- Email: [email protected]
Physical examination
CORRESPONDENCE
1
2
Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet 2003; 362: 1100–05. Sackett DL. The rational clinical examination: a primer on the precision and accuracy of the clinical examination. JAMA 1992; 267: 2638–44.
Sir—We congratulate Brendan Reilly1 on his study describing the value of the rapidly dying art of physical examination in the management of patients. However, we believe that the high incidence (26%) of findings that changed management is far higher than that seen in actual practice, and that this exaggerated figure is largely due to the study design. In Reilly’s report, the examiner attending has the benefit of knowing the history and examination findings documented by the emergency department physicians, and is aware of the treatment given and the initial response to treatment. If there was no initial response, the examiner has the benefit of that knowledge and can focus on specific clues on physical examination, which will increase the yield of pivotal findings. Furthermore, it is not fair to compare the findings of the emergency department physicians, who work at odd hours, with a physician who works in day hours. Often patients come to the emergency department sick, and the initial priority is to stabilise the vital signs; a detailed physical examination is less of a concern at that stage. Besides, many physical findings can be missed during the acute presentation—eg, a jugular venous pulsation might be more apparent once the patient’s tachypnoea improves. Thus, the high incidence of pivotal findings is unlikely to translate into tangible gains in clinical practice. However, there are many advantages of a meticulous physical examination that might not be obvious in a study of this nature. A detailed physical examination instils confidence in the patient that the physician is thorough in his approach. The contact of a physician is often reassuring to an anxious patient. And finally, as any clinician will tell you, there are few things in clinical medicine that can give you as much satisfaction as detecting a subtle physical finding that can dramatically alter the diagnosis and the care of a patient. *Binu V John, Smitha Mary Thomas Department of Medicine 2, Christian Medical College, Vellore 632004, Tamilnadu, India (e-mail: [email protected]) 1
Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet 2003; 362: 1100–05.
Sir—I am a believer in the value of the physical examination. At a minimum, it is a unique opportunity for a physician to spend time with the patient, touch the patient, and show in a most primitive humane way that he or she cares. However, the interesting observational study by Brendan Reilly1 sounds like a self-fulfilling prophecy. Setting aside the macabre comparison of physical examination with autopsies (are clinical skills as dead and buried?), Reilly is to be congratulated for the high rate of pivotal physical findings (26%) in his case series. However, I think this percentage is unlikely to be replicated elsewhere. Most clinicians would be thrilled if they could make a difference for one in 100 patients with their physical examination alone, especially among patients already examined by other physicians. Furthermore, for any diagnostic test, we should be given not only the successful diagnoses, but also the false positives. Many aspects of the physical examination have high error rates even among skilled practitioners. In the current defensive medicine climate, patients examined by many physicians (emergency-room and floor officers, staff, specialists, and subspecialists) might have additive false positive findings affect their care. This leads to unnecessary, costly diagnostic and interventional procedures with potential iatrogenic morbidity and mortality. For low-risk patients (including all outpatients, but also most inpatients), I seriously question whether increasing contact with action-oriented physicians is likely to produce more good than harm. For a low prevalence of serious disease, the positive predictive values are low. Most “patients” will be unnecessarily exposed to the medical profession and a dangerous mixture of old-fashioned and high-tech methods. These methods often share only the lack of good evidence for their application. For high-risk patients, the positive predictive values might be somewhat better. However, in such cases, the invasiveness and harms of subsequent diagnostic and therapeutic interventions are also likely to be greater. Moreover, Reilly regards the involvement of a consulting specialist as a gold standard for the validation of the physical examination findings. Where is the evidence that all the specialists of modern medicine do more good than harm? Could we even test with robust methods (eg, randomised trials) whether whole subspecialties of our profession are useful? I am not very
THE LANCET • Vol 362 • December 13, 2003 • www.thelancet.com
optimistic. When the major federal organisation on health-care research and quality in the USA issued a guideline that could have led to a striking reduction of the most common procedures by a surgical subspecialty, the organisation was almost annihilated by lobbyists.2 Would any professional ever do and report a study that proves that he or she is useless? Although we increasingly recognise that several medical interventions are unsupported by evidence, inefficient, and harmful,3,4 I doubt whether we are prepared to acknowledge that even core elements of our profession might be a compilation of dangerous perpetuated rituals. John P A Ioannidis Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina 45110, Greece (e-mail: [email protected]) 1
2
3
4
Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet 2003; 362: 1100–05. Appel A. Medical lobby seeks cuts in US health research agency. Nature 1995; 377: 379. Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts: treatments for myocardial infarction. JAMA 1992; 268: 240–48. Ioannidis JP, Lau J. Uncontrolled pearls, controlled evidence, meta-analysis and the individual patient. J Clin Epidemiol 1998; 51: 709–11.
Sir—Brendan Reilly1 has shown that physical examination is of value in the diagnosis of acute medical admissions to the Cook County Hospital in Chicago, USA, where presumably modern diagnostic technology is readily available. I have been working in a rural hospital in Africa where, like most hospitals in the developing world, access to diagnostic technology is very limited. Here the ability to take a history and to do a clinical examination is of paramount importance. Doctors who have not been adequately trained in these techniques are at a grave disadvantage. Medical schools and colleges in advanced and in developing countries must insist on a high standard of competence in these skills so that doctors can provide effective care not only in centres of excellence, but also where modern facilities are less easily available. F J C Millard 4 Vineyard Hill Road, London SW19 7JH, UK (e-mail: [email protected]) 1
Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet 2003; 362: 1100–05.
2023
For personal use. Only reproduce with permission from The Lancet publishing Group.
