Is the History and Physical Worth Doing 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.1 Let’s look at the data.
CLINICAL SKILLS VS HIGH-TECH IMAGING: WHAT THE DATA SHOW
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.2 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.”2
WHERE IS COMFORTABLE MIDDLE GROUND?
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.”2
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?
1. Paley L, Zornitzki T, Cohen J, et al. Utility of clinical examination in the diagnosis of emergency department patients admitted to the department of medicine of an academic hospital. Arch Intern Med. 2011;171:1394-1396.
2. Cheitlin MD. Medical technology—still an adjunct to clinical skills in making a diagnosis. Arch Intern Med. 2011;171:1396-1397.