice President for Education. "Teachers put themselves on the line when they teach," he said, "and the greatest vulnerability is at the bedside."

But faculty must make the effort to do more bedside teaching because it pays off for residents. Studies have shown that residents' skills in physical examination correlate with estimates of relative time spent by attending physicians at the bedside.

Auscultatory proficiency is one major area where skills are lacking. This may stem in part from the lack of structured teaching of cardiac and pulmonary auscultation. (For more on auscultation tips, see Improve your auscultation skills, this page.) As a result, residents are often inaccurate.

In one study conducted by Dr. Mangione, residents were incorrect four out of five times when they identified 12 commonly encountered cardiac auscultatory events. The rate did not improve throughout training: Residents were not significantly better than third-year medical students.

That's why we need the return to formal training in the physical exam, said cardiologist Howard Weitz, FACP, deputy chairman of the Jefferson Medical College department of medicine and co-author with Dr. Mangione of an editorial on the value of beside skills in JAMA (Sept. 3, 1997).

Fortunately, internal medicine programs are beginning to see the value of the physical exam. After years of absence in the curriculum, the physical exam is being taught in a structured way in more programs, according to Dr. Mangione.

"There's a beauty in the physical exam," said Dr. Weitz. "The laying on of hands creates a tangible connection with the patient. The physician who relies on technology only approaches patients from a distance."

Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.

Improve your auscultation skills

"The Auscultation Assistant," available online at www.med.ucla.edu/wilkes/intro.html, teaches heart and lung sounds. It was created by Chris Cable, ACP-ASIM Associate, a clinician teaching fellow at Seattle VA Medical Center.

"Residents could improve their auscultation skills," Dr. Cable said, "and the best way to learn is to hear the sounds repeated."

An annotated bibliography of literature on physical examination and interviewing is available from ACP-ASIM at www.acponline.org/public/bedside/index.html.

Auscultation case studies from Agilent Technologies, a medical equipment manufacturer, are available at www.healthcare.agilent.com/

medical_supplies/education/toolbox/.

The RALE Repository contains a collection of respiratory and heart sounds on the Web at www.rale.ca.

"Physiological Origins of Heart Sounds and Murmurs" by J. Michael Criley, FACP. For information go to the Lippincott Williams & Wilkins Web site at http://lww.com/home/, or call 800-638-3030.

The Rational Clinical Exam series, published from 1992 to present in The Journal of the American Medical Association, presents evidence-based approaches for more than 30 conditions.

(Editorials

Physical examination: bewitched @ bothered and bewildered

Brendan M Reilly, Christopher A Smith and Brian P Lucas

MJA 2005; 182 (8): 375-376)

Young physicians today seem confused about physical examination. 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.

Many medical professionals claim to be bothered by this trend, but you would not know it from reading the medical literature. Although laudable research has clarified the accuracy (likelihood ratios) and reliability (kappa statistics) of particular physical findings,1 next to nothing is known about physical findings’ impact on patient care.2 In fact, you can count on one hand the number of studies ever published about this issue, not one of them large, controlled or externally funded.2-6 This inattention by researchers to medicine’s core clinical skills seems especially striking in this era of evidence-based medicine, in sharp contrast to the glut of acronymic mega-trials funded by “Big Pharma” to achieve statistically significant (but often clinically trivial) results. Some say not to worry about the lack of published evidence, the clinical value of physical examination is self-evident. To these true believers, we recommend a brief visit to any US teaching hospital today. The National Board of Medical Examiners, not so sanguine, plans to test the bedside skill of US medical students as a new requirement for graduation. This is a wise plan — in part because it has worked well in other countries — but not worth the bother if it ends there.

What more can we do? In addition to evaluating how well our physicians learn the basics,7 we must continuously question what we teach them and why. For example, which physical findings have clinical utility in which clinical contexts? Palpating the carotid artery is essential in a patient with angina and a systolic murmur,1 less important in a patient with neck pain. Which physical findings, when shared with radiologists or pathologists, improve interpretation of diagnostic images or biopsies? Contrary to popular belief, the sensitivity and specificity of technological diagnostic tests may not be independent of patients’ clinical findings, knowledge of which may improve test performance.8 Conversely, which aspects of physical examination are useless (inaccurate, unreliable, redundant) or cost-inefficient when compared with technological testing?