1
2
Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet 2003; 362: 1100–05. Sackett DL. The rational clinical examination: a primer on the precision and accuracy of the clinical examination. JAMA 1992; 267: 2638–44.
Sir—We congratulate Brendan Reilly1 on his study describing the value of the rapidly dying art of physical examination in the management of patients. However, we believe that the high incidence (26%) of findings that changed management is far higher than that seen in actual practice, and that this exaggerated figure is largely due to the study design. In Reilly’s report, the examiner attending has the benefit of knowing the history and examination findings documented by the emergency department physicians, and is aware of the treatment given and the initial response to treatment. If there was no initial response, the examiner has the benefit of that knowledge and can focus on specific clues on physical examination, which will increase the yield of pivotal findings. Furthermore, it is not fair to compare the findings of the emergency department physicians, who work at odd hours, with a physician who works in day hours. Often patients come to the emergency department sick, and the initial priority is to stabilise the vital signs; a detailed physical examination is less of a concern at that stage. Besides, many physical findings can be missed during the acute presentation—eg, a jugular venous pulsation might be more apparent once the patient’s tachypnoea improves. Thus, the high incidence of pivotal findings is unlikely to translate into tangible gains in clinical practice. However, there are many advantages of a meticulous physical examination that might not be obvious in a study of this nature. A detailed physical examination instils confidence in the patient that the physician is thorough in his approach. The contact of a physician is often reassuring to an anxious patient. And finally, as any clinician will tell you, there are few things in clinical medicine that can give you as much satisfaction as detecting a subtle physical finding that can dramatically alter the diagnosis and the care of a patient. *Binu V John, Smitha Mary Thomas Department of Medicine 2, Christian Medical College, Vellore 632004, Tamilnadu, India (e-mail: [email protected]) 1
Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet 2003; 362: 1100–05.
Sir—I am a believer in the value of the physical examination. At a minimum, it is a unique opportunity for a physician to spend time with the patient, touch the patient, and show in a most primitive humane way that he or she cares. However, the interesting observational study by Brendan Reilly1 sounds like a self-fulfilling prophecy. Setting aside the macabre comparison of physical examination with autopsies (are clinical skills as dead and buried?), Reilly is to be congratulated for the high rate of pivotal physical findings (26%) in his case series. However, I think this percentage is unlikely to be replicated elsewhere. Most clinicians would be thrilled if they could make a difference for one in 100 patients with their physical examination alone, especially among patients already examined by other physicians. Furthermore, for any diagnostic test, we should be given not only the successful diagnoses, but also the false positives. Many aspects of the physical examination have high error rates even among skilled practitioners. In the current defensive medicine climate, patients examined by many physicians (emergency-room and floor officers, staff, specialists, and subspecialists) might have additive false positive findings affect their care. This leads to unnecessary, costly diagnostic and interventional procedures with potential iatrogenic morbidity and mortality. For low-risk patients (including all outpatients, but also most inpatients), I seriously question whether increasing contact with action-oriented physicians is likely to produce more good than harm. For a low prevalence of serious disease, the positive predictive values are low. Most “patients” will be unnecessarily exposed to the medical profession and a dangerous mixture of old-fashioned and high-tech methods. These methods often share only the lack of good evidence for their application. For high-risk patients, the positive predictive values might be somewhat better. However, in such cases, the invasiveness and harms of subsequent diagnostic and therapeutic interventions are also likely to be greater. Moreover, Reilly regards the involvement of a consulting specialist as a gold standard for the validation of the physical examination findings. Where is the evidence that all the specialists of modern medicine do more good than harm? Could we even test with robust methods (eg, randomised trials) whether whole subspecialties of our profession are useful? I am not very
THE LANCET • Vol 362 • December 13, 2003 • www.thelancet.com
optimistic. When the major federal organisation on health-care research and quality in the USA issued a guideline that could have led to a striking reduction of the most common procedures by a surgical subspecialty, the organisation was almost annihilated by lobbyists.2 Would any professional ever do and report a study that proves that he or she is useless? Although we increasingly recognise that several medical interventions are unsupported by evidence, inefficient, and harmful,3,4 I doubt whether we are prepared to acknowledge that even core elements of our profession might be a compilation of dangerous perpetuated rituals. John P A Ioannidis Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina 45110, Greece (e-mail: [email protected]) 1
2
3
4
Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet 2003; 362: 1100–05. Appel A. Medical lobby seeks cuts in US health research agency. Nature 1995; 377: 379. Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts: treatments for myocardial infarction. JAMA 1992; 268: 240–48. Ioannidis JP, Lau J. Uncontrolled pearls, controlled evidence, meta-analysis and the individual patient. J Clin Epidemiol 1998; 51: 709–11.
Sir—Brendan Reilly1 has shown that physical examination is of value in the diagnosis of acute medical admissions to the Cook County Hospital in Chicago, USA, where presumably modern diagnostic technology is readily available. I have been working in a rural hospital in Africa where, like most hospitals in the developing world, access to diagnostic technology is very limited. Here the ability to take a history and to do a clinical examination is of paramount importance. Doctors who have not been adequately trained in these techniques are at a grave disadvantage. Medical schools and colleges in advanced and in developing countries must insist on a high standard of competence in these skills so that doctors can provide effective care not only in centres of excellence, but also where modern facilities are less easily available. F J C Millard 4 Vineyard Hill Road, London SW19 7JH, UK (e-mail: [email protected]) 1
Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet 2003; 362: 1100–05.
2023
For personal use. Only reproduce with permission from The Lancet publishing Group.