Students learn many things during their time in medical
school. Some things that they learn are soon forgotten (think: the Kreb's
cycle). But other things stay with them forever. I can still remember learning
how to ask about thyroid symptoms from one of my family medicine mentors. I
still use the same words when I ask patients about thyroid symptoms.
Many schools start to teach about taking a history from a
patient at the very beginning of medical school. These courses are often called
an Introduction to Clinical Medicine.
There are many techniques used to teach students to do an appropriate
history and physical examination, but students really start to hone this skill
when they complete their clinical clerkships in the third year. The more
experience that a student gets in taking a history, the better they get at this
skill.
So, an article (1) in JAMA Internal Medicine (the Journal of the American Medical
Association's specialty journal for Internal Medicine) caught my eye. In this
study, the authors prospectively evaluated patients that were admitted from the
emergency room to an academic hospitalist service of Internists. Each patient
was interviewed and examined by an experienced senior resident. The patients
received a full history and physical examination, and the resident reviewed
laboratory tests and xrays done in the emergency room. The resident was then
forced to put her nickel down. She recorded her most likely diagnosis and
identified the things that were the most helpful in making the diagnosis.
The patients’ were also evaluated by a “senior” clinician,
someone with at least twenty years of experience. The senior clinician was a
hospitalist who had no knowledge of the senior resident’s diagnosis. The senior
resident spent more time (ave 40 minutes per patient) than the senior
hospitalist (ave 25 minutes). In this study, 80 percent of the patients
admitted were given the correct diagnosis at admission. I think that is really
high! 90 percent of the correctly diagnosed patients only received a history,
physical examination, and some basic tests.
A few CT scans of the head in the ED, but most did not get anything more
than a chest xray or an electrocardiogram.
The senior resident and the senior clinician missed the
diagnosis completely on ten percent of the patients but that is consistent with
or even lower than other studies of diagnosis. The author wrote, “Our results
do not mean that sophisticated studies need not be used after admission, but they
do suggest that their choice should be guided by the clinical data on
presentation.” That should be a duh, but it is worth repeating. Many studies
are ordered by reflex. They are coming into the orthopedic clinic they need an
xray of the joint or they are coming in to the cardiologist so they need an
electrocardiogram. It is worse in the hospital.
This study supports that a good physical examination and a thorough history are
still very sensitive tests. Maybe more sensitive than the CT scan that I am
about to order.
Two other quotes that I thought were memorable. From the
Editor (of JAMA Internal Medicine) “The (study) by Paley et al reminds us of
the value of lower-tech ways of making a diagnosis of patients seen in the
emergency department (ED), as technology increases in availability and complexity
and because ED health professionals now routinely order imaging tests, not
uncommonly without even examining patients.”
The other was from an invited commentary, who said (possibly without
actually knowing what he was talking about) that auscultation of the heart was
less effective than echocardiography.
So, keep teaching the physical examination and history
skills. Your students need them!
References
(1) Paley
L, 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(15):1393-1400.