Thus, the real dilemma today is uncertainty about the “value added” by particular aspects of physical examination to the quality of patient care. If more attention were paid to this issue, more effort could be devoted to maintaining and improving particular bedside skills throughout physicians’ professional careers. Instead, the strongest praise many observers can offer is their feeling that the “laying on of hands” improves communication and trust between doctors and patients, somehow “connecting” them better, not just physically but otherwise. Despite its New Age vibrations, this feeling rings true to us, at least in the sense that careful physical examination focuses the physician, intently and singularly, on this patient now. (As one expert examiner put it, “The stethoscope allows you to connect not only your ears, but also your mind, to the patient.”9) This phenomenon is notable, and deserves further study, but it is not enough to convince the bewildered or sceptical among us about the value of physical examination.

Proving scientifically physical examination’s clinical utility is difficult because this requires strict control of potential confounders. But to “isolate” the contribution of physical examination to diagnosis or prognosis — controlling methodologically and analytically for the patient’s history, test results and other confounders — makes little sense clinically. Physical findings add value precisely because they interact with and complement these other sources of information.3-6 For this reason, clinical epidemiologists commonly describe physical findings as “tests” whose result, when combined with a pre-test probability (based on prevalence, the clinical history or both), generates a post-test probability.1 This Bayesian approach makes it easier to describe the accuracy of physical findings, but there is scant evidence that physicians use this kind of reasoning when making clinical decisions. More promising, in our view, are clinical decision rules which, based on multivariate analysis of all potential clinical predictors (including physical findings), quantify the predictive power of the few key determinants of the outcome of interest.10 When impact analysis of such decision rules demonstrates that particular physical findings help to improve patient outcomes (for example, in the management of suspected pulmonary embolism or acute cardiac ischaemia),11,12 sceptics best take heed: these are things we all need to know. Much more research is needed in this area.

In the end, we find ourselves bewildered by the need to say these things, bothered by the medical profession’s reticence about them. Together with the history, physical examination is the doctor’s best kept secret — powerful, portable, fast, cheap, durable, reproducible and fun — but it must be allowed out of the closet. We admit we are biased about this, perhaps even bewitched. How could we not be? Like other experienced clinicians, we cannot forget those memorable moments when a careful physical examination yielded magical results: neck veins that resurrected a young mother, moribund from pericardial constriction; a tender temple that rejuvenated an octogenarian, wasted by months of fever; a Babinski reflex that saved an Olympian, his brain tumor too early to see. And more, many more. Such anecdotes prove nothing, of course, but they are . . . bewitching.

Modern medicine — bewitched by technology, bothered by its cost, bewildered by those who need it but cannot afford it — would do well to step back, re-examine itself. We recommend a thorough check-up. Preferably by a doctor who takes the time to look, listen, even touch. This should not be difficult to arrange. There are many such doctors out there. Good ones. For now, anyway.

McGee S. Evidence-based physical diagnosis. Philadelphia: WB Saunders, 2001.

Reilly BM. Physical examination in the care of medical inpatients. Lancet 2003; 362: 1100-1105. <PubMed>

Crombie DL. Diagnostic process. J Coll Gen Pract 1963; 6: 579-589.

Hampton JR, Harrison MJG, Mitchell JRA, et al. Relative contributions of history-taking, physical examination and laboratory investigation to diagnosis and management of medical outpatients. BMJ 1975; 2: 486-489. <PubMed>

Peterson MC, Holbrook JH, Hales DV, et al. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med 1992; 156: 163-165. <PubMed>

Roshan M, Rao AP. A study on the relative contributions of the history, physical examination and investigations in making medical diagnosis. J Assoc Physicians India 2000; 48: 771-775. <PubMed>

Holmboe ES. Faculty and the observation of trainees’ clinical skills: problems and opportunities. Acad Med 2004; 79: 16-22. <PubMed>

Loy CT, Irwig L. Accuracy of diagnostic tests read with and without clinical information. A systematic review. JAMA 2004; 292: 1602-1609. <PubMed>

Smith DS. Field guide to bedside diagnosis. Philadelphia: Lippincott Williams and Wilkins, 1999.

Laupacis A, Sekar N, Stiell IG. Clinical prediction rules. A review and suggested modifications of methodological standards. JAMA 1997; 277: 488-494. <PubMed>

Wells PS, Anderson DR, Rodger M. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med 2001; 135: 98-107. <PubMed>

Reilly BM, Evans AT, Schaider JJ, et al. Impact of a clinical decision rule on hospital triage of patients with suspected acute cardiac ischemia in the emergency department. JAMA 2002; 288: 342-350. <PubMed>

(Received 16 Dec 2004, accepted 31 Jan 2005)

Department of Medicine, Cook County Hospital, Chicago, USA.

Brendan M Reilly, MD; Christopher A Smith, MD; Brian P Lucas, MD.

Now what do you all think?

Out Here,

ACE844

For those who are interested in evidenced based Dx, H&P, P/E here's a great link: http://depts.washington.edu/physdx/pulmonary/evidence.html

http://www.carestudy.com/CareStudy/Default.asp

http://www.sgim.org/clinexam.cfm

http://www.dartmouth.edu/~biomed/resources...diagnosis.shtml

http://www.acponline.org/public/bedside/index.html

http://www.meddean.luc.edu/lumen/meded/med...pd/contents.htm

http://www.rale.ca/Recordings.htm

http://www.neuroexam.com/

http://araw.mede.uic.edu/cgi-bin/testcalc.pl

http://www.medal.org/visitor/login.aspx

http://members.tripod.com/~LouCaru/index-5.html

http://www.saem.org/download/part1c.pdf

Scaramedic · August 1, 2006

Great thread Ace, I was taught as a baby medic that the machines are there to back up what you have already discovered in your assessment. Machines do not think, they cannot see the patient, it is up to us to do our job and lay hands on our patients. I believe that is the problem with technology, too many people are getting caught up in what the machines say.

Pulse=look at the monitor

Breathing=check the pulse ox, capnography

BP=Auto NIBP

The machines are a great for quantifying what we have already discovered or suspect, but they should not be the sole diagnostic tool.

Peace,

Marty

:joker:

JakeEMTP · August 1, 2006

Informative post as always Ace. I agree with Scarmedic here. During my clinicals at the ED and in the field I have witnessed caregivers loading the pt into the ambulance and immediately hook up the monitor. In the ED it is the same.

This is a " hands on " business. As Scarmedic stated, the machines are there solely to back up your assessment. They are an excellent daignostic tool but we cannot rely on them solely. We have to use our eyes, ears, touch and sense of smell.

Actually, the Medic I rode with on Sunday took the monitor into the ED since he had been accused lately of having a mis-placed ETT. As if on cue, the 1st year resident said the tube was in incorrectly. When we showed the attending the monitor showing capnography was good, He asked the young MD if he wanted to check again. In this case, the Zoll saved his butt. Gotta love the fall at a teaching Hospital. Everybody wants the skill checked off.

chbare · August 1, 2006

Ace844, good thread. The history and physical exam is a dying art.

Take care,

chbare.

aussiephil · August 1, 2006

Ace,

I agree with what you are saying in this thread. Medicine can be machine oriented & we forget the human factor. However, we cannot forget that to gain a full differential diagnosis, most illnesses require a number of tests to confirm suspicions.

This is common sense, & usually done in hospital.

As an EMT we all need to use our experience & common sense to determine our provisional diagnosis. eg. a person presents with mid retrosternal chest pain with radiation into their arm & jaw & is ashen gray has a high probability of having a cardiac event. We then use an ECG to confirm this & instigate treatment.

However, there are many different causes of chest pain that do not require the same regime of therapy to be instigated. Present differently, & the use of a cardiac monitor in this situation can be useful to assist with diagnostic exclusion.

Our initial observations should be without machine & use the technology to your advantage. Work smarter, not harder.

I will always maintain that in the prehospital environment, we should treat what we see (based on our initial observations) & aim to get the patient to hospital ASAP, alive.

We use history & examination to assist with our index of suspicion, and we instigate treatment based on that information. Nowhere in the articles does it say that the use of technology should not be used.

My reading of the information provided by you is that a good history & examination will give a diagnosis, however, "it was possible to confirm anatomical and etiological diagnoses in 40 by matching the clinical syndromes with highly specific laboratory findings."

Pre hospital medicine is not the appropriate place to try & diagnose specific illnesses. We have limited resources in the vehicles, limited (usually nil) testing facilities, & where in an ER a general physician has available to him any number of staff specialists, we have ourselves & our partner to cover the entire list of medical specialties.

All medicine is continual learning & we should always look at it as such. To close our mind is not right. However it is not, & will never be my job to determine conclusively a patients illness, my job is to take a history, do an examination, instigate treatment based on my observations & hand the patient over to the hospital.

Most importantly, my job is to reassure the patient, talk to them & make them as comfortable as possible.

Let the doctors do their job, let the doctor decide conclusively with whatever testing they believe is appropriate the diagnosis & ongoing treatment for this patient. EMS is just that, an EMERGENCY MEDICAL SERVICE.

Phil

aussiephil · August 1, 2006